Healing touch as a supportive intervention for adult acute leukemia patients: a pilot investigation of effects on distress and symptoms

BACKGROUND

Goals were to determine the feasibility of conducting a study of Healing Touch (HT) for acute leukemia patients and to obtain preliminary data on its effectiveness.

METHODS

Forty hospitalized leukemia patients completed a brief survey of HT knowledge/experience. A prospective cohort (N = 12) was invited to participate in an HT intervention (9 30-minute sessions over 3 weeks); they completed measures of distress, symptoms, and sleep (at weeks 1 and 5), and completed single item ratings of fatigue, nausea, distress, and pain immediately pre-post selected HT sessions. The Wilcoxon signed rank test was used to analyze change in pre-post session ratings and distress, symptom, and sleep measures.

RESULTS

Among survey respondents, 8% had used HT in the past, and 71% were interested in using HT. In the prospective cohort, there were significant pre-post session improvements in fatigue and nausea (but not in distress and pain). There were no significant changes between weeks 1 and 5 in distress, symptoms, or sleep. Ratings and qualitative feedback on HT were positive, focused mainly on feeling relaxed following HT sessions.

CONCLUSIONS

It is feasible to recruit patients hospitalized for acute leukemia to a study of HT. Preliminary data on short-term improvements in symptoms indicate these are promising outcomes for future study.

Restorative yoga for women with ovarian or breast cancer: findings from a pilot study

Yoga has demonstrated benefit in healthy individuals and those with various health conditions. There are, however, few systematic studies to support the development of yoga interventions for cancer patients. Restorative yoga (RY) is a gentle type of yoga that has been described as "active relaxation." The specific aims of this pilot study were to determine the feasibility of implementing an RY intervention as a supportive therapy for women diagnosed with ovarian or breast cancer and to measure changes in self-reported fatigue, psychological distress and well-being, and quality of life. Fifty-one women with ovarian (n = 37) or breast cancer (n = 14) with a mean age of 58.9 years enrolled in this study; the majority (61%) were actively undergoing cancer treatment at the time of enrollment. All study participants participated in 10 weekly 75-minute RY classes that combined physical postures, breathing, and deep relaxation. Study participants completed questionnaires at baseline, immediately postintervention, and 2 months postintervention. Significant improvements were seen for depression, negative affect, state anxiety, mental health, and overall quality of life. Fatigue decreased between baseline and postintervention follow-up. Health-related quality of life improved between baseline and the 2-month follow-up. Qualitative feedback from participants was predominantly positive; relaxation and shared group experience were two common themes.

The role of negative CT of the abdomen and pelvis in the decision to admit adults from the emergency department after blunt trauma

RATIONALE AND OBJECTIVES

Computed tomography (CT) is widely used in the initial evaluation of blunt trauma patients and is associated with a high rate of negative imaging. A described benefit of negative imaging is prompt discharge. This study examined a single level 1 trauma center to determine whether adult blunt trauma patients are discharged from the emergency department (ED) after negative CT of the abdomen and pelvis (CT AP).

MATERIALS AND METHODS

The authors retrospectively created a data set of adult blunt trauma patients who received CT AP in the ED from August to November 2003. Statistical analysis of admission rates on the basis of positivity or negativity on CT AP was performed to determine if the test influenced admission rates. Additional subgroup analysis was made between the patients admitted with negative CT AP and those who were discharged from the ED.

RESULTS

Two thirds (316/469) had negative CT AP. Whereas 80.4% of the patients (254/316) with negative CT AP were admitted, 98.0% (148/151) with positive CT AP were admitted, a statistically significant difference in admission rate (P < .0001). The vast majority (208/254, 81.9%) of patients with negative CT AP were admitted for extra-abdominal injuries. There was no statistical difference in the characteristics of a subgroup of 45 patients who were admitted without any documented injuries from the group discharged from the ED in terms of age, gender, comorbidity, Glasgow Coma Scale score, or intoxication.

CONCLUSION

Under current practice, negative CT AP after blunt trauma results in a statistically significant decrease in admissions.

Total daily energy expenditure among middle-aged men and women: the OPEN Study

BACKGROUND

Few large doubly labeled water (DLW) studies have provided an objective measure of total energy expenditure (TEE) in free-living men and women. The committee that developed the 2002 Dietary Reference Intake (DRI) estimated energy requirements (EER) noted that DLW studies in adults aged 40 to 60 y were limited.

OBJECTIVE

We aimed to describe TEE and physical activity energy expenditure in middle-aged men and women by sex, age, menopausal status, and level of obesity, and to compare TEE to the DRI EER.

DESIGN

TEE was measured by the DLW method in 450 men and women aged 40-69 y from the Observing Protein and Energy Nutrition Study. Resting metabolic rate was estimated by use of the Mifflin equation.

RESULTS

Unadjusted TEE was lower in women than in men (591 kcal/d); however, when the analysis was adjusted for fat-free mass, women had significantly higher TEE than did men (182 kcal/d). This difference appeared to be due to higher physical activity levels in women (physical activity energy expenditure adjusted for FFM was 188 kcal/d greater in women than in men). Mean TEE was lowest in the seventh decade. TEE from DLW was highly correlated (r = 0.93) with EER from the DRI equations.

CONCLUSION

In this population, TEE was higher in women than in men when adjusted for FFM, apparently because of higher physical activity levels in women. There were no significant differences in TEE, FFM, or physical activity levels in women by menopausal status. TEE was inversely associated with age and increased linearly with body mass index. This study corroborates the use of the DRI equations for EER.

Comparative validation of standard, picture-sort and meal-based food-frequency questionnaires adapted for an elderly population of low socio-economic status

OBJECTIVE

To compare the validity of a modified Block food-frequency questionnaire (FFQ), a picture-sort administration of the FFQ (PSFFQ) and a meal pattern-based questionnaire (MPQ) in a multi-ethnic population of low socio-economic status (SES).

DESIGN

Participants completed six 24-hour dietary recalls (24HR) over six months; the FFQ, PSFFQ and MPQ were completed in random order in the subsequent month. Instruments were interviewer-administered. The PSFFQ and MPQ were developed in formative research concerning difficulties for older adults in responding to standard food-frequency instruments.

SETTING

Rural North Carolina, USA. Subjects One hundred and twenty-two African American, Native American and white adults aged > or = 65 years, with approximately one-third in each ethnic group. Inclusion criteria included education < or = 12 years and income < or = 150% of national poverty level or Medicaid recipient.

RESULTS

Comparing median intakes from the average of the 24HR with the three diet assessment instruments, the MPQ tended to overestimate intakes compared with the FFQ and PSFFQ. Correlations among nutrients obtained by the 24HR and the other three instruments were generally statistically significant and positive. Across nutrients, the PSFFQ was most highly correlated with the 24HR for women, while the FFQ was most highly correlated with the 24HR for men.

CONCLUSIONS

Dietary assessments using 24HR and FFQ were similar to results reported elsewhere, although correlations between 24HR and FFQ were somewhat lower. Interviewer-administered dietary assessments should be used with caution to evaluate dietary intake among older adults with low SES. Gender differences and the lower correlations should be investigated more thoroughly to assist in choosing dietary assessment instruments for this population.

Whole-grain intake and carotid artery atherosclerosis in a multiethnic cohort: the Insulin Resistance Atherosclerosis Study

BACKGROUND

Whole-grain intake has been shown to be inversely associated with cardiovascular events, but an association with atherosclerosis is less well established.

OBJECTIVE

We sought to evaluate the association of whole-grain intake with carotid intimal medial thickness (IMT) and IMT progression in a multiethnic cohort.

DESIGN

This study evaluated 1178 participants in the Insulin Resistance Atherosclerosis Study. Baseline whole-grain intake was estimated on the basis of intake of dark breads, cooked cereals, and high-fiber cereals assessed with a validated food-frequency questionnaire. Bilateral carotid IMT was evaluated ultrasonographically, yielding 16 IMT measures at baseline and year 5. Multivariate models evaluated the independent association of whole-grain intake with common carotid artery (CCA) and internal carotid artery (ICA) IMT and IMT progression.

RESULTS

The cohort had a mean (+/-SD) age of 55.2 +/- 8.4 y and was 56% female. The baseline median whole-grain intake was 0.79 servings/d. Whole-grain intake was inversely associated with CCA IMT (beta +/- SE: -0.043 +/- 0.013, P = 0.005) and IMT progression (beta +/- SE: -0.019 +/- 0.011, P = 0.09) in models adjusted for demographics, energy intake, energy expenditure, cardiovascular disease risk factors, and medication use. This association was less significant for ICA IMT (beta +/- SE: -0.049 +/- 0.023, P = 0.05) and not significant for ICA IMT progression (beta +/- SE: -0.013 +/- 0.014, P = 0.35). The relation between whole-grain intake and CCA IMT remained significant after adjustment for mediating pathways (lipids, adiposity, and insulin resistance), nutrient constituents, and a principal components-derived healthy dietary pattern.

CONCLUSIONS

Whole-grain intake is inversely associated with CCA IMT, and this relation is not attributable to individual risk intermediates, single nutrient constituents, or larger dietary patterns.

Nicotine, cotinine, withdrawal, and craving patterns during smoking and nicotine nasal spray use: results from a pilot study with African American men

Nicotine intake via smoking is highly variable. Individualized dosing of nicotine replacement therapy (NRT) may improve product efficacy, but a better understanding of the within-day and within-subject relationships between smoking, NRT use, nicotine and cotinine concentrations in blood, and cravings and withdrawal symptoms is needed to inform dosing algorithms. A pilot study was undertaken to collect data on these relationships and to assess the feasibility of the methods needed for this type of research, including a sophisticated statistical modeling technique (a two-part mixed-effects model with correlated random effects that accounts for clumping at zero). Because nicotine metabolism varies by gender and race, the sample was homogeneous with respect to these characteristics. In a within-subjects study, 27 African American adult male smokers carried a computerized cigarette dispenser for 1 week, capturing the time each cigarette was smoked. Subjects then entered an inpatient setting for 1 day of scheduled smoking (matched to data from the cigarette dispenser to create an ecologically valid schedule) and 4 days of ad libitum nicotine nasal spray use, while tobacco abstinent. Eight times per day, at 2-hour intervals, blood was drawn and ratings of cigarette cravings and withdrawal symptoms were obtained. On average, subjects used less than half of the manufacturer's recommended minimum daily dose of nicotine nasal spray. Large differences in nicotine and cotinine levels were observed between individuals. When predicting nicotine, cotinine, withdrawal, and cravings, we observed significant interactions between route of nicotine intake and a variety of independent variables.

Change in body size and the risk of colorectal adenomas

Adiposity has been recognized as a risk factor for colorectal adenoma, but the influence of weight gain, adipose tissue distribution, and possible differences between ethnic/racial and gender groups remains unanswered. The aim of this prospective study was to examine the association between adiposity and weight change and colorectal adenoma risk. Over approximately 10-year period, anthropometric measures and other risk factors were measured at three time points in the multicenter multiethnic Insulin Resistance Atherosclerosis Study cohort. Colonoscopies were then conducted on 600 cohort participants regardless of symptoms whose mean age at colonoscopy was 64 years. Multivariate logistic regression analyses were used to assess the association between colorectal adenomas and measures of adiposity and weight change over the approximately 10-year period before colonoscopy. Obesity was positively associated with risk of colorectal adenomas at the time of colonoscopy [adjusted odds ratio (OR(adj)), 2.16; 95% confidence interval (95% CI), 1.13-4.14] and was stronger in women (OR(adj), 4.42; 95% CI, 1.53-12.78) than in men (OR(adj), 1.26; 95% CI, 0.52-3.07). The risk of adenomas increased among participants who gained weight compared with those who maintained weight over the approximately 5 years (OR(adj), 2.30; 95% CI, 1.25-4.22) and approximately 10 years (OR(adj), 2.12; 95% CI, 1.25-3.62). These associations were similar for both advanced and nonadvanced adenomas. These results suggest a positive association between obesity, weight gain, and colorectal adenoma risk. Stronger associations were observed when obesity was measured at the time of colonoscopy, suggesting that obesity may be a promoting factor in the growth of colorectal adenomas.

High levels of low energy reporting on 24-hour recalls and three questionnaires in an elderly low-socioeconomic status population

Studies of low energy reporting in the elderly are limited, yet changes in energy balance and the incidence of chronic disease make this a critical time to assess energy intake in this population. The objective of this study was to assess low energy reporting on 24-h recalls (24HR), a FFQ, a picture sort FFQ (PSFFQ), and a meal pattern questionnaire (MPQ), and to relate low energy reporting status to personal characteristics and dietary characteristics, including the Healthy Eating Index. Monthly 24HR were completed over 6 mo, followed by 3 interviewer-administered questionnaires. The Goldberg equation was used to determine reporting status for the dietary assessment methods among older, rural, low socioeconomic status, white, African American, and Native American men and women. The relations of variables of interest to low energy reporting were considered one at a time and in multiple logistic regression models. The percentage of participants classified as accurate reporters varied from 40% (FFQ) to 63% (PSFFQ) among men and 60% (24HR, PSFFQ, MPQ) to 63% (FFQ) among women; high energy reporting was observed on the MPQ. Low energy reporters on the FFQ tended to be men and to be overweight or obese (P < 0.05). Underreporting seemed to be due to omitting foods from major food groups as well as from omitting discretionary energy foods. There was a high degree of low energy reporting in this population, particularly by men, even with six 24HR.

Older adults in the rural South are not meeting healthful eating guidelines

OBJECTIVE

To evaluate diet quality of rural older adults using national dietary guidelines and the Healthy Eating Index (HEI).

DESIGN

Five to six 24-hour recalls were conducted at monthly intervals over a 6-month period, using the Nutrition Coordinating Center food grouping system to calculate intake.

SUBJECTS

Included in this cross-sectional study were 63 females and 59 males aged 65 to 93 years residing in two rural North Carolina counties; one third of each sex group was African American, Native American, or white. Inclusion criteria included age>65 years, education<or=12 years, and low income.

ANALYSES

HEI scores were computed from the average of the recalls, and compared using one-way analysis of variance. Multiple regression modeling was utilized to evaluate effects of demographic and self-reported health variables on HEI score.

RESULTS

Most study participants did not meet minimum Food Guide Pyramid recommended servings of grains, fruits, vegetables, and dairy. They exceeded recommendations for discretionary calorie servings (median=3.3 and 5.3 for females and males, respectively). Using the HEI, 24% had poor diets, 75% needed improvement, and only 1% had good diets. Of the participants with an eighth-grade education or less, men had a mean HEI score 9.6 units lower than women.

CONCLUSION

These rural adults are not meeting recommended nutrition guidelines, and most are consuming diets considered poor or needing improvement. Health care providers should recognize barriers that put these older adults at risk for poor nutrition and should be prepared to initiate referrals to community resources. Nutrition counseling should include strategies to increase whole grain, fruit, vegetable, and reduced-fat dairy consumption with the ultimate goal of improving dietary intake to prevent declines in functional status and independence associated with aging.

Lack of clinical efficacy of rituximab in the treatment of autoimmune neutropenia and pure red cell aplasia: implications for their pathophysiology

We describe 11 patients with severe refractory autoimmune cytopenias treated with the anti-CD20 monoclonal antibody rituximab. Six patients had autoimmune neutropenia (AIN), two had pure red cell aplasia (PRCA), one had AIN and autoimmune haemolytic anaemia, one had AIN and immune thrombocytopaenia purpura (ITP) and one had PRCA and ITP. Rituximab was administered at a dose of 375 mg/m(2) as an intravenous infusion weekly for 4 weeks. Six of eight patients with AIN and all three patients with PRCA did not respond. Two patients died: one with resistant AIN and autoimmune haemolytic anaemia died of pneumocytis pneumonia infection, and one with PRCA and ITP died of an acute exacerbation of bronchiectasis. Rituximab in AIN and PRCA appears to be less effective than Campath-1H when compared to historical data from our group. This supports the hypothesis that T cells may be important in the pathophysiology of AIN and PRCA.

The Food Propensity Questionnaire: Concept, Development, and Validation for Use as a Covariate in a Model to Estimate Usual Food Intake

OBJECTIVE

Twenty-four-hour recalls capture rich information on food consumption, but suffer from inadequately measuring usual intakes of episodically consumed foods. We explore using food frequency questionnaire (FFQ) data as covariates in a statistical model to estimate individual usual intakes of episodically consumed foods and their distributions and describe the development of the Food Propensity Questionnaire, an FFQ introduced in the 2003-2004 National Health and Nutrition Examination Survey.

DESIGN

We analyzed data from 965 adult participants in the Eating at America's Table Study who completed four 24-hour recalls and an FFQ. We assessed whether or not increasing FFQ-reported frequency was associated with both number of 24-hour recall consumption days and amounts reported.

RESULTS

For 52 of 56 food groups (93%), and 218 of 230 individual foods (95%), there were significant monotonically increasing relationships between FFQ frequency and 24-hour recall probability of consumption. For 47 of 56 food groups (84%) and 55 of 230 (24%) individual foods, there were significant positive correlations between FFQ frequencies and consumption-day mean intake.

CONCLUSIONS

We found strong and consistent relationships between reported FFQ frequency of food and food-group consumption and probability of consumption on 24-hour recalls. This supports the premise that frequency data may offer important covariate information in supplementing multiple recalls for estimating usual intake of food groups.

Negative energy balance induced by voluntary wheel running inhibits polyp development in APCMin mice

Treadmill running of approximately 0.9 km/day has had inconsistent effects on spontaneous intestinal polyp development in C57BL/6J-Apc(Min)/J (Min) mice; the amount of energy expenditure and/or a lack of hormonal changes could account for this variability. The purpose of this study was to examine the effects of a negative energy balance induced by voluntary wheel running on polyps, insulin-like growth factor-1 (IGF-1) and corticosterone in Min mice. Seven-week-old male Min mice were randomly assigned to control (CON, n = 23) or wheel running (EX, n = 24) conditions for a 10-week study period. All mice had water and AIN-76A diet ad libitum for the first approximately 3 weeks on study, after which the EX group was pair-fed to the CON group to maintain a negative energy balance due to the exercise. EX mice voluntarily ran 3.8 km/day (2.7-6.0 km/day) (median, interquartile range) and weighed less than CON mice throughout the study. More CON mice died before the end of the study versus EX mice (26 versus 0%, P < 0.01). CON mice had significantly more polyps versus EX mice (21.6 +/- 1.5 versus 16.9 +/- 2.0, P < 0.01; mean +/- SE), and daily running distance in EX was inversely correlated with total polyp number (r = -0.70, P < 0.01). Urinary corticosterone output (P < 0.01) and serum IGF-1 were significantly higher in EX than CON (P < 0.001); however, total polyp number was unrelated to corticosterone (r = 0.05, P = 0.84) and IGF-1 (r = -0.01, P = 0.93). In this study, a negative energy balance produced by wheel running exercise and restricted feeding decreased polyp burden in male Min mice and appeared to have a dose-response effect on polyp number. Although EX affected IGF-1 and corticosterone, neither marker was related to total polyp number.

Demographic, HIV risk behavior, and health status characteristics of "crack" cocaine injectors compared to other injection drug users in three New England cities

OBJECTIVES

To compare demographic, HIV risk behaviors, and health status characteristics of injection drug users (IDUs) who have injected "crack" cocaine with IDUs who have not.

METHODS

Nine hundred and eighty-nine IDUs were recruited in New Haven, CT, Hartford, CT and Springfield, MA from January 2000 to May 2002. Participants were administered a modified version of the National Institute on Drug Abuse Risk Behavior Assessment Questionnaire.

RESULTS

Nine percent (n = 89) of participants reported "ever" injecting crack cocaine and 4.2% (n = 42) reported injecting crack in the past 30 days. Lifetime and current crack injectors did not differ significantly on any demographic characteristics. Lifetime and current crack injectors did not differ on gender, age or marital status from IDUs who have never injected crack. Significant differences were found on race, education, employment and residence, with crack injectors more likely to be white, employed, better educated and living in New Haven than IDUs who have never injected crack. After adjusting for current (past 30 day) speedball and powder cocaine injection, crack injectors reported higher rates of risky drug use behaviors and female crack injectors reported higher rates of risky sexual behaviors. Crack injectors reported higher rates of abscesses, mental illness and Hepatitis C infection, but not Hepatitis B or HIV infection.

CONCLUSIONS

The emergence of crack cocaine injection requires urgent attention, as this new drug use behavior is associated with elevated rates of high risk behaviors.

Consumption of sugar- and fat-modified foods among rural older adults: the Rural Nutrition and Health (RUN) Study

This study examines the levels of and factors associated with consumption of sugar and fat-reduced foods in sample of rural, ethnically diverse older adults. Data were collected from 122 older adults, including demographic and health characteristics and six 24-hour recalls over 16-month period. About one-quarter of sweetened foods were modified, while intake of fat-modified foods ranged from 4.4 to 76.1%. Few differences in intake of modified foods were observed by gender and ethnic groups. Diabetes status was associated with higher use of sugar-modified foods. This study shows high level of acceptance of sugar- and fat-modified foods among rural older adults across variety of demographic and health characteristics.

Psychosocial predictors of energy underreporting in a large doubly labeled water study

BACKGROUND

Underreporting of energy intake is associated with self-reported diet measures and appears to be selective according to personal characteristics. Doubly labeled water is an unbiased reference biomarker for energy intake that may be used to assess underreporting.

OBJECTIVE

Our objective was to determine which factors are associated with underreporting of energy intake on food-frequency questionnaires (FFQs) and 24-h dietary recalls (24HRs).

DESIGN

The study participants were 484 men and women aged 40-69 y who resided in Montgomery County, MD. Using the doubly labeled water method to measure total energy expenditure, we considered numerous psychosocial, lifestyle, and sociodemographic factors in multiple logistic regression models for prediction of the probability of underreporting on the FFQ and 24HR.

RESULTS

In the FFQ models, fear of negative evaluation, weight-loss history, and percentage of energy from fat were the best predictors of underreporting in women (R(2) = 0.09); body mass index, comparison of activity level with that of others of the same sex and age, and eating frequency were the best predictors in men (R(2) = 0.10). In the 24HR models, social desirability, fear of negative evaluation, body mass index, percentage of energy from fat, usual activity, and variability in number of meals per day were the best predictors of underreporting in women (R(2) = 0.22); social desirability, dietary restraint, body mass index, eating frequency, dieting history, and education were the best predictors in men (R(2) = 0.25).

CONCLUSION

Although the final models were significantly related to underreporting on both the FFQ and the 24HR, the amount of variation explained by these models was relatively low, especially for the FFQ.

Smoking status identification: two managed care organizations' experiences with a pilot project to implement identification systems in independent practice associations

OBJECTIVE

To determine whether managed care organizations (MCOs) can effectively promote the sustained use of smoking status identification systems among independent practice associations.

STUDY DESIGN

Quasi-experimental design measuring smoking status documentation before and after an intervention.

METHODS

A chart review of the MCOs' patients at 4 participating primary care clinics determined the baseline for smoking status documentation before intervention. Baseline data were unavailable from a fifth participating clinic. Two quality improvement personnel were sent by the MCOs to help the clinics chose and implement a system for identifying smoking status. All of the clinics chose a sticker system. The change in smoking status documentation was assessed by chart reviews of patients enrolled in the MCOs who were seen during the period between 3 and 16 months after implementation of the system.

RESULTS

Following the intervention, a significant increase in smoking status documentation was noted among participating clinics. The proportion of patients whose smoking status was identified and documented by any method increased from 50% to 87% (P < .01) at the 4 clinics with baseline data. By clinic, the increase varied from 6% to 60%. The sticker system was the method by which most patients' smoking status was documented (77%). There were no controls, so the influence of outside factors, including a regional smoking cessation campaign that coincided with this study, cannot be quantified.

CONCLUSIONS

Managed care organizations may be an effective change agent for implementing the guidelines for tobacco use and dependence treatment.

Analysis of repeated measures data with clumping at zero

Longitudinal or repeated measures data with clumping at zero occur in many applications in biometrics, including health policy research, epidemiology, nutrition, and meteorology. These data exhibit correlation because they are measured on the same subject over time or because subjects may be considered repeated measures within a larger unit such as a family. They present special challenges because of the extreme non-normality of the distributions involved. A model for repeated measures data with clumping at zero, using a mixed-effects mixed-distribution model with correlated random effects, is presented. The model contains components to model the probability of a nonzero value and the mean of nonzero values, allowing for repeated measurements using random effects and allowing for correlation between the two components. Methods for describing the effect of predictor variables on the probability of nonzero values, on the mean of nonzero values, and on the overall mean amount are given. This interpretation also applies to the mixed-distribution model for cross-sectional data. The proposed methods are illustrated with analyses of effects of several covariates on medical expenditures in 1996 for subjects clustered within households using data from the Medical Expenditure Panel Survey.

Platelet pheresis is not a useful adjunct to blood-sparing strategies in cardiac surgery

OBJECTIVE

To examine whether specific platelet pheresis (minimal plasma harvested) would contribute toward reduced blood loss and allogenic blood requirements after cardiac surgery.

DESIGN

A prospective randomized trial.

SETTING

A large cardiothoracic surgical center.

PARTICIPANTS

Consenting patients undergoing routine coronary artery or valve surgery (n = 54).

INTERVENTIONS

Patients in the pheresis group underwent platelet pheresis in the anesthetic preparation room before general anesthesia. Pheresed platelets were stored during cardiopulmonary bypass and were returned to the patients after reversal of heparin with protamine toward the end of surgery. Control patients underwent their operations without this intervention.

MEASUREMENTS AND MAIN RESULTS

Primary endpoints were blood loss and transfusion requirements. There were no differences between the 2 groups (pheresis v control: median loss, 960 mL v 1100 mL, p = 0.15; median blood transfused, 896 mL v 635 mL, p = 0.71). Secondary endpoints included analysis of platelet counts, platelet function, and surface markers. Counts remained the same after retransfusion of platelets up to 2 hours after surgery. Platelet aggregation to ristocetin was well preserved, but adenosine diphosphate caused almost no aggregation of the harvested platelets. Flow cytometry revealed the platelets to have a reduced surface density of the glycoprotein 1b receptor, and 13% of them were irreversibly activated.

CONCLUSION

Platelet pheresis activates a proportion of the harvested platelets and impairs the function of the remainder; this may explain its failure to reduce postoperative blood loss and transfusion requirements.

Predicting survival in idiopathic pulmonary fibrosis: scoring system and survival model

Our purpose was to identify clinical, radiological and physiological (CRP) determinants of survival and to develop a CRP scoring system that predicts survival in newly diagnosed cases of idiopathic pulmonary fibrosis (IPF). The study population consisted of 238 patients with biopsy confirmed usual interstitial pneumonia. For each patient, clinical manifestations, chest radiographs, and pulmonary physiology were prospectively assessed. We used Cox proportional-hazards models to assess the effect of these parameters on survival. The effects of age and smoking were included in the analysis. Survival was related to age, smoking status (longer in current smokers), clubbing, the extent of interstitial opacities and presence of pulmonary hypertension on the chest radiograph, reduced lung volume, and abnormal gas exchange during maximal exercise. A mathematical CRP score for predicting survival was derived from these parameters. We showed that this CRP score correlated with the extent and severity of the important histopathologic features of IPF, i.e., fibrosis, cellularity, the granulation/connective tissue deposition, and the total pathologic derangement. Using these models, clinicians are in a better position to provide prognostic information to patients with IPF and to improve the selection of the most appropriate patients for lung transplantation or other standard or novel therapeutic interventions.

Idiopathic pulmonary fibrosis: relationship between histopathologic features and mortality

It is hypothesized that the extent and severity of fibrosis and cellularity found on lung biopsy determine the prognosis and response to therapy in idiopathic pulmonary fibrosis (IPF). The objective of this study was to determine which histopathologic features predict survival in IPF. We prospectively studied 87 patients with usual interstitial pneumonia (UIP) confirmed by surgical lung biopsy. Four pathologists independently graded the extent and severity of specific histopathologic features. We used Cox proportional-hazards models to assess the effect of histopathologic patterns on patients' survival. The effects of age, sex, and smoking were also included in the analysis. Sixty-three patients died during the 17-yr study period. Survival was longer in subjects with lesser degrees of granulation/connective tissue deposition (fibroblastic foci). The degree of alveolar space cellularity, alveolar wall fibrosis, and cellularity did not affect survival. A history of cigarette smoking, the level of dyspnea, and the degree of lung stiffness at presentation were also shown to be independent factors predicting survival. The extent of fibroblastic foci present on lung biopsy predicts survival in IPF. These findings support the hypothesis that the critical pathway to end-stage fibrosis is not "alveolitis" but rather the ongoing epithelial damage and repair process associated with persistent fibroblastic proliferation. Controlling these processes, rather than stopping inflammation, appears most important in preventing progressive disease and the fatal outcome common in IPF.

The predictability of corneal flap thickness and tissue laser ablation in laser in situ keratomileusis

OBJECTIVE

To evaluate the relationship between predicted flap thickness and actual flap thickness and between predicted tissue ablation and actual tissue ablation.

DESIGN

Prospective, nonrandomized comparative (self-controlled) trial.

PARTICIPANTS

A total of 60 patients (102 eyes) who underwent laser in situ keratomileusis (LASIK).

MAIN OUTCOME MEASURES

Subtraction pachymetry was used to determine actual corneal flap thickness and corneal tissue ablation depth. Other measurements included flap diameter and keratometry readings.

RESULTS

Actual flap thickness was significantly different (P < 0.0001) from predicted flap thickness. Fifteen eyes had a predicted flap thickness of 160 micrometer and a mean actual flap of 105 micrometer (standard deviation [SD], +/-24. 3 micrometer range, 48-141 micrometer). Sixty-four had a predicted flap of 180 micrometer with an actual flap mean of 125 micrometer (SD, +/-18.5 micrometer range, 82-155 micrometer). Seventeen eyes had a predicted flap of 200 micrometer, with an actual flap mean of 144 micrometer (SD, +/-19.3 micrometer range, 108-187 micrometer). In addition, we found that significantly more tissue (P < 0.0001) was ablated than predicted. Linear regression of the observed ablation on predicted ablation yielded the following relationship: actual ablation = 14.5 + 1.5 (predicted ablation). Neither flap diameter nor flap thickness were found to increase with respect to steeper corneal curvatures.

CONCLUSIONS

Actual corneal flap thickness was consistently less than predicted regardless of the depth plate used; actual tissue ablation was consistently greater than predicted tissue ablation for the laser used in this study.

Effect of hyperinsulinemia on amino acid utilization in the ovine fetus

We studied the effect of an acute 4-h period of hyperinsulinemia (H) on net utilization rates (AAUR(net)) of 21 amino acids (AA) in 17 studies performed in 13 late-gestation fetal sheep by use of a novel fetal hyperinsulinemic-euglycemic-euaminoacidemic clamp. During H [84 +/- 12 (SE) microU/ml H, 15 +/- 2 microU/ml control (C), P < 0. 00001], euglycemia was maintained by glucose clamp (19 +/- 0.05 micromol/ml H, 1.19 +/- 0.04 micromol/ml C), and euaminoacidemia (mean 4.1 +/- 3.3% increase for all amino acid concentrations [AA], nonsignificantly different from zero) was maintained with a mixed amino acid solution adjusted to keep lysine concentration constant and other [AA] near C values. H produced a 63.7% increase in AAUR(net) (3.29 +/- 0.66 micromol. min(-1). kg(-1) H, 2.01 +/- 0.55 micromol. min(-1). kg(-1) C, P < 0.001), accounting for a 60.1% increase in fetal nitrogen uptake rate (2,064 +/- 108 mg. day(-1). kg(-1) H, 1,289 +/- 73 mg. day(-1). kg(-1) C, P < 0.001). Mean AA clearance rate (AAUR(net)/[AA]) increased by 64.5 +/- 18.9% (P < 0. 001). Thus acute physiological H increases net amino acid and nitrogen utilization rates in the ovine fetus independent of plasma glucose and [AA].

N-RAS gene mutation in patients with aplastic anemia and aplastic anemia/ paroxysmal nocturnal hemoglobinuria during evolution to clonal disease

Long-term survivors of aplastic anemia (AA) have a high incidence of clonal disorders, in particular paroxysmal nocturnal hemoglobinuria (PNH), myelodysplastic syndromes (MDS), and acute nonlymphocytic leukemia. To investigate the potential involvement of N-RAS gene mutations in the predisposition to leukemic evolution, a subset of patients at potentially increased risk for clonal disease was selected based on evidence of existing clonal evolution. Nine patients showed a monoclonal pattern of X-chromosome inactivation, 18 demonstrated a PNH clone, and in 3 MDS developed during the course of this study. No mutations were detected during the aplastic phase of disease; 2 of 3 patients with MDS after AA also showed no mutations. However, in 1 patient in whom the disease transformed from AA/PNH to MDS, a mutation of GGT --> GAT at N-RAS codon 13 became detectable, whereas the PNH mutation disappeared. The authors conclude that N-RAS mutations are not an early event preceding transformation of AA or AA/PNH to leukemia. In a subset of patients, RAS mutations may occur at the time of evolution to MDS, but preexisting RAS mutations do not explain the propensity of AA to leukemogenesis. Although PNH is also associated with leukemia, this may arise in the non-PNH cells, indicating that PIG-A gene mutation is not per se oncogenic. (Blood. 2000;95:646-650)