Rethinking fundamental assumptions: SUPPORT's implications for future reform. Study to Understand Prognoses and Preferences and Risks of Treatment

BACKGROUND

The intervention in SUPPORT, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments, was ineffective in changing communication, decision-making, and treatment patterns despite evidence that counseling and information were delivered as planned. The previous paper in this volume shows that modest alterations in the intervention design probably did not explain the lack of substantial effects.

OBJECTIVE

To explore the possibility that improved individual, patient-level decision-making is not the most effective strategy for improving end-of-life care and that improving routine practices may be more effective.

DESIGN

This paper reflects our efforts to synthesize findings from SUPPORT and other sources in order to explore our conceptual models, their consistency with the data, and their leverage for change.

RESULTS

Many of the assumptions underlying the model of improved decision-making are problematic. Furthermore, the results of SUPPORT suggest that implementing an effective intervention based on a normative model of shared decision-making can be quite difficult. Practice patterns and social expectations may be strong influences in shaping patients' courses of care. Innovations in system function, such as quality improvement or changing the financing incentives, may offer more powerful avenues for reform.

CONCLUSIONS

SUPPORT's intervention may have failed to have an impact because strong psychological and social forces underlie present practices. System-level innovation and quality improvement in routine care may offer more powerful opportunities for improvement.

Facial Expressions of Emotion: Are Angry Faces Detected More Efficiently?

The rapid detection of facial expressions of anger or threat has obvious adaptive value. In this study, we examined the efficiency of facial processing by means of a visual search task. Participants searched displays of schematic faces and were required to determine whether the faces displayed were all the same or whether one was different. Four main results were found: (1) When displays contained the same faces, people were slower in detecting the absence of a discrepant face when the faces displayed angry (or sad/angry) rather than happy expressions. (2) When displays contained a discrepant face people were faster in detecting this when the discrepant face displayed an angry rather than a happy expression. (3) Neither of these patterns for same and different displays was apparent when face displays were inverted, or when just the mouth was presented in isolation. (4) The search slopes for angry targets were significantly lower than for happy targets. These results suggest that detection of angry facial expressions is fast and efficient, although does not "pop-out" in the traditional sense.

Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart, or liver disease. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

CONTEXT

Many individuals involved with care of the dying advocate expanding access to hospice care for persons with advanced lung, heart, or liver disease. However, to be eligible, these patients generally must have a prognosis for survival of less than 6 months.

OBJECTIVE

To test the ability of currently available criteria to identify a population with a survival prognosis of 6 months or less among seriously ill hospitalized patients with 1 of 3 commonly fatal chronic diseases.

DESIGN

Validation study using data from the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) phase 1 (June 1989-June 1991) and phase 2 (January 1992-January 1994), with a 6-month follow-up.

SETTING AND PATIENTS

Consecutive sample of 2607 seriously ill patients from 5 US medical centers who were hospitalized with chronic obstructive pulmonary disease, congestive heart failure, or end-stage liver disease, and who survived to hospital discharge.

MAIN OUTCOME MEASURES

Descriptive and operating characteristics of 5 general and 2 disease-specific clinical criteria for identifying patients with a survival prognosis of 6 months or less, and 3 sets of combination criteria (broad, intermediate, and narrow inclusion) aimed at providing low, medium, and high thresholds for hospice eligibility based on National Hospice Organization guidelines.

RESULTS

Seventy-five percent of the sample survived more than 6 months after hospital discharge; 44% expressed a preference for palliative care. Broad inclusion criteria identified 923 patients eligible for hospice care, of whom 70% survived longer than 6 months. Intermediate inclusion criteria identified 300 patients, of whom 65% survived longer than 6 months. Narrow inclusion criteria identified 19 patients, of whom 53% survived longer than 6 months. Sensitivities and specificities of the combination criteria were 41.7% and 66.7% (broad inclusion), 16.2% and 90.1 % (intermediate inclusion), and 1.4% and 99.5% (narrow inclusion), respectively.

CONCLUSIONS

These data indicate that for seriously ill hospitalized patients with advanced chronic obstructive pulmonary disease, congestive heart failure, or end-stage liver disease, recommended clinical prediction criteria are not effective in identifying a population with a survival prognosis of 6 months or less.

Parasite density and malaria morbidity in the Pakistani Punjab

The relationship between quantitative Plasmodiumfalciparum or P. vivax parasitemia and clinical illness has not been defined in Pakistan or in other areas where malaria transmission is not highly endemic. Standardized questionnaires were given to and physical examinations and parasitologic tests were performed in 8,941 subjects seen in outpatient clinics in 4 villages for 13 consecutive months in the Punjab region of Pakistan. The results, based on multivariable analysis, showed that a clinical diagnosis of malaria, a history of fever, rigors, headache, myalgia, elevated temperature, and a palpable spleen among children were all strongly associated with the presence and density of P. falciparum or P. vivax malaria in a monotonic dose-response fashion. The malaria attributable fraction of a clinical diagnosis of malaria, and the same symptoms and signs also increased with increasing P. falciparum and, to a lesser extent, P. vivax, parasitemia. Unlike in sub-Saharan Africa, clinical illness due to malaria often occurs in the Punjab among adolescents and adults and in patients with parasite densities less than 1,000/microl. Clinical guidelines based upon parasitemia and symptomatology must be adjusted according to the intensity of transmission and be specific for each geographic area.

Incorporating palliative care into critical care education: principles, challenges, and opportunities

OBJECTIVE

To identify the goals and methods for medical education about end-of-life care in the intensive care unit (ICU).

DATA SOURCES AND STUDY SELECTION

A status report on palliative care, a summary report of recent research on palliative care education, articles in the medical literature on end-of-life care and critical care, and expert opinion were considered.

DATA EXTRACTION

A working group, including specialists in critical care, palliative care, medical ethics, consumer advocacy, and communications, was convened at the "Medical Education for Care Near the End of Life National Consensus Conference." A modified nominal group process was used to develop a consensus.

DATA SYNTHESIS

In the ICU, life and death decisions are often made in a crisis mode or in the face of uncertainty, and may necessitate the withholding and withdrawal of life-supporting technologies. Because critical illness often diminishes the capacity of patients to make decisions, clinicians must often make decisions in conjunction with surrogates, rather than with patients. Discontinuity of care can threaten trusting relationships, and cultural diversity can have a particularly powerful impact on choices for care. In the face of these realities, it is possible and appropriate to give compassionate palliative care to dying patients and their families in the ICU.

CONCLUSIONS

Teaching care of the dying in the ICU should emphasize the following: a) the goals of care should guide the use of technology; b) understanding of prognostication and treatment withholding and withdrawal is essential; c) effective communication and trusting relationships are crucial to good care; d) cultural differences should be acknowledged and respected; and e) the delivery of excellent palliative care is appropriate and necessary when patients die in the ICU.

Quantitative RT-PCR to evaluate in vivo expression of multiple transgenes using a common intron

An assay measuring RNA expression levels of a gene-encoded therapeutic must distinguish between endogenous mRNA and mRNA transcribed from the transgene. Specificity for the delivered transgene is especially critical when the treatment involves genes that are expressed in the target tissue. To facilitate uniform detection of transgene RNA without interference from endogenous mRNA, we have engineered expression vectors that include a 5' untranslated region (5' UTR) containing a synthetic intron (PGL3). The synthetic intron splice junction was the target sequence for a quantitative reverse transcription (RT)-PCR assay utilizing Taq-Man technology. In this study, we demonstrate that a quantitative RT-PCR assay designed to recognize an engineered intron splice site in the 5'UTR of expression constructs effectively measures the expression level of in vivo-delivered gene therapeutics.

SDQR migrations in Caenorhabditis elegans are controlled by multiple guidance cues and changing responses to netrin UNC-6

The netrin guidance cue, UNC-6, and the netrin receptors, UNC-5 and UNC-40, guide SDQR cell and axon migrations in C. elegans. In wild-type larvae, SDQR migrations are away from ventral UNC-6-expressing cells, suggesting that UNC-6 repels SDQR. In unc-6 null larvae, SDQR migrations are towards the ventral midline, indicating a response to other guidance cues that directs the migrations ventrally. Although ectopic UNC-6 expression dorsal to the SDQR cell body would be predicted to cause ventral SDQR migrations in unc-6 null larvae, in fact, more migrations are directed dorsally, suggesting that SDQR is not always repelled from the dorsal source of UNC-6. UNC-5 is required for dorsal SDQR migrations, but not for the ventral migrations in unc-6 null larvae. UNC-40 appears to moderate both the response to UNC-6 and to the other cues. Our results show that SDQR responds to multiple guidance cues and they suggest that, besides UNC-6, other factors influence whether an UNC-6 responsive cell migrates toward or away from an UNC-6 source in vivo. We propose that multiple signals elicited by the guidance cues are integrated and interpreted by SDQR and that the response to UNC-6 can change depending on the combination of cues encountered during migration. These responses determine the final dorsoventral position of the SDQR cell and axon.

Lipid mediated gene delivery in the adult rat brain: quantitative analysis of expression

Gene transfer into the adult brain is potentially an attractive alternative to commonly employed transgenic approaches. DNA-lipid complexes have been used to obtain brain gene transfer, but data are sparse to indicate to what extent this results in significant expression of functional protein. Here, an expression construct encoding the functional reporter, chloramphenicol-acetyl-transferase (CAT), was complexed to a novel biodegradable lipid, and delivered into the rat brain. CAT-activity was assayed in tissue extracts to allow a precise quantitation of functional enzyme protein. Following bilateral intraventricular (i.c.v.) injection, robust enzyme activity was found in all brain regions studied, peaking at 4 weeks. Other routes of administration, e.g. intra-parenchymal injection or chronic infusion of complexes, resulted in marginal or no activity. Presence of CAT mRNA and plasmid DNA in tissue extracts was confirmed at 4 weeks post i.c.v. administration. In agreement with previous studies, labelled lipid-DNA complexes were mainly found in the ventricular ependyma. Present data support the feasibility of lipid mediated brain gene transfer, and outline some of its anatomical and temporal limitations.

On the status of implicit memory bias in anxiety

The present study evaluated the status of mood congruent memory bias in implicit memory tasks for threat related information. A literature review complemented by three experiments on high and low trait anxiety participants found no implicit memory bias for threat-related information in anxious individuals on either word fragment completion or tachistoscopic word identification tasks. The theoretical implications of these results are discussed.

In vivo studies of gene expression via transient transgenesis using lipid-DNA delivery

As the sequencing of the human genome proceeds, the need for a new screen for in vivo function is becoming apparent. Many investigators are turning to various transgenic models as a means of studying function. However, these approaches are very time consuming, with a transgene-expressing mouse model often taking months to establish. We have developed an efficient system for delivering genes in vivo, which allows the gene product to be studied as early as 24 h after introduction into the mouse model. The delivery system employs a novel cationic lipid, 1-[2-(9-(Z)-octadecenoyloxy)ethyl]-2-(8-(Z)-heptadecenyl)-3- (hydroxyethyl)imidazolinium chloride (DOTIM), and a neutral lipid, cholesterol, complexed with an expression vector containing the reporter gene chloramphenicol acetyl transferase (CAT). After a single intravenous injection of these complexes, several tissues were seen to express the transgene. High, persistent expression in the vascular endothelial cells in the mouse lung was obtained. Delivery of DNA in vivo has been evaluated by quantitative polymerase chain reaction and protein expression by CAT activity assays. In vivo studies showed reproducible expression in more than 500 mice injected via the tail vein. An early peak of expression was followed by lower, but sustained, expression for > 50 days. Transgene expression of CAT could also be identified by immunohistochemistry staining in mouse lung and appeared to be located within the capillaries. The pattern of in vivo expression could be modulated and targeted to specific organs by altering the lipid-DNA formulation. New expression vectors with altered introns and polyadenylation sites further improved expression. The expression reported here may be sufficient in magnitude, duration, and flexibility to be an attractive alternative, in some cases, to establishing transgenic animals by stable gene transfer.

Role of netrin UNC-6 in patterning the longitudinal nerves of Caenorhabditis elegans

The nervous system of Caenorhabditis elegans comprises circumferential and longitudinal axon tracts. Netrin UNC-6 is required for the guidance of circumferential axon migrations and is expressed by ventral neuroglia and neurons in temporally and spatially regulated patterns. Migrating axons mediate the UNC-6 signal through the UNC-5 and UNC-40 receptors. It is thought that UNC-6 is secreted and becomes associated with basement membranes and cell surfaces to form gradients that direct circumferentially migrating axons toward or away from the ventral UNC-6 sources. Little is known about the effects of UNC-6 on longitudinally migrating axons. In unc-6, unc-5, and unc-40 null mutants, some longitudinal nerves are dorsally or ventrally misdirected. Furthermore, the organization of axons are disrupted within nerves. We show that cells ectopically expressing UNC-6 can redirect the migrations of some neighboring longitudinal axons, suggesting that the gradients postulated to direct circumferential migration also help specify the dorsoventral positions of these longitudinal nerves. We also manipulated the temporal and spatial expression pattern of UNC-6 by two different means. First, we removed the PVT midline neuron which expresses UNC-6 for a short time during axon outgrowths. Second, we expressed UNC-6 uniformly in the nervous system throughout development. The results suggest that changing UNC-6 expression patterns modify the distribution of the cue by providing new localized sources. This new guidance information is critical for organizing the axons of longitudinal nerves.

Who is fighting for the right to die? Older women's participation in the Hemlock Society

Who is fighting for the right to die? Past literature has been mixed as to the membership of this social movement. In the current study, 6,398 Hemlock Society members were surveyed in an effort to answer questions concerning who is participating in the right to die movement, whether these participants are rapidly approaching their own death or reacting to the death of a loved one, and whether the movement is invigorated by singular activists. The findings indicate that older, white, wealthy, highly educated, economically and politically active women are in the forefront of the right to die movement. These women report currently being mentally and physically healthy, yet already having taken the steps that will allow them to have an element of control over their death. Finally, right to die support seems to be part of a larger collective network concerning health care and political policy issues.

Perceptual grouping and visual selective attention

The present study demonstrates that incongruent distractor letters at a constant distance from a target letter produce more response competition and negative priming when they share a target's color than when they have a different color. Moreover, perceptual grouping by means of color, attenuated the effects of spatial proximity. For example, when all items were presented in the same color, near distractors produced more response competition and negative priming than far distractors (Experiment 3A). However, when near distractors were presented in a different color and far distractors were presented in the same color as the target, the response competition x distractor proximity interaction was eliminated and the proximity x negative priming interaction was reversed (Experiment 3B). A final experiment demonstrated that distractors appearing on the same object as a selected target produced comparable amounts of response competition and negative priming whether they were near or far from the target. This suggests that the inhibitory mechanisms of visual attention can be directed to perceptual groups/objects in the environment and not only to unsegmented regions of visual space.

Efficient in vivo delivery of DNA to pulmonary cells using the novel lipid EDMPC

We compared the efficacy of gene transfer in vitro and in vivo using various formulations of DNA-lipid complexes based on the novel cationic lipid EDMPC (1,2-dimyristoylsn-glycero-3-ethylphosphocholine, chloride salt). In vitro studies analyzed delivery of marker genes to four established cell lines, including two of pulmonary origin. The in vivo analysis used intralobar delivery of marker genes and CFTR to mice and rats. We observed a lack of positive correlation between those DNA-EDMPC formulations that delivered DNA most efficiently in vitro and those that worked best in vivo. Intralobar DNA delivery to rodents mediated by EDMPC was efficient. The high level of gene delivery by DNA-EDMPC formulations demonstrates that efficient lipid-mediated gene transfer to the lung is possible.

Characterization, expression and envelope association of a Chlamydia trachomatis 28 kDa protein

Genital serovariants of Chlamydia trachomatis establish infection by attachment, entry and multiplication within human endometrial epithelial cells. In previous studies, a chlamydial recombinant Escherichia coli was identified which exhibited a specific adherent phenotype to endometrial epithelial cells closely resembling that observed for a genital strain of C. trachomatis. One of the plasmid-encoded products expressed by the recombinant is a 28 kDa protein. In this study, localization of the 28 kDa protein in isolated outer membranes of recombinant E. coli and in chlamydial outer membrane complexes lends support for a potential role for this protein in the attachment process. Surprisingly, nucleic acid sequence analysis reveals that the 28 kDa protein shares a modest degree of homology with a member of the E. coli heat shock protein family.

Medical ethics education: past, present, and future

This paper examines undergraduate medical ethics education in the United States during its 25-year history. Included is a brief description of early efforts in medical ethics education and a discussion of the traditional model of ethics teaching, which emphasizes the knowledge and cognitive skills necessary for ethical decision making. The authors also discuss alternatives to the traditional model that focus more directly on students' personal values, attitudes, and behavior. Current areas of consensus in the field are then explored. Finally, the authors identify three incipient trends in medical ethics education--toward increased emphasis on everyday ethics, student ethics, and macroethics. Throughout the paper, examples of specific courses and curricula are used to illustrate the modes and trends described.

Pre-cuing target location reduces interference but not negative priming from visual distractors

Research on visual selective attention has shown that processing of distractors can produce (1) interference with response to a concurrent target, and (2) negative priming of response to a subsequent target. These results support late-selection accounts of attention. However, recent findings demonstrate that when conditions are optimal for attentional focusing, the interference effects are almost entirely eliminated. This result has been interpreted as supporting early-selection accounts. The present study investigates the impact of focusing attention on negative priming in addition to interference effects. In a letter-identification task, reliable interference and negative priming effects were observed from distractors. However, when the location of the target in the prime display was pre-cued, interference effects were significantly reduced, but negative priming effects did not decrease. This pattern of results provides further evidence that the absence of interference is insufficient to determine whether distractors have been semantically processed (Driver & Tipper, 1989).