Using Forensic Toxicology to Enhance Medicolegal Death Investigations

ABSTRACT

The Milwaukee County Medical Examiner's Office performed an evidence-based review of natural deaths certified without autopsy or toxicology testing. Three hundred fifteen such cases from 2020 and 2021 were selected. This study reviewed the deaths to determine if the cause was drug-related instead due to natural disease.Blood samples were screened by liquid chromatography-quadrupole mass spectrometry with time-of-flight detector. The analytes detected were evaluated for contribution to the cause resulting in a change in manner from natural to accident or suicide. Confirmatory analysis was performed where appropriate, and results were reported to the forensic pathologist for evaluation. Where appropriate, the death certificate was amended.As a result of the screening and confirmatory work, 18 cases were identified where significant drugs were detected, and thus the cause and manner of death were amended. One case was amended from natural to suicide after a conversation with the family about the toxicology findings. The remaining cases were amended to a manner of accident. The scope of drugs responsible for the deaths included prescription and illicit.

Examining the Examiners: How Medical Death Investigators Describe Suicidal, Homicidal, and Accidental Death

This study describes differences in medicolegal death investigators' written descriptions for people who died by homicide, suicide, or accident. We evaluated 17 years of death descriptions from a midsized metropolitan midwestern county in the United States to assess how death investigators psychologically respond to different manners of death (N = 10,408 cases). Automated text analyses suggest investigators describe accidental deaths with more immediacy relative to homicides, while they also described suicidal deaths in less emotional terms than homicides as well. These data suggest medicolegal death investigators have different psychological reactions to circumstances and manners of death as indicated by their professional writing. Future research may surface context-specific psychological reactions to vicarious trauma that could inform the design or personalization of workplace-coping interventions.

Opioid Deaths in Milwaukee County, Wisconsin 2013-2017: The Primacy of Heroin and Fentanyl

Heroin and fentanyl are the overwhelming and increasing cause of opioid deaths in Milwaukee County, Wisconsin. We reviewed all drug and opioid deaths from 2013 to 2017 to delineate the specific opioid drugs involved and changes in their incidence. From 2013 to 2017, 980 deaths were due to opioids, rising from 184 in 2013 to 337 in 2017. In 2017, opioid deaths exceeded combined non-natural deaths from homicide and suicide. Illicit heroin and fentanyl/analogs caused 84% of opioid deaths and 80% of drug deaths, with no increase in deaths due to oral prescription drugs such as oxycodone and hydrocodone. Any approach to decreasing this dramatic increase in opioid deaths should first focus on interdicting the supply and cheap availability of these illicit opioids. Fentanyl and its analogs represent the most deadly opioids and the greatest threat to human life in our population.

A phase I multi-institutional study of systemic sorafenib in conjunction with regional melphalan for in-transit melanoma of the extremity

BACKGROUND

Isolated limb infusion with melphalan (ILI-M) corrected for ideal body weight (IBW) is a well-tolerated treatment for patients with in-transit extremity melanoma with an approximate 29 % complete response (CR) rate. Sorafenib, a multi-kinase inhibitor, has been shown to augment tumor response to chemotherapy in preclinical studies.

METHODS

A multi-institutional, dose-escalation, phase I study was performed to evaluate the safety and antitumor activity of sorafenib in combination with ILI-M. Patients with AJCC stage IIIB/IIIC/IV melanoma were treated with sorafenib starting at 400 mg daily for 7 days before and 7 days after ILI-M corrected for IBW. Toxicity, drug pharmacokinetics, and tumor protein expression changes were measured and correlated with clinical response at 3 months.

RESULTS

A total of 20 patients were enrolled at two institutions. The maximum tolerated dose (MTD) of sorafenib in combination with ILI-M was 400 mg. Four dose-limiting toxicities occurred, including soft tissue ulcerations and compartment syndrome. There were three CRs (15 %) and four partial responses (20 %). Of patients with the Braf mutation, 83 % (n = 6) progressed compared with only 33 % without (n = 12). Short-term sorafenib treatment did alter protein expression as measured with reverse phase protein array (RPPA) analysis, but did not inhibit protein expression in the MAP kinase pathway. Sorafenib did not alter melphalan pharmacokinetics.

CONCLUSION

This trial defined the MTD of systemically administered sorafenib in combination with ILI-M. Although some responses were seen, the addition of sorafenib to ILI-M did not appear to augment the effects of melphalan but did increase regional toxicity.

A phase II study to optimize dasatinib dosing in metastatic breast cancer patients using real-time pharmacodynamic tissue and urinary biomarkers

Abstract #3123

Background: In order to optimize drug efficacy and patient selection for targeted agents such as dasatinib, a tyrosine kinase inhibitor, there is a need for adaptive trial methodologies and validated marker endpoints. Predictive and pharmacodynamic (PD) biomarkers of dasatinib activity will be crucial for individualized drug dosing and enrichment of patient populations treated with the drug. Multiple potential predictive and PD markers exist for dasatinib including active/total Src, active/total EphA2, and downstream targets of Src such as focal adhesion kinase (FAK) and paxillin (pax). Given Src's role in bone modeling, markers of bone resorption may also serve as important biomarkers. We designed a phase II trial in metastatic breast cancer (MBC) wherein real-time assessment of these potential biomarkers is used to optimize the dose and anti-tumor effects of dasatinib.
 Material and methods: Key eligibility includes patient with MBC, ECOG 0-1, unlimited prior therapies, and biopsiable tumor. Patients with bone-only MBC were excluded due to tissue quality required for PD analysis. Metastatic biopsies at baseline and week 4 of dasatinib therapy were analyzed using quantitative immunohistochemistry (IHC) (measured in optical densitometry (OD) units) for the following markers: phospho-Src (p-Src), phospho-FAK (p-FAK) and phospho-pax (p-pax). For patients who tolerated the starting dose of dasatinib (50 mg bid), and displayed suboptimal Src inhibition (<80% inhibition of phosphorylation of either biomarker), dasatinib dosing was escalated at week 4 to 70 mg bid. Urinary N-telopeptide (NTX), a marker of bone resorption, was measured monthly.
 Results: Since 12/2007, 12 patients have enrolled and 8 have evaluable, paired metastatic biopsies. Of the other 4 patients, 2 withdrew due to toxicity, 1 voluntarily withdrew, and 1 patient has not yet reached week 4. There has been one case of dyspnea related to possible drug toxicity. Other grade 3/4 toxicities are as follows: anorexia (3), pleural effusion (1), DVT (1). All eligible patients underwent dasatinib dose escalation at week 4 based on their individual tumor biomarker results. All tumors displayed some level of Src inhibition but none of the tumors reached the pre-defined "optimal" level of Src inhibition at week 4; the median changes in tissue biomarker levels are as follows: p-FAK -20%, p-pax -13%, p-Src -9%, and urinary NTX level -11%.
 Conclusions: Our initial analysis of sequential tumor biopsies collected in a phase II trial of single-agent dasatinib in MBC illustrates that real-time biomarkers will both optimize the dosing of targeted agents and define potential on- and off-target drug effects. Accrual is ongoing and updated results of all biomarker endpoints as well as efficacy and toxicity data will be presented.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3123.

Impact of therapy With chlorambucil, fludarabine, or fludarabine plus chlorambucil on infections in patients with chronic lymphocytic leukemia: Intergroup Study Cancer and Leukemia Group B 9011

PURPOSE

We sought to determine whether therapy with single-agent fludarabine compared with chlorambucil alone or the combination of both agents had an impact on the incidence and spectrum of infections among a series of previously untreated patients with B-cell chronic lymphocytic leukemia (CLL).

PATIENTS AND METHODS

Five hundred fifty-four previously untreated CLL patients with intermediate/high-risk Rai-stage disease were enrolled onto an intergroup protocol. Patients were randomized to therapy with chlorambucil, fludarabine, or fludarabine plus chlorambucil. Data pertaining to infection were available on 518 patients. Differences in infections among treatment arms were tested with the Kruskal-Wallis, Wilcoxon, and chi(2) tests.

RESULTS

A total of 1,107 infections (241 major infections) occurred in 518 patients over the infection follow-up period (interval from study entry until either reinstitution of initial therapy, therapy with a second agent, or death). Patients treated with fludarabine plus chlorambucil had more infections than those receiving either single agent (P <.0001). Comparing the two single-agent arms, there were more infections on the fludarabine arm (P =.055) per month of follow-up. Fludarabine therapy was associated with more major infections and more herpesvirus infections compared with chlorambucil (P =.008 and P =.004, respectively). Rai stage and best response to therapy were not associated with infection. A low serum immunoglobulin G was associated with number of infections (P =.02). Age was associated with incidence of major infection in the combination arm (P =.004).

CONCLUSION

Combination therapy with fludarabine plus chlorambucil resulted in significantly more infections than treatment with either single agent. Patients receiving single-agent fludarabine had more major infections and herpesvirus infections compared with chlorambucil-treated patients.

Use and cost of outpatient visits of AD patients: CERAD XXII

OBJECTIVE

To determine the probability, frequency, and cost of outpatient visits of patients with AD in the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) as a function of stage of dementia and institutional status.

METHODS

Clinical information on 388 patients with AD enrolled in CERAD who had no serious comorbidities at baseline and for whom the stage of disease and institutional status were known, were linked to Health Care Financing Administration Physician/Supplier and Outpatient Standard Analytic (institutional outpatient) files for 1991 through 1995. None was registered in a health maintenance organization. Repeated measures regression models were used to examine the relationship of stage of disease to probability, frequency, and cost of outpatient visits for institutionalized and noninstitutionalized patients, with demographic characteristics and calendar time controlled.

RESULTS

The annual proportion of patients with AD and a Medicare-reimbursed outpatient visit ranged from 81% to 95% and was not related to stage of dementia or institutional status. Among those with at least one outpatient visit, however, those living at home had fewer visits than did those in institutions, but their number of visits increased as dementia worsened. Those in institutions had a larger number of outpatient visits, but these did not vary significantly by stage of dementia. Neither location of residence nor stage affected the cost of outpatient visits.

CONCLUSION

Among those with an outpatient visit, the frequency of visits and their relationship to stage of disease depends on institutional status.

Changes in weight, body composition, and factors influencing energy balance among premenopausal breast cancer patients receiving adjuvant chemotherapy

PURPOSE

Weight gain is a common problem among breast cancer patients who receive adjuvant chemotherapy (CT). We undertook a study to determine the causes of this energy imbalance.

PATIENTS AND METHODS

Factors related to energy balance were assessed at baseline (within 3 weeks of diagnosis) and throughout 1 year postdiagnosis among 53 premenopausal women with operable breast carcinoma. Thirty-six patients received CT and 17 received only localized treatment (LT). Measures included body composition (dual energy x-ray absorptiometry), resting energy expenditure (REE; indirect calorimetry), dietary intake (2-day dietary recalls and food frequency questionnaires) and physical activity (physical activity records).

RESULTS

Mean weight gain in the LT patients was 1.0 kg versus 2.1 kg in the CT group (P =.02). No significant differences between groups in trend over time were observed for REE and energy intake; however, a significant difference was noted for physical activity (P =.01). Several differences between groups in 1-year change scores were detected. The mean change (+/- SE) in LT versus CT groups and P values for uncontrolled/controlled (age, race, radiation therapy, baseline body mass index, and end point under consideration) analysis are as follows: percentage of body fat (-0.1 +/- 0.4 v +2.2 +/- 0.6%; P =.001/0.04); fat mass (+0.1 +/- 0.3 v +2.3 +/- 0.7 kg; P =.002/0.04); lean body mass (+0.8 +/- 0.2 v -0.4 +/- 0.3 kg; P =.02/0.30); and leg lean mass (+0.5 +/- 0.1 v -0.2 +/- 0.1 kg; P =.01/0.11).

CONCLUSION

These data do not support overeating as a cause of weight gain among breast cancer patients who receive CT. The data suggest, however, that CT-induced weight gain is distinctive and indicative of sarcopenic obesity (weight gain in the presence of lean tissue loss or absence of lean tissue gain). The development of sarcopenic obesity with evidence of reduced physical activity supports the need for interventions focused on exercise, especially resistance training in the lower body, to prevent weight gain.

Personality factors differentially predict exercise behavior in men and women

Personality assessed with the Minnesota Multiphasic Personality Inventory (MMPI) in college was used to predict exercise behavior measured at midlife in 3,630 men and 796 women enrolled in the University of North Carolina Alumni Heart Study. Logistic regression models were fitted for each of the MMPI clinical scales to test the predictive effect of personality, gender, and their interaction on adult exercise behavior. Lower depression, social introversion, and psychopathic deviance scores were associated with increased probability of exercising in midlife for both men and women. Furthermore, better psychological health (indexed by lower hypochondriases and psychasthenia) in college was generally predictive of increased exercise for men, whereas higher scores on these same factors predicted midlife exercise for women. There were two other patterns of gender interactions: (a) for men, lower scores on hysteria and schizophrenia scales were associated with increased probability of exercising at midlife, whereas these factors were unrelated to exercise for women and (b) for women, lower ego strength and higher college scores on paranoia and mania were associated with exercise behavior at midlife. These data suggest that early adulthood personality predictors of exercise behavior at midlife are both gender-neutral and gender-specific; that is, where no gender differences exist, healthier personality traits predict exercise at midlife, and when gender differences do occur, healthier college patterns of personality predict exercise behavior for men and sedentary behavior for women.

Detecting treatment-by-centre interaction in multi-centre clinical trials

This paper considers several permutation tests for treatment-by-centre interaction in multi-centre clinical trials in which the endpoint is survival time subject to censoring. Some of the tests are based on existing tests and some are new. To evaluate and compare the tests with respect to power under different conditions, we generated survival times and censoring times through simulation. We used special methodology to handle the unusual problems that arise in power simulations when the tests under study are permutation tests. Different conditions yielded different interaction tests as the best performers. Although one test gave comparatively good power under almost all conditions, some of the other tests also appear to be useful. For the sample sizes and configurations in the simulations, power is generally low; thus it may not be possible to detect interaction reliably when it exists, a finding in agreement with the known low power for interaction tests in general.

Use and cost of hospitalization of patients with AD by stage and living arrangement: CERAD XXI

OBJECTIVE

To determine the probability, frequency, length of stay, and Medicare costs of hospitalization of institutionalized and noninstitutionalized patients with AD at various stages of dementia.

METHODS

The authors analyzed the 1991 to 1995 Medicare records of 420 CERAD patients with AD, a group which, at entry, had no serious comorbidities. They were geographically distributed across the United States and observed for a median of 2.5 years. Repeated measures logistic regression and generalized estimating equations were used to model the probability of hospitalization. Among those hospitalized, the general linear mixed model was used to determine number of admissions, length of stay, and Medicare cost. Demographic characteristics and calendar date were controlled in all analyses.

RESULTS

As dementia worsened, the probability of hospitalization increased among patients living at home, but decreased among those who were institutionalized. Number of admissions, length of stay, and cost also decreased significantly as stage worsened among the institutionalized patients, but the stage of dementia had no effect in non-institutionalized patients.

CONCLUSION

The hospitalization experience of patients with AD living at home differs from that of patients with AD living in institutions. Residential setting appears to be an important determinant of hospitalization in patients with AD.

Fludarabine compared with chlorambucil as primary therapy for chronic lymphocytic leukemia

BACKGROUND

Fludarabine is an effective treatment for chronic lymphocytic leukemia that does not respond to initial treatment with chlorambucil. We compared the efficacy of fludarabine with that of chlorambucil in the primary treatment of chronic lymphocytic leukemia.

METHODS

Between 1990 and 1994, we randomly assigned 509 previously untreated patients with chronic lymphocytic leukemia to one of the following treatments: fludarabine (25 mg per square meter of body-surface area, administered intravenously daily for 5 days every 28 days), chlorambucil (40 mg per square meter, given orally every 28 days), or fludarabine (20 mg per square meter per day for 5 days every 28 days) plus chlorambucil (20 mg per square meter every 28 days). Patients with an additional response at each monthly evaluation continued to receive the assigned treatment for a maximum of 12 cycles.

RESULTS

Assignment of patients to the fludarabine-plus-chlorambucil group was stopped when a planned interim analysis revealed excessive toxicity and a response rate that was not better than the rate with fludarabine alone. Among the other two groups, the response rate was significantly higher for fludarabine alone than for chlorambucil alone. Among 170 patients treated with fludarabine, 20 percent had a complete remission, and 43 percent had a partial remission. The corresponding values for 181 patients treated with chlorambucil were 4 percent and 33 percent (P< 0.001 for both comparisons). The median duration of remission and the median progression-free survival in the fludarabine group were 25 months and 20 months, respectively, whereas both values were 14 months in the chlorambucil group (P<0.001 for both comparisons). The median overall survival among patients treated with fludarabine was 66 months, which was not significantly different from the overall survival in the other two groups (56 months with chlorambucil and 55 months with combined treatment). Severe infections and neutropenia were more frequent with fludarabine than with chlorambucil (P=0.08), although, overall, toxic effects were tolerable with the two single-drug regimens.

CONCLUSIONS

When used as the initial treatment for chronic lymphocytic leukemia, fludarabine yields higher response rates and a longer duration of remission and progression-free survival than chlorambucil.

Psychological impact of diagnosis and risk reduction among cancer survivors

Life-threatening health events prompt psychological distress that may motivate individuals to reduce health risks. If so, interventions timed to take advantage of these 'teachable moments' could be particularly effective. To explore this association, early stage prostate and breast cancer patients were identified from a hospital-based tumor registry within 6 years of diagnosis. These patients (n=920) completed a mailed survey assessing the Horowitz impact of events scale, risk behaviors and readiness to change the behaviors. Breast cancer patients, younger patients and those reporting poor health status reported the greatest impact of the cancer diagnosis. Impact was inversely associated with time from diagnosis for prostate, but not breast cancer patients. Prostate patients who reported exercising regularly had lower impact scores than those who were not exercising (medians: 0.13 vs 0.56, respectively; p=0.02). Breast patients who were eating five or more fruits and vegetables reported lower impact scores than those who were not eating the recommended servings (0.75 vs 1.06, respectively; p=0.03). Breast patients who were non-smokers reported lower impact scores than smokers (0.88 vs 1.31, respectively; p=0. 02). Prospective studies are needed to understand the psychological impact of cancer diagnosis and how it might facilitate or impede the adoption of health promoting behaviors.

World population data for the HLA-DQA1, PM and D1S80 loci with least and most common profile frequencies for combinations of loci estimated following NRC II guidelines

All published and unpublished gene frequency data for the PCR-based loci HLA-DQA1, LDLR, GYPA, HBGG, D7S8, GC, and D1S80 that could be located are presented in summary tables. These gene frequencies provide the data necessary for estimating probabilities of chance match according to NRC II guidelines for any DNA profile that includes any combination of these loci for any of the populations. To illustrate the range of polymorphism for combined locus profiles, least and most common profile frequencies were estimated following NRC II guidelines for: the PM loci for all populations for which PM data were available; and for combinations of HLA-DQA1/PM, HLA-DQA1/D1S80, PM/D1S80, and HLA-DQA1/ PM/D1S80 for populations for which data were available for the relevant combinations. The profile frequencies were calculated at theta values of zero and 0.01. Minimum allele frequencies (MAF) were calculated, and are shown, for each data set for which the MAF was greater than the lowest observed allele frequency. Least common profile frequencies were calculated using MAF in those cases to illustrate a conservative estimate. The effect of using MAF versus lowest observed allele frequency in estimating least common profile frequencies is briefly illustrated as well. We finally show that aggregate U.S. gene frequency data for the classical MN and GC polymorphisms for both Caucasian and African-American populations is fully in accord with the DNA-based gene frequency data obtained from PM reverse dot-blot strips for GYPA and GC, respectively.

Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization. A randomized, controlled trial

BACKGROUND

Control of hyperglycemia delays or prevents complications of diabetes, but many persons with diabetes do not achieve optimal control.

OBJECTIVE

To compare diabetes control in patients receiving nurse case management and patients receiving usual care.

DESIGN

Randomized, controlled trial.

SETTING

Primary care clinics in a group-model health maintenance organization (HMO).

PATIENTS

17 patients with type 1 diabetes mellitus and 121 patients with type 2 diabetes mellitus.

INTERVENTION

The nurse case manager followed written management algorithms under the direction of a family physician and an endocrinologist. Changes in therapy were communicated to primary care physicians. All patients received ongoing care through their primary care physicians.

MEASUREMENTS

The primary outcome, hemoglobin A1c (HbA1c) value, was measured at baseline and at 12 months. Fasting blood glucose levels, medication type and dose, body weight, blood pressure, lipid levels, patient-perceived health status, episodes of severe hypoglycemia, and emergency department and hospital admissions were also assessed.

RESULTS

72% of patients completed follow-up. Patients in the nurse case management group had mean decreases of 1.7 percentage points in HbA1c values and 43 mg/dL (2.38 mmol/L) in fasting glucose levels; patients in the usual care group had decreases of 0.6 percentage points in HbA1c values and 15 mg/dL (0.83 mmol/L) in fasting glucose levels (P < 0.01). Self-reported health status improved in the nurse case management group (P = 0.02). The nurse case management intervention was not associated with statistically significant changes in medication type or dose, body weight, blood pressure, or lipids or with adverse events.

CONCLUSIONS

A nurse case manager with considerable management responsibility can, in association with primary care physicians and an endocrinologist, help improve glycemic control in diabetic patients in a group-model HMO.

Predictors of pain self-report in nursing home residents

The purpose of this study was to examine the influence of cognitive function and other biopsychosocial factors on test-retest agreement, four-week variability, and intensity of self-reported pain using the verbal 0 to 10 scale and a pain thermometer in 115 nursing home residents over four weeks. Pain was assessed twice on three days during week 1, and once each during weeks 2, 3 and 4. A forward stepwise regression procedure was used to examine the influence of biopsychosocial parameters (age, race, gender, educational status, marital status, comorbidity, cognitive function, depression, social support, physical function and self-rated health) on pain intensity, test-retest agreement and variability. There was a quadratic association between cognitive function and test-retest agreement with the 0-10 scale; residents with Folstein scores of 22-26 were more likely to show disagreement (50% of 34) than residents with scores < 22 or > 26 (7% of 71). Higher Folstein scores were also associated with greater pain intensity for both pain scales (p < 0.001). Baseline pain intensity was significantly related to pain variability (0-10 scale only). The clinician should be cognizant of these relationships when interpreting verbalizations of pain in long-term care facilities.

Cerebral infarcts in patients with autopsy-proven Alzheimer's disease: CERAD, part XVIII. Consortium to Establish a Registry for Alzheimer's Disease

OBJECTIVE

To study the relation between cerebral infarction and clinical and neuropsychologic manifestations in patients with autopsy-proven Alzheimer's disease (AD) enrolled in the Consortium to Establish a Registry for Alzheimer's Disease (CERAD).

BACKGROUND

Prior studies report that subjects with neuropathologic evidence of AD and concomitant brain infarcts had poorer cognitive function and higher frequency of dementia than those with AD alone.

METHODS

Clinical and neuropsychologic manifestations of dementia were studied in 74 subjects with neuropathologic findings of AD alone and 32 with AD and concomitant cerebral infarcts or lacunar lesions.

RESULTS

The 32 patients with both AD and vascular lesions were significantly older at time of death (median age, 81 years) than the 74 patients with AD alone (76 years; p = 0.02). At the final follow-up visit, the severity of the dementia was greater in AD patients with vascular lesions (median Clinical Dementia Rating [CDR] = 3) than in those with AD alone (CDR = 2; p = 0.03). Patients with AD and vascular lesions performed significantly worse on verbal fluency, Boston Naming, and Mini-Mental State Examination (MMSE) tests. No differences between the groups were observed, however, in the semiquantitative measures of frequency of neuritic plaques or neurofibrillary tangles.

CONCLUSIONS

The clinical-neuropathologic correlations in CERAD patients generally confirm those in prior studies, indicating that the presence of cerebral infarction in patients with AD is associated with greater overall severity of clinical dementia and poorer performance on specific tests of language and cognitive function.

Religious coping in the nursing home: a biopsychosocial model

OBJECTIVE

To examine psychosocial and physical health correlates of religious coping in medically ill chronically institutionalized older adults. Religious coping is defined as the extent to which persons use religious beliefs and practices to help them to cope.

METHOD

This is a cross-sectional cohort study conducted in a 120 bed VA-affiliated and a 125 bed university affiliated community-based nursing home in Durham, North Carolina. Participants were 115 chronic care nursing home residents; mean age of the sample was seventy-nine years, 44 percent were women, and 17 percent were African Americans. Subjects were enrolled for a one-month period during which comprehensive psychosocial and health assessments were performed, including evaluation of cognitive function (Mini-Mental State Exam), physical function (Barthel index), severity of medical comorbidity (Cumulative Illness Rating Scale), self-reported physical pain (vertical verbal descriptor scale), depressive symptoms (Geriatric Depression Scale), social support (social network), and religious coping (Religious Coping Index).

RESULTS

Over 43 percent of the sample scored in the depressed range of the Geriatric Depression Scale. Almost 60 percent reported they used religion at least to a large extent when coping with their problems; 34 percent said that it was the most important factor that enabled them to cope. Patients who used religion to cope had greater social support (p = .01), more severe medical illness (p = .04), and better cognitive functioning (p = .02).

CONCLUSIONS

Religious beliefs and practices are frequently used by chronically institutionalized older adults to help them to cope. Religious coping is associated with more severe medical illness, higher social support, and better cognitive functioning.

Religiosity and remission of depression in medically ill older patients

OBJECTIVE

The effects of religious belief and activity on remission of depression were examined in medically ill hospitalized older patients.

METHOD

Consecutive patients aged 60 years or over who had been admitted to medical inpatient services at a university medical center were screened for depressive symptoms. Of 111 patients scoring 16 or higher on the Center for Epidemiologic Studies Depression Scale, 94 were diagnosed with depressive disorder (DSM-III major depression or subsyndromal depression) by a psychiatrist using a structured psychiatric interview. After hospital discharge, depressed patients were followed up by telephone at 12-week intervals four times. At each follow-up contact, criterion symptoms were reassessed, and changes in each symptom over the interval since last contact were determined. The median follow-up time for 87 depressed patients was 47 weeks. Religious variables were examined as predictors of time to remission by means of a multivariate Cox model, with controls for demographic, physical health, psychosocial, and treatment factors.

RESULTS

During the follow-up period, 47 patients (54.0%) had remissions; the median time to remission was 30 weeks. Intrinsic religiosity was significantly and independently related to time to remission, but church attendance and private religious activities were not. Depressed patients with higher intrinsic religiosity scores had more rapid remissions than patients with lower scores.

CONCLUSIONS

In this study, greater intrinsic religiosity independently predicted shorter time to remission. To the authors' knowledge, this is the first report in which religiosity has been examined as a predictor of outcome of depressive disorder.

Depression in medically ill hospitalized older adults: prevalence, characteristics, and course of symptoms according to six diagnostic schemes

OBJECTIVE

The purpose of this study was to examine and compare rates of depression, correlates, and course of symptoms in medically ill hospitalized elders through use of six diagnostic schemes (inclusive, etiologic, exclusive-inclusive, exclusive-etiologic, substitutive-inclusive, and substitutive-etiologic).

METHOD

A consecutive series of 460 cognitively unimpaired patients aged 60 or over who were admitted to the medical inpatient services of Duke Hospital underwent a structured psychiatric evaluation administered by a psychiatrist. Patients with depression were contacted by telephone at 12-week intervals after discharge to assess weekly change in depressive symptoms (median follow-up time = 47 weeks).

RESULTS

The prevalence of major depression varied from 10% to 21% depending on diagnostic scheme; similarly, minor depression varied from 14% to 25%. Diagnostic strategy made little difference in known psychological and health characteristics of patients with depression (predictive validity) or severity of depressive symptoms (convergent validity). The diagnostic strategy that best distinguished a severe and persistent major depression was the exclusive-etiologic approach; however, this strategy missed 49% of patients with major depression identified by the inclusive approach, almost 60% of whom continued to experience persistent symptoms of depression many weeks after discharge.

CONCLUSIONS

Diagnostic strategy affects rates of major and minor depression, with about a twofold difference between the extremes. There is little reason, however, to choose one diagnostic scheme over another in all cases. Diagnostic strategy should be chosen on the basis of the specific goals and purposes of the examiner. While the exclusive-etiologic approach identifies the most severe and persistent depressions, the inclusive approach is the most sensitive and reliable approach and is an intermediate predictor of persistent depression.

Continuous infusion 5-fluorouracil as first-line therapy for metastatic breast cancer

Previous phase II studies of continuous infusion Fluorouracil (5-FU) (CI 5-FU) in refractory metastatic breast cancer have shown modest activity with low toxicity. Its activity in a first-line setting has not been formally tested. Patients were eligible if they fulfilled the following criteria: metastatic breast cancer; measurable or evaluable disease, no prior chemotherapy in the metastatic setting; ECOG performance status of 0, 1, or 2: adequate bone marrow and liver function. Patients were treated with 5-FU 250 mg/m2 per day by continuous intravenous infusion for 5 weeks in a 6-week cycle. Treatment was continued until disease progression or unacceptable toxicity. In addition to the traditional endpoints of response, survival, and toxicity, quality of life was assessed with the Functional Living Index-Cancer (FLIC) and the Symptom Distress Scale (SDS). Twenty-one patients were enrolled. Among the 16 patients with measurable disease, the objective response rate was 44% (95% CI 20%, 68%) with CR rate 13% and PR rate 31%. The median duration of response was 37 weeks. Responses were not observed in patients with visceral (lung or liver) disease. Among all 21 patients in the study, the median time to disease progression was 12 weeks, and median overall survival was 64 weeks. Grade 1 or 2 mucosal and cutaneous toxicity were common. Only 4 patients (19%) had toxicity greater than grade 2; three patients had grade 3 mucositis, and 1 patient developed an indwelling catheter infection requiring its removal. Among responding patients, mean FLIC scores improved from 114.3 at baseline to 128.7 at week 8 (p = 0.11). Symptoms reported on the SDS generally improved in responding patients. Continuous infusion 5-FU as a first-line therapy for metastatic breast cancer has moderate activity and low toxicity. Its use should be considered in the first-line setting when toxicity needs to be minimized.

A phase II trial of didemnin B in myeloma. A Cancer and Leukemia Group B (CALGB) study

Didemnin B is a member of a class of compounds, derived from a marine source, undergoing phase II study. Twenty-two patients with relapsed myeloma were treated with didemnin B at an initial dose of 4.9 mg/m2, given once every 28 days. All were evaluable for toxicity, and 15 were evaluable for myeloma response. No tumor regressions occurred in the 15 patients evaluable for response. Vomiting was the major toxicity, occurring in 73% of patients despite vigorous pre- and post-treatment medication with at least three intravenous antiemetics. Two instances of grade 4 hypersensitivity reaction occurred. We conclude that didemnin B has no activity at this dose and schedule in myeloma that has relapsed after one or two prior therapeutic regimens.

Using college alumni populations in epidemiologic research: the UNC Alumni Heart Study

The UNC Alumni Heart Study (UNCAHS) is a prospective study of the role of psychosocial factors, in particular hostility, in the development of coronary heart disease. The target population is composed of persons who completed the Minnesota Multiphasic Personality Inventory while attending the University of North Carolina in the mid-1960s. Logistic regression analyses were used to determine whether hostility, demographic and other variables were significant determinants of the subjects' locatability and participation. It was found that MMPI hostility scores at initial testing were unrelated to either potential or actual locatability or participation. Thus there is no evidence that hostility is the source of selection bias in the UNCAHS. Selection into the study was predicted by age, sex, degree status and variables concerned with the conditions under which the MMPI was administered. It is concluded that follow-up studies of college cohorts may have study-specific sources of selection bias.

Disease severity in rheumatoid arthritis: relationships of plasma tumor necrosis factor-alpha, soluble interleukin 2-receptor, soluble CD4/CD8 ratio, neopterin, and fibrin D-dimer to traditional severity and functional measures

Rheumatoid arthritis is a complex inflammatory disease of unknown cause. Although various laboratory and clinical measurements are useful in managing these patients, there is a need for better tests to quantitatively assess disease activity. The purpose of this study was to investigate the association of certain immune and inflammation (I-I) parameters with four traditional disease severity measures and a functional measure in rheumatoid arthritis patients. A single set of patient blood samples was analyzed, and four traditional disease severity measures and patient functional statuses were determined from 64 consecutive outpatients with rheumatoid arthritis. Plasma tumor necrosis factor-alpha (TNF), soluble interleukin-2 receptor (sIL-2R), sCD4 and sCD8 (and the sCD4/sCD8 ratio), neopterin, and fibrin D-dimer were analyzed in relationship to Westergren erythrocyte sedimentation rate (ESR), physician assessment of disease activity, joint pain count, grip strength, and Arthritis Impact Measurement Scale (AIMS) scores. Rheumatoid arthritis patients had higher mean levels of all I-I measures (except sCD4) compared to healthy subjects. Initial significant correlations between TNF, sIL-2R, and D-dimer and several disease severity and functional measures were detected. When we controlled for the covariates age, gender, race, and medications, regression analyses indicated that, as a group, the I-I measures were significantly related to grip strength, physician disease severity rating, ESR, and total joint pain. When the predictive values of the I-I measures were tested controlling for the covariates and ESR, D-dimer was independently and significantly associated with variability in grip strength, physician disease severity, and AIMS physical disability, while TNF was associated with a significant amount of variability in total joint pain.(ABSTRACT TRUNCATED AT 250 WORDS)

Hostility during late adolescence predicts coronary risk factors at mid-life

Hostility, as measured by the Cook-Medley Hostility Scale of the Minnesota Multiphasic Personality Inventory, has been found to predict higher rates of both coronary heart disease and all-cause mortality. To evaluate one mechanism whereby hostility might contribute to health problems, the authors used regression models to determine whether hostility measured in college (1964-1966) predicted coronary risk factors assessed 21-23 years later (1987-1990) in 4,710 men and women. Of this group, 828 had lipids measured (1988-1991). Persons with higher hostility scores in college were significantly more likely at follow-up to consume more caffeine (r = 0.043), to have a larger body mass index (r = 0.055), to have higher lipid ratios (r = 0.092), and to be current smokers (r = 0.069) than those with lower hostility scores during college. Cross-sectional analyses found significant associations of contemporaneous hostility scores with the same four risk factors, as well as with alcohol consumption and hypertension (rs ranging from 0.043 to 0.117). These associations are large enough to have possible public health significance. We conclude that hostility may contribute to health problems through its influences on several coronary risk factors across the adult life span.

Measures of neuroticism and disease status in coronary angiography patients

A high percentage of patients who undergo diagnostic angiography because they have chest pain are found to be free of significant coronary artery disease. To examine the psychological characteristics of these patients, we used several Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1943) measures to assess the relationships between different aspects of neuroticism and coronary artery disease severity (CADSEV) in a sample of 1,462 angiography patients. The Conversion V profile was inversely and most strongly related to CADSEV. Single high scores on hypochondriasis or hysteria were also inversely related to CADSEV, but psychasthenia and Taylor Manifest Anxiety Scale (TMA; Taylor, 1953) scores were not. Using measures derived by a factor analysis of the MMPI, items relating somatic complaints were inversely related to CADSEV, but a measure of general neuroticism was not. These results support the hypothesis that the association between neuroticism and angiographic findings may be specific to a particular aspect of neuroticism, somatic preoccupation. The implications for neuroticism measurement and clinical practice are discussed.

External beveling of cranial gunshot entrance wounds

Entrance gunshot wounds of the skull generally have internal beveling. External beveling has been previously described in association with internal beveling (keyhole defect) and with wounds from handgun projectiles. An accidental shooting is described in which a 22-year-old male sustained a perforating gunshot wound of the head at distant range from a 5.56-mm (.223-caliber) fully jacketed rifle round. Although the entrance wound had symmetrical external beveling, misinterpretation of this particular entrance wound as an exit wound would have been difficult.

Hostility patterns and health implications: Correlates of Cook-Medley Hostility Scale scores in a national survey

Correlated Cook-Medley Hostility Scale (Ho) scores with sociodemographic variables in a national survey of 2,536 adults. Multiple regression models revealed that Ho scores were associated with race (p less than .0001), years of education (p less than .001), sex (p less than .001), occupation (p = .0002), and income (p = .0025). Higher scores were found in non-Whites, men, and those of lower socioeconomic status. There was a Race x Income interaction (p less than .005), such that the greatest Ho score differences between the races occurred among those with the lowest incomes. Age was related to Ho scores in a curvilinear fashion: higher scores in the youngest and oldest age groups than in the middle-aged groups (p = .025). Marital status was unrelated to Ho scores. These patterns of hostility are similar to the patterns of health indicators in the population. Because hostility has been found to be associated with adverse health outcomes, hostility may account for some of the demographic variations in health status. However, it is argued that research must first establish the generality of the hostility-health relationship across subgroups of the population.

Type A behavior and survival: a follow-up study of 1,467 patients with coronary artery disease

Patients with documented coronary artery disease, admitted to Duke Medical Center between 1974 and 1980, were assessed for type A behavior pattern and were followed until 1984. The relation of type A behavior to survival was tested using data from coronary angiography to control for disease severity. Cox model regression analyses demonstrated an interaction (p less than 0.01) between type A behavior and an index of disease severity in the prediction of cardiovascular death. Among those with relatively poor left ventricular function, type A patients had better survival than type B. This difference was not present among patients with better prognoses. Type A behavior did not predict the subsequent incidence of nonfatal myocardial infarctions. Differential risk modification and differential selection into postinfarction status are possible explanations for the findings. These results need not conflict with the proposition that type A behavior plays a role in the pathogenesis of coronary artery disease.

The Cook-Medley hostility scale: item content and ability to predict survival

Previous studies have identified the MMPI-based Cook and Medley hostility scale (Ho) as a predictor of health outcomes. To achieve a better understanding of the construct measured by this scale, Ho items were classified on an a priori basis. Six subsets were identified: Cynicism, Hostile Attributions, Hostile Affect, Aggressive Responding, Social Avoidance, and Other. Study 1 examined the correlations of these subsets with scales of the NEO Personality Inventory in two samples of undergraduates. Good convergent and discriminant validity were demonstrated, but there was some evidence that items in the Social Avoidance and Other categories reflect constructs other than hostility. Study 2 examined the ability of the Ho scale and the item subsets to predict the 1985 survival of 118 lawyers who had completed the MMPI in 1956 and 1957. As in previous studies, those with high scores had poorer survival (chi 2 = 6.37, p = 0.012). Unlike previous studies, the relation between Ho scores and survival was linear. Cynicism, Hostile Affect, and Aggressive Responding subsets were related to survival, whereas the other subsets were not. The sum of the three predictive subsets, with a chi 2 of 9.45 (p = 0.002), was a better predictor than the full Ho scale, suggesting that it may be possible to refine the scale and achieve an even more effective measure of those aspects of hostility that are deleterious to health.

Suspiciousness, health, and mortality: a follow-up study of 500 older adults

Scores on Factor L of the 16 PF, a measure of suspiciousness that is closely related to the Cook and Medley hostility scale, predicted survival in a sample of 500 older men and women during a follow-up of approximately 15 years. Those individuals with scores indicating higher levels of suspiciousness had greater mortality risk. This association remained significant after controlling for age, sex, physician's ratings of functional health, smoking, cholesterol, and alcohol intake. In addition, Factor L was associated with physician's ratings of health at the initiation of follow-up. These findings add to the weight of evidence that implicates a set of negative interpersonal attitudes in the domain of hostility, anger, cynicism, and mistrust as a prospective marker of individuals at risk for adverse health outcomes.

Cytologic effects of Thiotepa and Adriamycin on normal canine urothelium

An experimental investigation was carried out to produce and observe controlled, sequential changes in normal bladder urothelium of female dogs caused by Thiotepa (triethylene thiophosphoramide) and Adriamycin (doxorubicin hydrochloride). Thiotepa (30 mg in 30 ml saline) was instilled for two hours into the bladders of five dogs at weekly intervals, and Adriamycin (1 ml/kg body weight) was given intravenously to five dogs at weekly intervals for a period of ten weeks. Control animals underwent only bladder irrigation with saline. Periodic catheterized urine and saline bladder irrigations and bladder biopsy specimens were obtained. After the tenth week all dogs were killed and autopsies conducted. Major observations in the experimental animals included cellular enlargement, bizarre cell shapes, cytoplasmic vacuolization, nuclear and nucleolar enlargement, multinucleation, pyknosis, karyorrhexis and infiltration by neutrophilic leukocytes. In some animals, reversion to a normal cytologic pattern occurred in the ten-week period. The application of these observations to human urinary cytopathology is discussed.

Hostility patterns and health implications: correlates of Cook-Medley Hostility Scale scores in a national survey

Correlated Cook-Medley Hostility Scale (Ho) scores with sociodemographic variables in a national survey of 2,536 adults. Multiple regression models revealed that Ho scores were associated with race (p less than .0001), years of education (p less than .001), sex (p less than .001), occupation (p = .0002), and income (p = .0025). Higher scores were found in non-Whites, men, and those of lower socioeconomic status. There was a Race x Income interaction (p less than .005), such that the greatest Ho score differences between the races occurred among those with the lowest incomes. Age was related to Ho scores in a curvilinear fashion: higher scores in the youngest and oldest age groups than in the middle-aged groups (p = .025). Marital status was unrelated to Ho scores. These patterns of hostility are similar to the patterns of health indicators in the population. Because hostility has been found to be associated with adverse health outcomes, hostility may account for some of the demographic variations in health status. However, it is argued that research must first establish the generality of the hostility-health relationship across subgroups of the population.