Effect of Whole-Genome Sequencing on the Clinical Management of Acutely Ill Infants With Suspected Genetic Disease: A Randomized Clinical Trial

IMPORTANCE

Whole-genome sequencing (WGS) shows promise as a first-line genetic test for acutely ill infants, but widespread adoption and implementation requires evidence of an effect on clinical management.

OBJECTIVE

To determine the effect of WGS on clinical management in a racially and ethnically diverse and geographically distributed population of acutely ill infants in the US.

DESIGN, SETTING, AND PARTICIPANTS

This randomized, time-delayed clinical trial enrolled participants from September 11, 2017, to April 30, 2019, with an observation period extending to July 2, 2019. The study was conducted at 5 US academic medical centers and affiliated children's hospitals. Participants included infants aged between 0 and 120 days who were admitted to an intensive care unit with a suspected genetic disease. Data were analyzed from January 14 to August 20, 2020.

INTERVENTIONS

Patients were randomized to receive clinical WGS results 15 days (early) or 60 days (delayed) after enrollment, with the observation period extending to 90 days. Usual care was continued throughout the study.

MAIN OUTCOMES AND MEASURES

The main outcome was the difference in the proportion of infants in the early and delayed groups who received a change of management (COM) 60 days after enrollment. Additional outcome measures included WGS diagnostic efficacy, within-group COM at 90 days, length of hospital stay, and mortality.

RESULTS

A total of 354 infants were randomized to the early (n = 176) or delayed (n = 178) arms. The mean participant age was 15 days (IQR, 7-32 days); 201 participants (56.8%) were boys; 19 (5.4%) were Asian; 47 (13.3%) were Black; 250 (70.6%) were White; and 38 (10.7%) were of other race. At 60 days, twice as many infants in the early group vs the delayed group received a COM (34 of 161 [21.1%; 95% CI, 15.1%-28.2%] vs 17 of 165 [10.3%; 95% CI, 6.1%-16.0%]; P = .009; odds ratio, 2.3; 95% CI, 1.22-4.32) and a molecular diagnosis (55 of 176 [31.0%; 95% CI, 24.5%-38.7%] vs 27 of 178 [15.0%; 95% CI, 10.2%-21.3%]; P < .001). At 90 days, the delayed group showed a doubling of COM (to 45 of 161 [28.0%; 95% CI, 21.2%-35.6%]) and diagnostic efficacy (to 56 of 178 [31.0%; 95% CI, 24.7%-38.8%]). The most frequent COMs across the observation window were subspecialty referrals (39 of 354; 11%), surgery or other invasive procedures (17 of 354; 4%), condition-specific medications (9 of 354; 2%), or other supportive alterations in medication (12 of 354; 3%). No differences in length of stay or survival were observed.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, for acutely ill infants in an intensive care unit, introduction of WGS was associated with a significant increase in focused clinical management compared with usual care. Access to first-line WGS may reduce health care disparities by enabling diagnostic equity. These data support WGS adoption and implementation in this population.

TRAIL REGISTRATION

ClinicalTrials.gov Identifier: NCT03290469.

Twelve-month frequency of drug-metabolizing enzyme and transporter-based drug-drug interaction potential in patients receiving oral enzyme-targeted kinase inhibitor antineoplastic agents

OBJECTIVE

To describe 12-month rates and patterns of coprescription of drugs that potentially create drug-drug interactions (DDIs) through shared metabolic or transport pathways for 9 enzyme-targeted kinase inhibitor oral antineoplastic drugs (OADs).

PATIENTS AND METHODS

We used a deidentified pharmacy claims database identifying patients prescribed dasatinib, erlotinib, everolimus, imatinib, lapatinib, nilotinib, pazopanib, sorafenib, or sunitinib between January 1, 2008, and May 31, 2010. Coprescribing was 1 or more overlapping days of supply between the OAD and potential DDI drugs during the 12-month period beginning on the OAD index date. Product labels identified the cytochrome P450 metabolic enzymes used and whether P-glycoprotein was used by the OADs. Drugs that induce and/or inhibit these pathways were identified from the label and online resources.

RESULTS

Sample sizes ranged from 96 (pazopanib group) to 4617 (imatinib group). Coprescribing rates with drugs that may decrease OAD effectiveness were 359/1546 (23%) (sunitinib group) to 1851/3263 (57%) (erlotinib group). Coprescribing rates with drugs that may increase OAD toxicity were 364/1546 (24%) (sunitinib group) to 71/96 (74%) (pazopanib group). Patients coprescribed DDI drugs had a median of 1 to 4 more medications present on the OAD index date than those not coprescribed a DDI drug. Most groups coprescribed DDI drugs had a median of 180 or more OAD days of supply during follow-up. The proportion of OAD days of supply with overlapping days of DDI drugs ranged from 7% to 85%. Generally, oncologists prescribed the OAD and nononcologists the DDI drug.

CONCLUSION

Coprescription of drugs that induce or inhibit metabolic pathways used by enzyme-targeted kinase inhibitor OADs is high. The clinical consequences need further study.

A comparison of echocardiography and pulmonary artery catheterization for evaluation of pulmonary artery pressures in pregnant patients with suspected pulmonary hypertension

OBJECTIVE

This study was undertaken to compare the accuracy of echocardiography versus pulmonary artery catheterization to estimate pulmonary artery pressures in pregnant women with suspected pulmonary hypertension.

STUDY DESIGN

A retrospective chart review was performed between January 1990 and February 2000 for all pregnant patients with cardiac disease. Patients with pulmonary artery pressure values estimated by cardiac catheterization and echocardiography during pregnancy were included. Pulmonary hypertension is defined as pulmonary artery systolic pressure >30 mm Hg.

RESULTS

Twenty-seven patients were included in the study. There was a significant overestimation of the mean pulmonary artery pressure with echocardiography compared with catheterization (55.4 vs 51.1 mm Hg; P <.005). Of the 20 patients, pulmonary artery pressure was significantly greater when estimated by echocardiography than when measured by catheterization (59.6 vs 54.8 mm Hg; P <.004). Thirty-two percent (8/25) of the patients had pulmonary hypertension when estimated by echocardiography but had normal pulmonary artery pressures on subsequent catheterization.

CONCLUSION

Echocardiography significantly overestimated pulmonary artery pressures compared with catheterization in pregnant patients with suspected pulmonary hypertension. Patients with structural cardiac defects appear to have a significantly greater difference in pulmonary artery pressures. Thirty-two percent of pregnant patients with normal pulmonary artery pressures may be misclassified as having pulmonary artery hypertension when measured by echocardiography alone.

Duplex directed caval filter insertion in multi-trauma and critically ill patients

This study was undertaken to determine the safety and feasibility of inferior vena cava (IVC) filter insertion at the bedside using duplex imaging in multi-trauma and/or critically ill patients. From February 1996 to August 1997, 53 multi-trauma and/or critically ill patients, who were in the intensive care unit and referred for an IVC filter, were prospectively evaluated for possible duplex directed caval filter (DDCF) insertion. Screening IVC duplex scans were performed in all patients. Satisfactory ultrasound visualization in 46 patients (87%) allowed attempted DDCF insertion. All procedures were percutaneously performed at the bedside using Vena Tech IVC filters. The results from this series showed that DDCF insertion can be safely and rapidly performed at the bedside in multi-trauma or critically ill patients. The procedure is dependent on satisfactory visualization of the IVC by duplex ultrasonography, which was possible in 45 out of 53 (85%) patients. Insertion at the bedside substantially reduces the procedural cost and avoids the need for transport, radiation exposure, and intravenous contrast.

Endoleak after aortic stent graft repair: diagnosis by color duplex ultrasound scan versus computed tomography scan

PURPOSE

The purpose of this study was to compare the accuracy of a color duplex ultrasound scan (CDU) to a computerized axial tomography scan (CT) in the diagnosis of endoleaks after stent graft repair of abdominal aortic aneurysms.

METHODS

The Endovascular Aneurysm Clinical Trial Core Laboratory records were reviewed from 117 concurrent CDU and CT studies that were performed in 79 patients who were implanted with the Endovascular Technologies stent graft device between December 1995 and January 1997. All of the studies were interpreted by the Core Laboratory as having the presence or the absence of an endoleak or as being indeterminate because of technical factors. Of the 117 videotaped CDU studies available for reexamination, 100 were reassessed for technical adequacy on the basis of the following criteria: a satisfactory imaging of the aneurysm sac and of the stent graft with gray scale, and both color and spectral Doppler scan evaluation for endoleak outside the endograft and within the aneurysm sac.

RESULTS

Of the 117 studies, 103 CDUs (88%) and 114 CTs (97%) were recorded as having the presence or the absence of an endoleak and 14 CDUs (12%) and 3 CTs (3%) were indeterminate. For the studies that were recorded to have the presence or the absence of an endoleak, the sensitivity, the specificity, the positive and the negative predictive values, and the accuracy of CDUs as compared with CTs were 97%, 74%, 66%, 98%, and 82%, respectively. Of the 100 CDU videotaped studies available for review, the following results were seen: (1) 93 CDUs had satisfactory B-mode images, (2) 76 had satisfactory color Doppler scan images to evaluate for endoleaks, (3) 55 had color Doppler scan assessment of the entire abdominal aortic aneurysm sac for endoleak, and (4) 27 had spectral Doppler scan waveform confirmation of suspected endoleaks. Only 19 CDU studies (19%) with all 4 criteria for complete assessment of endoleak were performed.

CONCLUSION

Although most of the CDU studies were technically suboptimal, the CDUs reliably identified endoleaks with an excellent sensitivity and a negative predictive value as compared with CT scans.

A comparison of surgery for neurogenic thoracic outlet syndrome between laborers and nonlaborers

OBJECTIVE

To determine factors of outcome following surgical intervention for neurologic thoracic outlet syndrome (NTOS).

METHODS

In a retrospective study of patients surgically treated for NTOS, outcome was evaluated by postoperative symptoms and the ability of patients to return to work.

RESULTS

Good, fair, and poor results were obtained in 26 (48%), 21 (39%), and 7 (13%) patients, respectively. The best predictor of a good outcome was occupation. Nonlaborers were more likely to have good outcome (21 of 32, 66%) when compared with laborers (5 of 22, 23%; P = 0.0025). Only 6 of 20 (30%) laborers were able to return to their original occupation compared with 17 of 26 (65%) nonlaborers (P = 0.036).

CONCLUSIONS

Laborers with NTOS are less likely to have a good result from surgical intervention, are unlikely to return to their original occupation, and may require retraining for a non-labor-intensive occupation if they cannot return to their original work.

Improved maze learning through early music exposure in rats

Rats were exposed in utero plus 60 days post-partum to either complex music (Mozart Sonata (k. 448)), minimalist music (a Philip Glass composition), white noise or silence, and were then tested for five days, three trials per day, in a multiple T-maze. By Day 3, the rats exposed to the Mozart work completed the maze more rapidly and with fewer errors than the rats assigned to the other groups. The difference increased in magnitude through Day 5. This suggests that repeated exposure to complex music induces improved spatial-temporal learning in rats, resembling results found in humans. Taken together with studies of enrichment-induced neural plasticity, these results suggest a similar neurophysiological mechanism for the effects of music on spatial learning in rats and humans.

The development of a Family Caregiver Cancer Education Program

BACKGROUND

Recent years have seen an escalating trend toward early discharge of hospital patients, resulting in increasing numbers of patients being cared for at home by family members. Fear and anxiety concerning the well-being of the patient, the inability to provide adequate care, the cost of cancer treatment, and the anticipation of emotional stress are major factors that can contribute to the difficulty of this transition.

METHODS

The Family Caregivers Cancer Education Program has been funded by the Pennsylvania Department of Health, Cancer Control Program to address these issues. This program encompasses education and support for caregivers as well as the Local Instructor Course to provide nurse and social worker teams with materials, information, and support to offer the caregiver course within their areas. Focus groups were conducted to determine course content.

RESULTS AND CONCLUSIONS

Participant evaluations demonstrate that caregivers who attend the course feel less overwhelmed and better able to cope with the caregiver experience.

Long-term outcome after early infrainguinal graft failure

PURPOSE

To determine the long-term outcome and prognostic factors after early infrainguinal graft failure (< 30 days).

METHODS

Retrospective analysis of limb salvage data, patency data, and prognostic risk factors in 112 new infrainguinal bypass grafts from 1985 to 1995 that occluded within 30 days of operation.

RESULT

Thirty-six femoropopliteal and 76 femorotibial/femoropedal arterial bypass ("index") procedures were performed for rest pain (50%), tissue loss (31%), or disabling claudication (19%). In 103 patients, an immediate additional revascularization ("takeback") procedure was performed at the time of early graft failure. Life table analysis of the takeback procedures for threatened limbs (n = 84) revealed limb salvage rates of 74%, 54%, 40%, and 31% at 1 month, 1 year, 3 years, and 5 years, respectively. The 1-month limb salvage rate (threatened limbs) was 12% (1 of 8) in patients who were not taken back for revascularization and 33% (4 of 12) in patients who had undergone more than one takeback procedure within 30 days. The secondary graft patency rates for the takeback procedures (n = 103) were 70%, 37%, 27%, and 23% at 1 month, 1 year, 3 years, and 5 years, respectively. Univariate and life table analysis revealed that patients who were given anticoagulation medication after the index procedure (before graft thrombosis) or patients who had undergone previous ipsilateral leg revascularization had significantly lower rates of limb salvage and graft patency (p < 0.05). The limb salvage rate was also significantly worse in patients who had single-vessel runoff compared with those who had multiple-vessel runoff (p < 0.01). Thrombectomy and revision or complete graft replacement had a better secondary patency rate than thrombectomy alone (p < 0.05). Autogenous vein grafts had better outcome than polytetrafluoroethylene-containing grafts, but statistical significance was not achieved. No significant differences in limb salvage or graft patency rates were found between femoropopliteal versus femorotibial/femoropedal bypass grafting, age, gender, previous inflow surgery, diabetes, hypertension, smoking, or cardiac, renal, or pulmonary disease.

CONCLUSION

The long-term limb salvage and graft patency rates after takeback revascularization procedures for early graft failure are poor. Despite poor outcome, a single takeback procedure appears warranted in all patients. Multiple takeback procedures, however, do not appear to be justified, especially in patients who are given anticoagulation medication after the index bypass procedure, repeat leg bypass procedures, or if there is no potential for graft revision.

Gene therapy of cancer

OBJECTIVE

To provide a review of the basic concepts and terminology of human genetics, the clinical application and risks of gene therapy, and ethical and societal issues.

DATA SOURCES

Review articles, research studies, and book chapters related to genetics and human gene therapy.

CONCLUSIONS

The genetic changes that play a role in the development of cancer have begun to be elucidated, and these discoveries have led to strategies to destroy cancers by correcting genetic defects or manipulating genes to induce tumoricidal activities. Gene therapy is a novel investigational intervention that is constantly evolving.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses will need an increased understanding of cellular biology, genetics, and genetics engineering. Major considerations for nursing practice include patient and family education, informed consent, side effects, and ethical and societal issues.

Reaching out to the African American community through innovative strategies

PURPOSE/OBJECTIVES

To describe the University of Pittsburgh Cancer Institute's African American Cancer Program, including innovative strategies that were used, barriers that were encountered, an evaluation of each component, and future directions and implications.

DATA SOURCES

Published articles, references from bibliographies, census data, personal contact, unpublished data.

DATA SYNTHESIS

Cancer morbidity and mortality is higher among African Americans than Caucasians. The University of Pittsburgh Cancer Institute pilot-tested four interventions to increase awareness, provide education and early detection opportunities, and overcome barriers to cancer care among African Americans.

CONCLUSION

Constant presence, cultural sensitivity, and repetition are necessary to overcome the barriers to increased awareness and behavioral changes in the African American community. A more formalized evaluation component is necessary to draw definitive conclusions.

IMPLICATIONS FOR NURSING PRACTICE

To develop cancer prevention and education programs that meet the unique needs of African Americans, nurses must be aware of barriers and cultural differences.

Cognitive behavioral treatment of felony drug offenders: a five-year recidivism report

70 male felony offenders treated with the cognitive behavioral approach of Moral Reconation Therapy during and after reincarceration were assessed for reincarceration and rearrests five years after their release. They were compared to a nontreated control group of 82 male felony offenders. Reincarceration in the treated group (37.1%) was significantly lower than recidivism in controls (54.9%). Also, the treated group showed fewer rearrests and fewer days of additional sentence.

Patterns of self-care needs and interventions related to biologic response modifier therapy: fatigue as a model

Many patients receiving biologic response modifier (BRM) therapy experience fatigue as a significant and, at times, dose-limiting side effect. For this reason, a multiinstitutional pilot study was designed to collect data about the needs and self-care interventions of patients who had undergone at least one prior treatment with a BRM and had experienced fatigue as a symptom. Information was also obtained on the extent to which the needs and self-care interventions identified by patients compared with those perceived by their family members and nurses. Of the 16 patients who participated in the study, seven were being treated with interleukin-2 (IL-2), eight with interferon alfa (IFN-alpha), and one with tumor necrosis factor (TNF). The study found no significant correlation between the degree or duration of fatigue and the BRM or dosage administered. Not surprisingly, patient and family member responses correlated fairly well. However, in several parameters, including the degree and duration of fatigue, nurses' perceptions did not correlate at all with those of the patient. While 46% of nurse responses matched those of the patient as to useful self-care interventions, only 17% of nurses accurately identified factors or events that patients perceived as worsening fatigue. Further, there was no correlation among patient, family member, and nurse responses on interventions that could be used by others to help the patient cope with fatigue. The overall results of this pilot study indicate that nurses need to be more attuned to assessing fatigue as a side effect of BRM therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Treating drug offenders with Moral Reconation Therapy: a three-year recidivism report

70 male felony offenders treated with the cognitive behavioral approach of Moral Reconation Therapy during and after incarceration were assessed for rearrests and reincarceration 38 months after their release. They were compared to a nontreated control group of 82 male felony offenders. Recidivism in the treated group was 24.3% as compared to 36.6% for the control group. Analysis showed that steps completed significantly correlated with rearrests and recidivism and that the correlation between number of aftercare sessions and recidivism approached significance.

Treating drunk drivers with Moral Reconation Therapy: a three-year report

115 DWI-convicted male inmates were treated with the cognitive behavioral system of Moral Reconation Therapy during their incarceration. Three years after their release, subjects' postrelease arrest and reincarceration records were collected. In the treated group, 24 subjects participated in an extended aftercare program and were compared to a control group of 65 DWI-convicted inmates who did not enter treatment due to limited bed space. Analysis showed reincarceration rates of 36.9% for the 65 controls, 22.6% of the 115 treated subjects, and only 16.7% of the 24 aftercare clients.

Treating drunk drivers with Moral Reconation Therapy: a two-year recidivism study

115 DWI-convicted male inmates were treated with Moral Reconation Therapy during incarceration. Nearly two years after their release, subjects' postrelease arrest records were collected. Treatment group data were compared to a control group of 65 inmates who applied but did not enter treatment as bed space was limited. Analysis showed that 10.4% of the treatment group obtained additional DWI arrests after release compared to 15.6% of the control group. 14.3% of treated subjects received additional sentences compared to 21.5% of nontreated controls. Results were also analyzed for a group of 24 treated subjects who continued to participate in treatment after release. This aftercare group showed a postrelease DWI rate of only 4.2% and reincarceration rate of 8.3%.

Relationship of DUI recidivism to moral reasoning, sensation seeking, and MacAndrew alcoholism scores

115 convicted male DUI offenders were treated with Moral Reconation Therapy during their incarceration. Postrelease recidivism status (arrests) was correlated with the pretest, posttest, and change scores on the MacAndrew Alcoholism Scale, Sensation Seeking Scale, Life-purpose scores, and Moral Reasoning scores. Analysis showed that recidivism correlated positively and significantly with the pretest scores on the MacAndrew scale and approached significance with both pre- and posttest scores on the Sensation Seeking Scale. Recidivism status correlated negatively and significantly with scores on the highest levels of moral reasoning (Scale 6 pretest and posttest and Principled Reasoning pretest).

Treating drunk drivers with moral reconation therapy: a one-year recidivism report

115 convicted drunk drivers were treated with Moral Reconation Therapy during their incarceration. Postrelease recidivism (rearrest) and convictions of these treated subjects was compared to a control group of 65 convicted drunk drivers who did not receive treatment due to limited bed space. Analysis showed a rearrest rate of 20% for the treated group during the first year of the program's operation compared to 27.6% for the control group during the same period. Subjects who participated in a structured aftercare program after release showed only a 4.3% recidivism rate.

Effects of moral reconation therapy upon moral reasoning, life purpose, and recidivism among drug and alcohol offenders

40 incarcerated DWI offenders and 62 drug offenders who were treated with Moral Reconation Therapy were assessed with respect to levels of moral reasoning, their perceived purpose in life, and subsequent recidivism. Analysis showed that, as clients progress in the program, levels of moral reasoning and purpose in life increase significantly. Level of moral reasoning appears to increase with clients' completion of therapeutic steps. Preliminary recidivism data on 103 male and female inmate-clients who have participated in an aftercare program using the therapy appear encouraging.

Moral reconation therapy: a systematic step-by-step treatment system for treatment resistant clients

Moral Reconation Therapy is a systematic treatment strategy designed to enhance ego, social, moral, and positive behavioral growth in a progressive, step-by-step fashion. It is based upon the assumption that fully functioning, reasonably content, happy persons have a strong sense of identity and that their behavior and relationships are based upon relatively high moral judgment levels. The therapist strives to reeducate clients socially, morally, and behaviorally and to instill appropriate goals, motivation, and values. Moral Reconation Therapy has slowly evolved in response to the unique needs of particular client populations who are considered resistant to treatment. The therapy is an adaptable and utilitarian treatment system. This article is a review of the treatment system and relevant personality theory, and a description of how the system is applied to drug abusers and clients with antisocial personalities. In addition, the article presents preliminary research on the system.

One-day dropouts from correctional drug treatment

13 one-day dropouts of treatment scored on the MMPI more impulsive, antisocial, and pathological than the stayers with whom they were matched. Dropouts also had used drugs longer (6.46 vs 3.23 yr.).