Lung cancer physicians' referral practices for palliative care consultation

BACKGROUND

Integration of palliative care with standard oncologic care improves quality of life and survival of lung cancer patients. We surveyed physicians to identify factors influencing their decisions for referral to palliative care.

METHODS

We provided a self-administered questionnaire to physicians caring for lung cancer patients at five medical centers. The questionnaire asked about practices and views with respect to palliative care referral. We used multiple regression analysis to identify predictors of low referral rates (<25%).

RESULTS

Of 155 physicians who returned survey responses, 75 (48%) reported referring <25% of patients for palliative care consultation. Multivariate analysis, controlling for provider characteristics, found that low referral rates were associated with physicians' concerns that palliative care referral would alarm patients and families [odds ratio (OR) 0.45, 95% confidence interval (CI) 0.21-0.98], while the belief that palliative care specialists have more time to discuss complex issues (OR 3.07, 95% CI 1.56-6.02) was associated with higher rates of referral.

CONCLUSIONS

Although palliative care consultation is increasingly available and recommended throughout the trajectory of lung cancer, our data indicate it is underutilized. Understanding factors influencing decisions to refer can be used to improve integration of palliative care as part of lung cancer management.

Maximum geographic range of a mutant allele considered as a subtype of a Brownian branching random field

A rare allelic type is modeled as a field of individuals diffusing independently in d-dimensional space (d = 1,2,...), in which individuals are replaced by random numbers of offspring at a constant rate. In an infinite-allele model with selectively identical alleles, the offspring distribution would have mean 1 - u, in which u is the mutation rate; otherwise mean (1 - u)w, in which w is the relative fitness of the allele. Let p(x) be the probability that some descendent of an individual initially at zero diffuses unilaterally as far as x(d = 1), or else the probability that some descendent of an individual at x diffuses within a > 0 of the origin (d >/= 2). A nonlinear differential equation is found for p(x) that is solvable for d = 1 and related to Emden's equation for d >/= 2. For p(x) >/= 10(-4) and u </= 10(-5), genetic drift is more important than mutation in the behavior of p(x) (d = 1). If u = 0 and w = 1, p(x) approximately C/x(2) as x --> infinity for d </= 3. As a mathematical application, it is shown that if the initial distribution is uniform Poisson, a bounded open set K is visited by individuals in the field at arbitrarily large times if d >/= 2 but not if d = 1.

The impact of synthesis teaching and parent training with mothers of conduct-disordered children

A procedure to enhance the impact of parent training with multistressed mother-child dyads was explored with 29 clinic-referred dyads. The procedure, called synthesis teaching, was provided for one randomly selected group of dyads, while the other group was engaged in problem discussions about their children. Both groups received parent training as the principal intervention for the mothers' conduct-disordered children. Results showed that these interventions had no effects on dyads in the clinic setting, but had a progressively more significant effect at home for the synthesis teaching group. That is, mothers in this group showed reductions in their indiscriminate parenting and their children demonstrated behavioral improvements. In contrast, mothers in the control group did not change their behavior and their children did not demonstrate observed behavioral changes. Interpretations of the results center on how synthesis teaching might have produced these effects.

Efficacy of argon laser photocoagulation in the treatment of circinate diabetic retinopathy

We evaluated 115 eyes in 105 diabetic patients with circinate retinopathy and, in most cases, associated macular edema. Of these 115 eyes, 68 were treated with argon laser photocoagulation to leaking vessels, primarily in the center of the circinate ring. Forty-seven eyes that had similar findings but received no treatment were followed up for one year and some patients were followed up for as long as three years. In each year of follow-up the treated eyes did significantly better visually than the untreated eyes. The circinate complex was eliminated in 23 of the 24 treated eyes (96%) followed up for three years, whereas it disappeared in only two of the ten untreated eyes (20%). Complete resolution of macular edema, however, was achieved in only two of the treated eyes (3%) and in none of the untreated eyes. Eyes with initial visual acuities of 6/18 (20/60) or better did significantly better with treatment than eyes treated after visual acuity was less than 6/18 (20/60). The former group was the only one to show a mean improvement in visual acuity.

Disparities in obstructive sleep apnea and its management between a minority-serving institution and a voluntary hospital

We assessed disparities in severity of obstructive sleep apnea (OSA) and associated comorbidities, as well as in provision of sleep medicine health care, between patients evaluated for OSA in a voluntary hospital (VH) primarily serving a middle-class population with health-care insurance and a city hospital-based minority-serving institution (MSI) largely treating lower income, uninsured, and indigent patients. A retrospective chart review of patients evaluated for OSA at the VH (n=200) and at the MSI (n=103) was performed. Despite similar age and apnea hypopnea index, MSI patients had a greater body mass index, higher daytime systemic blood pressure, more comorbid medical conditions, and a lower minimum sleep SaO2 than VH patients. Systemic hypertension, diabetes mellitus, asthma, and congestive heart failure were more prevalent in the MSI group. Forty-two percent of the MSI patients diagnosed with OSA failed to follow up for treatment compared with 7% in the VH group, p<0.001. Disparities in OSA-associated comorbid conditions, as well as in delivery of sleep medicine-related health care, were evident between the VH and MSI groups. These findings suggest that OSA may be an important factor contributing to socioeconomic-based differences in morbidity and mortality.

Empyema due to ventriculopleural shunt

Empyema developing seven weeks after craniotomy in a 62-year-old black woman with an ipsilateral ventriculopleural (V-PL) shunt is described. Infection of the pleural space presumably resulted from transfer of organisms from a proximal V-PL shunt infection to the thorax. Empyema resulting from V-PL shunt infection has not previously been reported. Pleural effusions in patients with V-PL shunts must be considered as a potential site of infection with possible development of empyema.

HTLV-1-associated adult T cell leukemia lymphoma presenting as granulomatous pneumocystis jiroveci pneumonia (PJP) and hypercalcemia

BACKGROUND

Since the initial description of human T cell lymphotropic virus (HTLV-1), clusters of this infection have been detected globally. Unlike HIV infection, most patients infected with HTLV-1 remain asymptomatic throughout their lifetime.

CASE REPORT

We report the case of a 39-year-old Afro-Caribbean man with HTLV-1 infection presenting as hypercalcemia and granulomatous pneumocystis jiroveci pneumonia.

RESULTS

Interestingly, the hypercalcemia presented with normal parathyroid hormone-related protein and low 1,25 dihydroxyvitamin D levels, and the presence of pneumocystis jiroveci in the granulomas was diagnosed with transbronchial biopsy taken during bronchoscopy. HTLV-1-associated adult T cell leukemia lymphoma (ATLL) was diagnosed in this patient by bone marrow and lymph node biopsy.

CONCLUSION

Increased bone resorption, likely cytokine-mediated, is the most likely mechanism of hypercalcemia in this patient. This is believed to be the first description of this type of reaction to pneumocystis jiroveci in a HTLV-1-infected ATLL patient.

A new intraocular aspiration probe with bipolar cautery and reflux capabilities

The design of the Mentor Wet-Field eraser (Mentor O & O Inc, Norwell, Mass) has been modified so as to include fluid aspiration and reflux capabilities. This 20-gauge disposable probe minimizes instrument exchange through sclerotomy ports and provides sensitive control over reflux action by minimizing the dead-space volume over which reflux occurs. Safer manipulation of detached retina, membranes, and clots is therefore achieved.

Distribution of ferrochelatase activity in density gradient separated bone marrow cells

A simple, reproducible, and economical procedure for separating bone marrow cells into distinct populations and stages of maturation was developed and used to investigate the distribution of ferrochelatase activity in rat bone marrow cells. Density gradient ultracentrifugation of normal rat marrows on discontinuous arabinogalactan layers of 16.5-30.0% resulted in six distinct fractions enriched for myeloblasts, neutrophils, pronormoblasts, normoblasts, or lymphocytes. Segregation reflecting different stages of cell development was demonstrated. Neutrophils appeared at a greater density and were clearly separated from precursor myeloblasts. Normoblasts appeared at a greater density and were clearly separated from precursor pronormoblasts. Lymphocyte distribution within the gradient followed a normal curve (P < 0.05). A single gradient layer which consisted of greater than 80% lymphocytes was shown to be associated with significantly increased (P < 0.05) ferrochelatase specific activity (units/mg protein); the remaining cell populations did not differ significantly from each other in specific activity.

IgA:IgM and IgA:IgA hybrid hybridomas secrete heteropolymeric immunoglobulins that are polyvalent and bispecific

Polyvalent bispecific antibodies were secreted by hybrid hybridoma cells when both parental clones expressed a naturally polymerizing immunoglobulin. Hybrid hybridomas made from IgA lambda 2 anti-trinitrophenyl (TNP) and IgA kappa anti-phosphocholine (PC) parental cells secreted polymeric IgA antibodies that bound both TNP and PC. Some of the TNP binding was dissociated from the PC binding under conditions of mild reduction and alkylation suggesting that the bispecific polymeric IgA contained disulfide-linked parental monomers as well as bispecific hybrid monomers. Hybrid hybridomas constructed from IgA lambda 2 anti-TNP and IgM kappa anti-ox erythrocyte parental cells secreted bispecific, polymeric immunoglobulin that contained mu-, alpha-, kappa-, and lambda 2-chains. The mu and kappa-chains dissociated from the alpha- and lambda 2-chains under conditions of mild reduction and alkylation, indicating that both parental monomers had been incorporated into the same polymeric immunoglobulin to form a heteropolymeric antibody molecule. Heterologous pairing of alpha and mu heavy chains in monomers was not detected. Hybrid hybridomas constructed from IgA lambda 2 and IgG3 lambda 2 or IgA lambda 2 and IgG1 kappa parents co-secreted both parental immunoglobulins, but the antibodies secreted by these clones did not form heteropolymers or exhibit heterologous heavy chain pairing. These findings establish that polyvalent, bispecific, polymeric immunoglobulin molecules can be produced by hybrid hybridomas when both parents express a naturally polymerizing class of heavy chain but not when only one parent does. Hybrid hybridomas that produce heteropolymeric immunoglobulins are sources of high avidity bispecific antibodies that may find a number of basic and practical applications. The hybridoma cells that produce these antibodies may provide useful tools for investigating the in situ determinants of immunoglobulin chain association and the regulation of antibody assembly and secretion.

IgA:IgM and IgA:IgA hybrid hybridomas secrete heteropolymeric immunoglobulins that are polyvalent and bispecific

Polyvalent bispecific antibodies were secreted by hybrid hybridoma cells when both parental clones expressed a naturally polymerizing immunoglobulin. Hybrid hybridomas made from IgA lambda 2 anti-trinitrophenyl (TNP) and IgA kappa anti-phosphocholine (PC) parental cells secreted polymeric IgA antibodies that bound both TNP and PC. Some of the TNP binding was dissociated from the PC binding under conditions of mild reduction and alkylation suggesting that the bispecific polymeric IgA contained disulfide-linked parental monomers as well as bispecific hybrid monomers. Hybrid hybridomas constructed from IgA lambda 2 anti-TNP and IgM kappa anti-ox erythrocyte parental cells secreted bispecific, polymeric immunoglobulin that contained mu-, alpha-, kappa-, and lambda 2-chains. The mu and kappa-chains dissociated from the alpha- and lambda 2-chains under conditions of mild reduction and alkylation, indicating that both parental monomers had been incorporated into the same polymeric immunoglobulin to form a heteropolymeric antibody molecule. Heterologous pairing of alpha and mu heavy chains in monomers was not detected. Hybrid hybridomas constructed from IgA lambda 2 and IgG3 lambda 2 or IgA lambda 2 and IgG1 kappa parents co-secreted both parental immunoglobulins, but the antibodies secreted by these clones did not form heteropolymers or exhibit heterologous heavy chain pairing. These findings establish that polyvalent, bispecific, polymeric immunoglobulin molecules can be produced by hybrid hybridomas when both parents express a naturally polymerizing class of heavy chain but not when only one parent does. Hybrid hybridomas that produce heteropolymeric immunoglobulins are sources of high avidity bispecific antibodies that may find a number of basic and practical applications. The hybridoma cells that produce these antibodies may provide useful tools for investigating the in situ determinants of immunoglobulin chain association and the regulation of antibody assembly and secretion.

Castleman's disease and superior vena cava thrombi: a rare presentation and a review of the literature

Castleman's disease is a clinicopathological entity in which growth of lymphoid tissue is unregulated. It may present as asymptomatic involvement of one lymph node group or as a multicentric disease with systemic symptoms. Unlike localized disease, for which surgical excision is curative regardless of the histological type, multicentric disease often necessitates aggressive systemic therapy and portends a poor outcome. Superior vena caval thrombosis is an uncommon manifestation associated with Castleman's disease.

Successful management of acute retinal necrosis with intravenous acyclovir

Two patients (3 eyes) had a history and clinical findings typical of acute retinal necrosis syndrome. Ten-day treatment with intravenous acyclovir and topical cycloplegia resulted in rapid resolution of the vitreoretinal findings and a swift return to near normal vision. All three eyes have maintained normal vision, and there have been no retinal detachments over a year after treatment.

The impact of synthesis teaching and parent training with mothers of conduct-disordered children

A procedure to enhance the impact of parent training with multistressed mother-child dyads was explored with 29 clinic-referred dyads. The procedure, called synthesis teaching, was provided for one randomly selected group of dyads, while the other group was engaged in problem discussions about their children. Both groups received parent training as the principal intervention for the mothers' conduct-disordered children. Results showed that these interventions had no effects on dyads in the clinic setting, but had a progressively more significant effect at home for the synthesis teaching group. That is, mothers in this group showed reductions in their indiscriminate parenting and their children demonstrated behavioral improvements. In contrast, mothers in the control group did not change their behavior and their children did not demonstrate observed behavioral changes. Interpretations of the results center on how synthesis teaching might have produced these effects.

An urban nutrition education and rehabilitation centre: a description of the programme and change in nutritional status of children who were enrolled

We report on a community-based day care nutrition rehabilitation and education centre which was established by the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) in a slum in Dhaka, Bangladesh. Between March-December, 1985 approximately 10 children aged 1 to 5 years with a percent weight for height (% wt/ht) of 60 to 85 were enrolled in each of 9 sessions which were 3 to 5 weeks long. The children were fed 3 meals and 2 snacks daily made from locally available inexpensive foods. A nutrition education programme, developed with input from several feeding centres in Dhaka, included daily lessons, participatory cooking and personal hygiene sessions. Of the 85 children entering the programme, 82 (95%) completed 3 or more weeks. Relative to baseline, a median increase of 8.7% wt/ht was observed at 5 weeks (p less than 0.001), with the greatest improvement occurring in those children presenting with the lowest weights. Median increases of 7.2 and 7.4% wt/ht were noted 6 and 10 months after admission, respectively. Gender and minor illness did not have a significant impact on change in nutritional status. Poor performance of mothers in assigned chores was associated with inferior improvement in nutritional status 5 weeks but not 6 months post-admission. These results suggest that the intervention implemented by the centre may have been effective in improving nutritional status and that more rigorous evaluation of participants in relation to suitably matched concurrent controls should be performed.