Frailty is associated with long-term outcome in patients with sepsis who are over 80 years old: results from an observational study in 241 European ICUs

BACKGROUND

Sepsis is one of the most frequent reasons for acute intensive care unit (ICU) admission of very old patients and mortality rates are high. However, the impact of pre-existing physical and cognitive function on long-term outcome of ICU patients ≥ 80 years old (very old intensive care patients (VIPs)) with sepsis is unclear.

OBJECTIVE

To investigate both the short- and long-term mortality of VIPs admitted with sepsis and assess the relation of mortality with pre-existing physical and cognitive function.

DESIGN

Prospective cohort study.

SETTING

241 ICUs from 22 European countries in a six-month period between May 2018 and May 2019.

SUBJECTS

Acutely admitted ICU patients aged ≥80 years with sequential organ failure assessment (SOFA) score ≥ 2.

METHODS

Sepsis was defined according to the sepsis 3.0 criteria. Patients with sepsis as an admission diagnosis were compared with other acutely admitted patients. In addition to patients' characteristics, disease severity, information about comorbidity and polypharmacy and pre-existing physical and cognitive function were collected.

RESULTS

Out of 3,596 acutely admitted VIPs with SOFA score ≥ 2, a group of 532 patients with sepsis were compared to other admissions. Predictors for 6-month mortality were age (per 5 years): Hazard ratio (HR, 1.16 (95% confidence interval (CI), 1.09-1.25, P < 0.0001), SOFA (per one-point): HR, 1.16 (95% CI, 1.14-1.17, P < 0.0001) and frailty (CFS > 4): HR, 1.34 (95% CI, 1.18-1.51, P < 0.0001).

CONCLUSIONS

There is substantial long-term mortality in VIPs admitted with sepsis. Frailty, age and disease severity were identified as predictors of long-term mortality in VIPs admitted with sepsis.

Family Studies of Patients with Reduced Ristocetin Aggregation and Abnormalities of Factor VIII and/or Platelet Function

Factor VIII procoagulant activity (VIIIc), antigen (vWa), mobility of the antigen on two dimensional Immunoelectrophoresis and platelet function were studied in 9 families with reduced ristocetin induced platelet aggregation rate (RIPA) and/or deficiency of plasma factor(s) required for ristocetin aggregation of washed normal platelets (vWf). The families could be subdivided into 4 groups. Group I showed dominant inheritance and reduced levels of VIIIc and vWa characteristic of typical von Willebrand’s disease. All patients had reduced vWf and in 7 of 10 RIPA was reduced. Group II showed normal levels of VIIIc but reduced vWa. All showed reduced vWf but RIPA was reduced in one patient only. There was a good correlation between vWf and vWa and VIIIc in both groups. The bleeding time correlated with vWf in group I but not group II. Group III showed normal or nearly normal VIIIc and vWa but there was an increased mobility of vWa compared to normals and to groups I and II. RIPA was markedly reduced as was the vWf in one patient. Group IV is represented by one child with a strong family history of bleeding, who had reduced RIPA and defective platelet release reaction. The vWf in this child was normal and the ratio between VIIIc and vWa was similar to that seen in carriers of haemophilia. This spectrum of abnormalities of ristocetin aggregation justifies the use of the term ‘von Willebrand’s syndrome’.

Potential for using a hermetically-sealed, positive-pressured isocage system for studies involving germ-free mice outside a flexible-film isolator

Germ-free mice are used to examine questions about the role of the gut microbiota in development of diseases. Generally these animals are maintained in semi-rigid or flexible-film isolators to ensure their continued sterility or, if colonized with specific microbiota, to ensure that no new species are introduced. Here, we describe the use of a caging system in which individual cages are hermetically sealed and have their own filtered positive airflow. This isopositive caging system requires less space and reduces animal housing costs. By using strict sterile techniques, we kept mice germ-free in this caging system for 12 weeks. We also used this caging system and approach to conduct studies evaluating a) the stability of the microbiome in germ-free mice receiving a fecal transplant and b) the stability of dietary-induced microbiota changes in fecal-transplanted mice. As has been shown in fecal transfer studies in isolators, we found that the transferred microbiota stabilizes as early as 2 weeks post transfer although recipient microbiota did not completely recapitulate those of the donors. Interestingly, we also noted some sex effects in these studies indicating that the sex of recipients or donors may play a role in colonization of microbiota. However, a larger study will be needed to determine what role, if any, sex plays in colonization of microbiota. Based on our studies, an isopositive caging system may be utilized to test multiple donor samples for their effects on phenotypes of mice in both normal and disease states even with limited available space for housing.

Improving rehabilitation after critical illness through outpatient physiotherapy classes and essential amino acid supplement: A randomized controlled trial

PURPOSE

Patients recovering from critical illness may be left with significant muscle mass loss. This study aimed to evaluate whether a 6-week program of enhanced physiotherapy and structured exercise (PEPSE) and an essential amino acid supplement drink (glutamine and essential amino acid mixture [GEAA]) improves physical and psychological recovery.

MATERIALS AND METHODS

Intensive care patients aged 45 years or older, with a combined intensive care unit stay/pre-intensive care unit stay of 5 days or more were recruited to a randomized controlled trial examining the effect of PEPSE and GEAA on recovery. The 2 factors were tested in a 2 × 2 factorial design: (1) GEAA drink twice daily for 3 months and (2) 6-week PEPSE in first 3 months. Primary efficacy outcome was an improvement in the 6-minute walking test at 3 months.

RESULTS

A total of 93 patients were randomized to the study. Patients receiving the PEPSE and GEA had the biggest gains in distance walked in 6-minute walking test (P < .0001). There were also significant reductions in rates of anxiety in study groups control supplement/PEPSE (P = .047) and GEAA supplement/PEPSE (P = .036) and for GEAA supplement/PEPSE in depression (P = .0009).

CONCLUSION

Enhanced rehabilitation combined with GEAA supplement may enhance physical recovery and reduce anxiety and depression.

Does participation in CME SLG (small group learning) influence medical practice? The experience of general practitioners attending CME SLG after the introduction of the Medical Practitioners Act

In Ireland, Continuing Medical Education (CME) for GPs is delivered by a national network of 37 tutors who coordinate learning sessions for between 2 and 5 small groups of physicians (SGL). Each group meets up to 8 times per year; 1100 to 1700 doctors attend CME-SGL nationally each month, with numbers increased since the Irish Medical Practitioners Act. This study investigated whether CME-SGL improves clinical knowledge of doctors. A questionnaire was administered by 35 CME tutors at their scheduled meetings in November/December 2012; 1366 (96%) attendees responded. In total 1312 (97%) doctors reported that they want to improve their clinical practice, and 1143 (86.3%) agreed that CME had helped them to do so. Of these, 1041 (91.1%) doctors gave specific examples. This survey provides evidence of how CME-SGL has impacted on the knowledge, skills, attitudes, prescribing, use of investigations, and application of guidelines and audit of these Irish GPs.

Promoting social inclusion through Unified Sports for youth with intellectual disabilities: a five-nation study

BACKGROUND

Although the promotion of social inclusion through sports has received increased attention with other disadvantaged groups, this is not the case for children and adults with intellectual disability who experience marked social isolation. The study evaluated the outcomes from one sports programme with particular reference to the processes that were perceived to enhance social inclusion.

METHOD

The Youth Unified Sports programme of Special Olympics combines players with intellectual disabilities (called athletes) and those without intellectual disabilities (called partners) of similar skill level in the same sports teams for training and competition. Alongside the development of sporting skills, the programme offers athletes a platform to socialise with peers and to take part in the life of their community. Unified football and basketball teams from five countries--Germany, Hungary, Poland, Serbia and Ukraine--participated. Individual and group interviews were held with athletes, partners, coaches, parents and community leaders: totalling around 40 informants per country.

RESULTS

Qualitative data analysis identified four thematic processes that were perceived by informants across all countries and the two sports to facilitate social inclusion of athletes. These were: (1) the personal development of athletes and partners; (2) the creation of inclusive and equal bonds; (3) the promotion of positive perceptions of athletes; and (4) building alliances within local communities.

CONCLUSIONS

Unified Sports does provide a vehicle for promoting the social inclusion of people with intellectual disabilities that is theoretically credible in terms of social capital scholarship and which contains lessons for advancing social inclusion in other contexts. Nonetheless, certain limitations are identified that require further consideration to enhance athletes' social inclusion in the wider community.

What do general practitioners think of the new professional competence scheme?

The Irish Medical Practitioners Act 2007 places a statutory obligation on all registered Medical Practitioners to maintain their professional competence by participating in a recognised Professional Competence Scheme. A questionnaire survey was conducted among 48 GPs attending educational meetings to see if doctors had concerns about the Professional Competence Scheme and to ask if they felt they had the necessary time, skills and knowledge to carry out an audit. Twenty-eight GPs (58%) had concerns regarding their participation in the Professional Competence Scheme; 75% were concerned about the time required, and 67% felt they needed further education about the scheme. Although 73% of doctors reported that they understand how to undertake a clinical audit and 50% reported they have carried out an audit in practice, 60% have never had any teaching on audit and 85% would like teaching in this area. Only 48% of the group surveyed felt that audit was practical in their current practice. Doctors have some concerns about the new Professional Competence Scheme, including the audit component. In particular, they report a requirement for more teaching in this area, and are concerned about the time involved.

What do health visitors do? A national survey of activities and service organisation

BACKGROUND

Early interventions targeting health inequalities, and changing policies for mothers and pre-school children, have focused attention on existing interventions.

OBJECTIVES

To collect baseline data about current roles and activities undertaken by health visitors; and to understand the relationship between existing services and recommended practice shown in research about preventive programmes.

METHODS

A national postal survey was used to collect data about current roles and activities undertaken by health visitors across the UK (n=1459, 46% response rate).

RESULTS

A description is provided of activities undertaken and the types of needs addressed by health-visiting services. The established health-visiting purpose of using a caseload of infants and pre-school children as a base from which to reach out to a wider community seems to be still in place, with difficulty. The major focus of their work was on primary and secondary prevention, but included provision for identified problems. Two main patterns of service provision were identified; one 'comprehensive' and one that was more restricted. The 'restricted service,' available in most places, was mainly reactive, with child protection and social factors predominant. Even the 'comprehensive services' were far lower in intensity than programmes shown, through research, to improve family wellness. In addition, less than half of respondents thought that it was always feasible to deliver services as planned.

CONCLUSIONS

The results question the premise, upon which universal provision rests, that all families receive a service offering proactive health promotion and the timely identification of additional health needs.

Bereaved adults with intellectual disabilities: a combined randomized controlled trial and qualitative study of two community-based interventions

BACKGROUND

Bereaved adults with intellectual disabilities are known to experience prolonged and atypical grief which is often unrecognized. The aim of this project was to find an effective way to improve mental health and behavioural outcomes.

METHODS

Subjects were randomized to two different therapeutic interventions: traditional counselling by volunteer bereavement counsellors, and an integrated intervention delivered by carers which offered bereavement specific support. Qualitative and quantitative methods were used to determine their effectiveness and efficacy.

RESULTS

The counselling intervention resulted in measurable gains both clinically and in terms of quality of life; the second intervention proved impracticable in most settings and no improvement in mental health or behaviour resulted.

CONCLUSIONS

Despite small numbers, the quantitative findings were highly significant, were supported by the qualitative data, and were of practical relevance to primary care practitioners and specialist mental health and intellectual disability staff.

A review of the emotional, psychiatric and behavioural responses to bereavement in people with intellectual disabilities

BACKGROUND

Our knowledge and understanding of grief and its consequences have grown rapidly in recent years. There is a growing understanding that bereavement and loss represent a very significant event in the lives of people with intellectual disabilities (IDs). To date, there is no systematic review of the literature on the emotional, psychiatric and behavioural responses to bereavement in people with IDs.

METHOD

This comprehensive literature review firstly examines the current opinion regarding the phenomenology of pathological grief in the general population. Research examining the ability of people with IDs to understand the concept of death is explored. In addition, a systematic review of the literature looking at the emotional, behavioural and psychiatric responses to bereavement is carried out.

RESULTS

Bereavement and loss have distinct effects on the mental health, behaviour and emotional lives of people with IDs. Following a bereavement, symptoms of depression and anxiety increase, and general behaviour is altered. Traumatic grief symptoms have not yet been specifically studied and quantified.

CONCLUSIONS

Particular difficulties are associated with researching the effects of bereavement on people with IDs. Further work needs to be done to more accurately describe the nature, time-scale, severity and frequency of the symptoms of traumatic grief in people with IDs, in order to improve assessment and treatment of affected individuals.

Immunocompetent orthotopic isograft mouse model of ovarian cancer for high-intensity focused ultrasound (HIFU) treatment

Ovarian epithelial carcinoma is the most common form of ovarian cancer, causing more deaths than any other cancer in women with gynecologic malignancies in the United States. The poor outcome for women with late-stage ovarian cancer underscores the need for early detection strategies and for new treatment options to be developed. High-intensity focused ultrasound (HIFU) is a therapeutic modality that is safe and effective against various types of solid tumors, and has the potential to serve as a treatment for ovarian cancer. Use of an appropriate animal model is important in obtaining relevant data for translational research. The purpose of the study reported here was to modify and create an immunocompetent orthotopic tumor isograft model for evaluation of intra-operative HIFU application. This model would resemble the clinical presentation of human patients with late-stage ovarian cancer. We were able to consistently produce a surgical model that presented with a single large, intra-abdominal tumor nodule within the left ovarian bursa, as well as multiple small nodules on the surface of other organs and tissues. This technique may also be used to refine other tumor models, using the ovarian bursa as an implant site for heterotopic tumor isografts.

Ireland, the UK and Europe: a review of undergraduate medical education in palliative care

Palliative Care is an important and emerging medical speciality, formally recognised by the Irish Medical Council in June 1995. Three years previously, in 1992, the Association of Palliative Medicine for Great Britain and Ireland published an official curriculum for undergraduate medical education in palliative care. The European Association of Palliative Care held a workshop the following year and reported that, with the exception of the UK, education for medical students is incomplete. This review examines the evidence that European undergraduate medical education in palliative care is underdeveloped. Key elements of effective undergraduate teaching programmes in this discipline are identified. Finally, it is noted that little has been written about undergraduate palliative care education in Irish medical schools; the situation in this country is thus unknown. A study to determine current education in palliative care in Irish medical schools is required.

The effects of fear of humans and pre-slaughter handling on the meat quality of pigs

This study using 90 commercial pigs examined the relationships between the handling that pigs received immediately prior to slaughter and some measures of their meat quality. A number of significant correlations were found between the number of negative interactions that pigs received from the stockperson and subsequent meat quality of the pigs. For example, the number of highly negative interactions received by the pigs was negatively (P < 0.01) correlated with plasma glucose concentrations post-slaughter and positively correlated (P < 0.05) with both post-slaughter plasma lactate concentrations and the light reflectance of the ham. Most of these highly negative interactions were prods with an electric goad. Both the number of interactions by the pig with the experimenter in a standard test used to assess fear of humans and the time taken by the pig to move along the final route to the stunning area were positively correlated (P < 0.05) with the number of highly negative interactions received by the pig prior to slaughter. Regression analysis revealed that the number of highly negative interactions received by the pig, plasma lactate concentration, and the time to physically interact by the pig with the experimenter in the standard test were significant (P < 0.001) predictors of ham lightness. These variables accounted for 18% of the variance in ham lightness. It is concluded that there are some important associations between the behaviour of the stockperson and the muscle physiology of pigs. Although no significant associations were found between stockperson behaviour and ham pH, the correlations between stockperson behaviour, plasma lactate and glucose, and muscle lightness reflect increased muscle glycogenolysis, presumably associated with increased handling stress prior to slaughter. Such results indicate the opportunity to manipulate the behaviour of stockpeople prior to slaughter to improve meat quality.

The effects of cognitive behavioral intervention on the attitude and behavior of stockpersons and the behavior and productivity of commercial dairy cows

Two experiments, one involving 29 commercial farms and the other involving 94 commercial farms, were conducted to examine the effects of a training program targeting a number of attitudinal and behavioral variables in stockpeople. These stockperson variables had been previously shown to be related to fear of humans and productivity of commercial cows. In both experiments, two treatments were imposed: an Intervention treatment, consisting of a cognitive-behavioral intervention procedure designed to improve the attitude and behavior of stockpeople toward cows, and a Control treatment, in which no intervention was attempted. In Exp. 1, an analysis of covariance, using previous lactation variables as the covariate, revealed effects of the Intervention treatment on the attitude and behavior of the stockpeople and the behavior of cows. Stockpeople at Intervention farms showed more (P < 0.01) positive beliefs about handling cows and used a lower (P < 0.05) number and percentage of negative tactile interactions in handling cows than stockpeople at the Control farms. Cows at the Intervention farms showed a shorter (P < 0.05) flight distance to humans, indicating a lower level of fear of humans by these cows. However, 36% of the Intervention farms failed to show a reduction in average flight distance over the two lactations. Although there was no significant treatment effect on milk yield, the Intervention farms in which fear levels declined following the intervention had a higher (P < 0.05) milk yield than the other farms. In Exp. 2, a significant (P < 0.05) increase was found in the milk yield of cows following the Intervention treatment. Similar treatment effects were observed on both milk protein and milk fat. These results indicate that cognitive-behavioral interventions that successfully target the key attitudes and behavior of stockpeople that regulate the cow's fear of humans offer the industry good opportunities to improve the productivity of cows.

Nurses taking on junior doctors' work: a confusion of accountability

The number of hospital based posts in which nurses take over clinical work previously done by junior doctors is growing. Accountability for the scope of such new roles and the standards of practice which apply to them are still unclear. When analysed together and compared, the regulations arising from the professional bodies (GMC and UKCC), civil law concerning certain wrongs to patients, and employment law are sometimes contradictory and hard to interpret. The resulting uncertainties about appropriate management for clinical roles evolving between the professions, coupled with an increasingly litigious public, put the nurses and consultants involved at risk of complaints and of disciplinary and legal action. Drawing on our current research into changing clinical roles at the medical-nursing interface, we suggest strategies to reduce risk. Doctors and nurses should be equal partners in planning and managing these new posts, patients should be informed adequately about the nature of the postholder's role and training, significant changes in the work of such postholders should be formally acknowledged by the employer and relevant insurers, individuals taking up new roles should have access to legal advice and support to cover legal risk, and national regulatory bodies need to work together to harmonise their codes of practice in relation to changing clinical roles between the professions.

An evaluation of percutaneous endoscopic gastrostomy feeding in AIDS

Between October 1991 and October 1993, 17 AIDS patients (14 intravenous drug users, 3 sexually acquired) were commenced on percutaneous endoscopic gastrostomy (PEG) feeding in St James's Hospital. Indications were progressive weight loss related to severe anorexia, persistent oesophageal candidiasis (5) and absence of gag reflex (1). Two patients requested PEG tube removal after one week because of crampy abdominal pain without peritonitis. Five patients died from AIDS related infections within 6 weeks of PEG insertion. Ten patients were followed up for > 2 months (mean 5.2 months, range 2.5-15.5 months). In these 10 patients, 1 patient developed a PEG site infection which responded to topical antibiotics. There were no other complications. There was a significant (P < 0.001) increase in energy and protein intake at 2 months. Variant degrees of weight gain occurred in all patients (mean 2.6 kg) (P < 0.01). Small but significant increases in other anthropometric variables occurred. Patients who died within 6 weeks of PEG insertion were older, and had a lower serum albumin than the group who survived > 2 months (P < 0.01). A self-administered questionnaire demonstrated that the majority of patients found PEG feeding acceptable and preferable to nasogastric (NG) feeding.

With nurse practitioners, who needs house officers?

The boundaries between the work of doctors and that of nurses are changing, with nurses taking over important parts of junior hospital doctors' clinical work. In 1993 an exploratory study was carried out to identify the professional, educational, and management issues that such developments raise. Interviews were carried out with a range of stakeholders in three innovatory posts in which nurses were doing much of the clinical work of house officers. A complex picture of perceived benefits and problems for patients, junior doctors, and nurses emerged. These seemed to be associated with (a) the extent to which the contribution of professional nursing was valued in the new role and (b) the amount of clinical discretion which the postholder was allowed, this depending on the type of preparatory education provided and the management of the post. The study points to the need for strategic issues--such as the development of appropriate education and the professional recognition of these new clinical roles--to be addressed at a national and regional level.

Vitamin B12 and folate status in human immunodeficiency virus infection

Vitamin B12 and folate status were determined in 35 male HIV seropositive patients. Of these, 16 were asymptomatic (CDC II/III) and 19 were symptomatic (CDC IV) according to the Centre for Disease Control (CDC) Classification. Deviations from normal values for serum B12, serum folate and red cell folate were not a common finding in this sample of patients. No patient had low serum B12. One CDC IV patient and two CDC II/III patients were found to have raised serum B12. Dietary intake of vitamin B12 was well above the Reference Nutrient Intake for all patients. Three patients displayed low folate values (one CDC IV patient had low serum folate, one had low red cell folate and one CDC II/III patient had both). No patient displayed elevated serum or red cell folate. Only 56% of the CDC II/III and 36% of the CDC IV group were meeting the Lower Reference Nutrient Intake for folate. The only significant difference between the CDC II/III group and the CDC IV group was a lower red cell folate (although within the normal laboratory range) in the CDC IV group. There was no significant difference in dietary intake and haematological status between the drug users and the homosexuals.

An analysis of radiotherapy data from the CNS cancer consortium's randomized prospective trial comparing AZQ to BCNU in the treatment of patients with primary malignant brain tumors. The CNS cancer consortium

The CNS Cancer Consortium has conducted a phase III study comparing diaziquone (AZQ) with carmustine (BCNU) in the treatment of adults with primary anaplastic glial brain tumors. Patients eligible for this study were 18 years of age or older at the time of biopsy, subtotal resection, or gross total resection of an anaplastic glial brain tumor. Within 3 weeks of surgery, patients received whole brain radiotherapy at 1.7 to 2 Gy per fraction to a total whole brain dose of 42-48 Gy. This was followed by a boost to the tumor bed as ascertained by computed tomography (CT), angiography, and/or magnetic resonance imaging (MRI) of 1.7 to 2 Gy per fraction to a dose of 12-19 Gy. The recommended cumulative dose to the tumor bed was therefore 55-61 Gy. At 8 weeks following radiotherapy, patients were randomized to receive either AZQ at 15 mg/day for 3 days i.v. every 4 weeks or BCNU at 200 mg i.v. every 8 weeks. Chemotherapy was continued for at least 1 year unless death occurred, treatment failure was declared, or toxicity necessitated alteration of therapy. In the 249 randomized patients, there was no difference between the AZQ- and BCNU-treated patients in age, sex distribution, race, tumor histology, type of surgical resection, or Karnofsky performance status (KPS). Age and KPS at the initiation of therapy and tumor histology were the best overall predictors of survival. The type of chemotherapy (AZQ vs BCNU) was not predictive of survival. Two-year Kaplan-Meier survival was 22% in the AZQ-treated patients and 25% in BCNU-treated patients. In an analysis of radiotherapy administered we found that, within the range of doses required for this study, there was no influence of whole brain dose, boost dose, total dose, or size of the boost field on survival. The institution providing radiotherapy (teaching hospital vs nonteaching facility) did not influence survival.

Impaired motor function (clumsiness) in 5 year old children: correlation with neonatal ultrasound scans

All 155 surviving children from a cohort of 200 very low birthweight infants originally studied in 1984-5 were traced. These infants had careful sequential ultrasound examinations in the neonatal period. The children were examined again at entry into school at 5 years of age. The test of motor impairment (TOMI) and the vocabulary subscale of the Wechsler preschool and primary scale of intelligence (WPPSI) were administered to 152 of the index cohort and 144 control children of the same age in the same class at school. Twelve of the cohort had cerebral palsy, but eight of these were in mainstream schools. The index group scored significantly higher on both the TOMI and the WPPSI subscale compared with the controls. The index cases were subdivided on the basis of their neonatal ultrasound scans into four groups: group 1, consistently normal; group 2, 'prolonged flare'; group 3, germinal matrix haemorrhage-intraventricular haemorrhage (GMH-IVH), without parenchymal haemorrhage, but no evidence of prolonged flare; and group 4, both GMH-IVH and prolonged flare. The group of index children with consistently normal ultrasound scans had a higher TOMI and lower WPPSI compared with their controls. There was a statistically significant increase in the TOMI subscore 1 (manual dexterity) in group 4 infants compared with group 1, but not differences between the other groups. Regression analysis suggests that neither prolonged flare nor GMH-IVH has an important individual contribution to the variation, but the low birth weight does have a significant relationship with motor impairment. It appears that relatively minor ultrasound appearances such as prolonged flare and GMH-IVH are associated with motor impairment (clumsiness) at 5 years, but this has a small effect compared with low birth weight.

Fluosol and hyperbaric oxygen as an adjunct to radiation therapy in the treatment of malignant gliomas: a pilot study

Several clinical trials have been reported using Fluosol and oxygen breathing as an adjunct to radiation. Theoretical considerations and animal experiments, however, indicate that a combination of perfluorochemicals and hyperbaric oxygen (HBO) increases tumor oxygenation and radiation response to a greater extent than is seen either with a perfluorochemical and normobaric oxygen or with HBO alone. This is the first report of a pilot study of the use of Fluosol and HBO with radiation in humans. Twenty patients with anaplastic astrocytoma or glioblastoma multiforme were treated in a phase I trial of radiation with Fluosol and HBO at three atmospheres. Total Fluosol dose was escalated from 42 ml/kg in six courses to 80 ml/kg in four courses. Patients were irradiated in an HBO chamber with 600 cGy weekly fractions following Fluosol administration. Sixteen patients completed treatment; no interruption was necessitated by treatment toxicity. The addition of Fluosol/HBO did not increase the incidence of HBO related toxicities. No significant chronic toxicities were seen. This pilot study demonstrates that Fluosol and HBO can safely be used as an adjunct to radiation in the treatment of human tumors.

Intraobserver and interobserver reliability in assessment of neonatal cranial ultrasounds

Intraobserver and interobserver reliability in assessing neonatal cranial ultrasounds for periventricular-intraventricular hemorrhage (PVH-IVH) is not well studied; therefore, studies were designed to address this. For intraobserver reliability 180 cranial ultrasounds (360 hemispheres) were randomly selected from greater than 2000 ultrasounds and read twice by one radiologist in a blinded fashion. Ninety-eight percent were interpreted identically; of the 2% reinterpreted differently, all were initially abnormal but normal on the second reading. The least agreement occurred when interpreting ventricular size. Only four infants (1.1%) were placed in an unfavorable prognostic category (grades III and IV) on the first reading and a favorable prognostic category on the second interpretation (no bleed, grades I and II). To determine interobserver reliability, 20 sonograms were interpreted by eight independent observers representing five institutions. Using the multiple rater kappa kappa statistic, we determined interobserver agreement on overall impression (normal vs. abnormal), presence and extent of PVH-IVH (i.e. grade), presence of residual cyst, and ventricular dilatation. Greatest degree of agreement occurred when determining normal vs. abnormal, residual cyst, no bleed, and grades III and IV PVH-IVH. Poorest agreement occurred when reading grades I and II PVH-IVH and ventricular dilatation. After condensing interpretations of cranial ultrasounds into two prognostic categories, i.e. favorable (no bleed, grades I and II) and unfavorable (grades III and IV), there was excellent agreement among the observers.

Pathologic stage I and II Hodgkin's disease. Long-term results at three Connecticut hospitals

Three radiation therapy departments in Connecticut (Uncas on Thames Hospital, Norwich; Yale-New Haven Hospital, New Haven; and the Hospital of Saint Raphael, New Haven) have consistently used the strategy of staging laparotomy with splenectomy for clinical stage I and II Hodgkin's disease patients with primary radiation therapy as initial therapy for most pathologic stage (PS) I and II patients. From 1971 through 1986, 239 PS I and II patients were treated at these three institutions and 94% received radiation therapy alone as initial treatment. With a minimum follow-up time of one year and a maximum follow-up time of 18 years (mean: 7.3 years), only 19 (8%) of the 239 patients have ultimately died of Hodgkin's disease. Two factors were responsible for the low death rate due to Hodgkin's disease: 1) 176 patients (74%) went into complete remission following initial therapy and did not experience a relapse; and 2) 63 patients relapsed following initial therapy; however, subsequent salvage therapy was successful in 44 (70%) of these 63 patients. The overall 10-year and 18-year survival rates were 81% and 78%, respectively. Staging laparotomy with initial radiation therapy for most PS I and II patients remains an important and highly successful strategy for Hodgkin's disease.

Nutrition in the management of HIV antibody positive patients: a longitudinal study of dietetic out-patient advice

The efficacy of a dietetic service was evaluated in an AIDS clinic; 17 asymptomatic (CDC II) and 17 symptomatic (CDC IV) patients participated in a 12 week evaluation of out-patient dietetic advice. The symptomatic group, classified as CDC stage IV according to the Centre for Disease Control classification, were significantly lighter (P less than 0.05) and had significantly lower values for usual weight, current body mass index, mid-upper arm and mid-arm muscle circumferences and triceps and subscapular skinfold thicknesses (P less than 0.05) at the outset of the study. There were no significant differences in nutrient intakes between the two groups. After 12 weeks of dietetic intervention which included personalised advice, prescription of food supplements and the provision of a special food allowance as social welfare payments for the unemployed, there were significant increases in the intakes of most nutrients, the effect being greater with the symptomatic CDC IV group. It is concluded that dietetic intervention has a significant role to play in the management of HIV antibody positive patients.

Neonatal intracranial hemorrhage: I. Changing pattern in inborn low-birth-weight infants

Many reports of the occurrence of periventricular-intraventricular hemorrhage (PVH-IVH) are biased by the inclusion of both inborn and outborn infants. To obviate this selection bias we examined a large inborn population of low-birth-weight infants to determine if the incidence of PVH-IVH changed over a 3-year interval from March, 1982 through February, 1985. Serial cranial ultrasonography was performed in 463 consecutive infants of birth weight less than or equal to 1500 g who survived for more than 8 h. The incidence of PVH-IVH decreased from 31.5% and 29.3% in years 1 and 2, respectively, to 23.7% in year 3 (P less than 0.05). The latter reflected a fall in the incidence of grades III and IV PVH-IVH, but no change in the incidence of grades I and II. This observation was not attributable to changes in mortality, the distribution of infants by birth weight and estimated gestational age in each year of the study, or infants excluded from the analysis. Contrary to most reports, 21.9% of all PVH-IVH during the 3 years were first diagnosed after 14 days postnatal age and were predominantly grade I. These results document not only a change in the epidemiology of PVH-IVH in an inborn population, but also the importance of serial cranial ultrasonography beyond the first week of life.

Neonatal intracranial hemorrhage: II. Risk factor analysis in an inborn population

The ability to predict the occurrence of neonatal periventricular-intraventricular hemorrhage (PVH-IVH) would be useful in the design of clinical trials to prevent its occurrence. Therefore, data were collected from 463 consecutive infants less than or equal to 1500 g birth weight delivered between March 1, 1982 and February 28, 1985. This large population made it feasible to divide the infants into two groups, using one group to develop a model predictive of ICH and the second group to test the validity of the model. Infants were randomly grouped by sex, race, gestational age, birth weight, month of birth, mortality, and incidence and grade of worst PVH-IVH. In Group A (n = 232), respiratory distress syndrome, ventilator therapy, PaCO2 greater than or equal to 60 mmHg, PO2 less than or equal to 40 mmHg greater than or equal to 2 h, lower 1- and 5-min Apgar scores, lower pediatric estimation of gestational age, and pneumothorax were significantly associated with PVH-IVH by univariant analyses (chi 2, P less than 0.03). Multivariant discriminant analysis performed on Group A revealed that pneumothorax, cesarean section, PaCO2, and ventilator therapy were most predictive of PVH-IVH, but sensitivity was 55% and specificity 78%. Applying the model to Group B, sensitivity decreased to 21% while specificity rose to 93%. Logistic regression, which takes into account non-normally distributed variables, did not improve predictability.(ABSTRACT TRUNCATED AT 250 WORDS)

Fantasy formation: a child analyst's perspective

Unconscious fantasy is the principal unit of psychoanalytic investigation. Though individual fantasies, either conscious or unconscious, may emphasize drive, defense, or superego interests, all fantasy life develops from a limited number of themes; these themes concern drive-related issues, experiences of helplessness, or combinations of both. Fantasy formation and fantasy content undergo developmental change. Sensorimotor, behavioral memories occur prior to fantasy and are influential in determining repetitive behavioral enactments. The complexities of infant behavior do not require the postulation of fantasy or representational memory. A complex, innate, instinctual organization of the newborn, similar in many respects to that of other newborn mammals, and distinct from the psychological organization of the older infant, is suggested as an explanation of these phenomena.

An analysis of potential biases in the loss of indigent infants to follow-up

Loss to follow-up is a major problem in indigent inner-city populations. We evaluated a large, well-described, inborn indigent population of high-risk infants (HRI) and control infants (CI) to assess possible selection biases in loss to follow-up at one year adjusted age. Serial clinic visits, phone calls, and letters and payment of $20.00 for attending at 1 year was used to minimize patient loss. Yet, the 1 year loss rate was high, and among HRI, greater for ventilator-treated infants greater than 1500 g birthweight (71/114; 62%) than for ventilator-treated very-low-birthweight (VLBW; less than 1500 g) infants (39/108; 36%) or non-ventilated VLBW infants (62/145; 43%) (P less than 0.05). Multivariate analyses indicated that those lost to follow-up were at no greater risk of a poor outcome on the basis of prenatal and perinatal medical and socioeconomic findings than were those in the same risk group (HRI or CI) or subgroup of HRI who were examined at 1 year. In a review of hospital records, similar rates of hospitalization and neurologic problems during infancy were identified for HRI examined and HRI lost to follow-up. The identification of such morbidity during infancy may be less complete for HRI lost to follow-up than for those examined. Thus, the high frequency of deficits observed in follow-up evaluation of indigent HRI is unlikely to result from loss of unaffected infants.

Disappointing follow-up findings for indigent high-risk newborns

Indigent populations have received little attention in neonatal follow-up studies. We conducted "blinded" evaluations one year past term for 204 indigent high-risk infants who were ventilator treated or had a very low birth weight (VLBW) (less than or equal to 1500 g) and 85 healthy term controls from families similar to those of the high-risk infants. Marked developmental delay (Bayley Mental Developmental Index, less than 70) or gross motor abnormality occurred in 2% of controls, 27% of VLBW infants, 33% of ventilator-treated infants, and 39% of ventilator-treated VLBW infants. Despite considerable effort to prevent attrition, 43% of high-risk survivors were unavailable for follow-up at the one-year visit. Even if all of these infants were assumed to be normal, the incidence of developmental delay exceeded that in 11 of 12 recent studies. Indigent high-risk infants deserve considerable follow-up attention because of their high rate of attrition and developmental delay.

A prospective comparison of selective and universal electronic fetal monitoring in 34,995 pregnancies

We investigated the effects of using intrapartum electronic fetal monitoring in all pregnancies, as compared with using it only in cases in which the fetus is judged to be at high risk. Predominant risk factors included oxytocin stimulation of labor, dysfunctional labor, abnormal fetal heart rate, or meconium-stained amniotic fluid. This prospective alternate-month clinical trial took place over a 36-month period during which 34,995 women gave birth. In alternate months, either 7 (for "selective monitoring") or 19 (for "universal monitoring") fetal monitors were made available in the labor and delivery unit. During the "selective" months, 6420 of 17,409 women (37 percent) were electronically monitored, as compared with 13,956 of 17,586 women (79 percent) during the "universal months." Universal monitoring was associated with a small but significant increase in the incidence of delivery by cesarean section because of fetal distress, but perinatal outcomes as assessed by intrapartum stillbirths, low Apgar scores, a need for assisted ventilation of the newborn, admission to the intensive care nursery, or neonatal seizures were not significantly different. We conclude that not all pregnancies, and particularly not those considered at low risk of perinatal complications, need continuous electronic fetal monitoring during labor.

Brainstem auditory evoked potentials in very-low-birth-weight neonates with intracranial hemorrhage

A study was conducted in very-low-birth-weight (VLBW) neonates to correlate structural damage to the central nervous system due to intracranial hemorrhage (ICH) with electrophysiological function of the lower auditory system as measured by brainstem auditory evoked potentials (BAEP). BAEP testing of 61 VLBW neonates was completed at 36 weeks conceptional age. BAEP Wave III and V latencies significantly increased with increasing severity of ICH. Although significant at conventional levels (P less than 0.05), these correlations were of modest size. Furthermore, after adjusting for the effects of birthweight, hypoxia, lowest pH and associated pCO2 the correlation between ICH and BAEP was reduced in magnitude and no longer significant. Thus, there is little evidence that ICH shortly after birth affected functioning of the auditory brainstem pathways in VLBW neonates at 36 weeks conceptional age.

Cognitive complexity, rhetorical sensitivity: contributing factors in clinical skill?

Rhetorical sensitivity and cognitive complexity, measures of interpersonal sensitivity and complexity of interpersonal construct systems, were investigated in this study as they relate to clinical skill. A clinical evaluation tool was developed and validated in order to identify outstanding and failing clinicians. Cognitive complexity and rhetorical sensitivity data were collected and analyzed to compare two groups of clinicians representing the extremes of clinical ability. Outstanding and failing clinicians were not differentiated on the basis of these measures. The clinical implications of these findings were addressed.

Two Epstein-Barr viral nuclear neoantigens distinguished by gene transfer, serology, and chromosome binding

We recently identified, by means of cotransformation of LTK- cells, a region of the Epstein-Barr virus (EBV) genome (the BamHI K fragment) that encodes or induces an EBV nuclear neoantigen (EBNA) serologically related to the EBNA found in lymphoid cells carrying the entire EBV genome. We now find that a second EBV DNA fragment, BamHI M, is also able to give rise to cotransformed LTK- cells with stable expression of a nuclear antigen. The BamHI K and M fragments have no apparent DNA homology. Many human sera that are reactive to EBNA in Raji cells detect both antigens; however, certain anti-EBNA-positive human sera are discordant and react only with the BamHI M or only with the BamHI K nuclear antigen. Every Raji cell appears to express both "M" and "K" antigens; D98 Raji cells, a somatic cell hybrid, express only "K" antigen. The K antigen is found on metaphase chromosomes of LTK cells and Raji cells. The M-induced antigen is not located on chromosomes when the cells are in metaphase but is present as granules within the nucleus.

Teaching clinic conference participant interaction

The purpose of this study was to analyze the talk behaviors that occur during teaching clinic supervisory conferences. Two matched groups of five clinicians participated in teaching clinic supervision for 4 wk. Two supervisors alternately supervised both groups. The teaching clinic conferences were videotaped at the end of the second and fourth week. Segments of the conferences were coded using the Multidimensional Observational System for the Analysis of Interactions in Clinical Supervision (MOSAICS). Supervisors, peers, and clinicians did not differ statistically in quantity or in categories of talk during conferences. The teaching clinics appeared to have characteristics of both direct and indirect conferencing. Teaching clinic supervision appeared to foster the development of selfsupervisory behaviors in student speech--language pathologists as reflected by their active conference participation, problem-solving, and strategy development. Participants, in general, expressed satisfaction with the process and its outcomes.

Culatta and Seltzer content and sequence analysis of the supervisory session: question of reliability and validity

The Culatta and Seltzer (1976) Content and Sequence Analysis of the Supervisory Session was a pioneer effort in the evolution of an observation tool for use in charting the supervisory conference in speech-language pathology. The purpose of this study was to evaluate the reliability, validity, and practicality of data collected with this system. Supervisory conferences of three certified speech-language pathologists, each of whom supervised four students representing four experience levels, were audiotaped three times. Trained individuals coded specified segments of the conferences using the Culatta and Seltzer system. Data collected with the system was found to be unreliable. The observation system meets criteria for face validity but not content or construct validity. Criterion validity was not evaluated. The major strength of the system is practicality.