Attitudes of patients toward cardiopulmonary resuscitation in the dialysis unit

Some dialysis units have a policy of performing cardiopulmonary resuscitation (CPR) on all patients who experience cardiac arrest while undergoing dialysis. However, to perform CPR on patients who do not want it is contrary to ethics and the law. We interviewed hemodialysis patients in 12 units in Missouri, New York, and West Virginia to learn their attitudes about CPR. Four hundred sixty-nine of 830 patients (57%) agreed to be interviewed. Eighty-seven percent of patients wanted to undergo CPR if cardiac arrest were to occur while undergoing dialysis. Patients who had seen CPR on television were more likely to report that they knew what CPR was (94% versus 68%; P < 0.001) and to want CPR (88% versus 78%; P = 0.033). Thirteen percent of patients did not want CPR if cardiac arrest were to occur while undergoing dialysis. Compared with patients who wanted CPR, those who did not were older (69 versus 59 years; P = 0.026), had more comorbid conditions (2.0 versus 1.5 comorbid conditions; P = 0.016), and were more likely to have a living will (61% versus 43%; P = 0.01), be widowed (36% versus 20%; P = 0.026), and live in a nursing home (9% versus 3%; P = 0.017). Blacks were significantly more likely to want CPR than whites (adjusted odds ratio, 6.56; 95% confidence interval, 2.57 to 22.27). Only 20 of 58 patients (35%) who did not want CPR were certain they had a do-not-resuscitate order in their dialysis chart. Ninety-two percent of patients who wanted CPR agreed that patients who did not want CPR should have their wishes respected by the dialysis unit. We conclude that most dialysis patients want to undergo CPR, but also want other patients' preferences not to be resuscitated to be respected. Dialysis units need to do a better job of identifying patients who prefer not to be resuscitated and respecting their wishes in the event of cardiac arrest while undergoing dialysis. Most importantly, nephrologists and dialysis unit staff need to educate dialysis patients about the poor outcomes with CPR so that dialysis patients' decisions about CPR are informed.

Personality profile and neuropsychological test performance in chronic cocaine-abusers

Little is known about the association between personality disorders and neuropsychological test performance in chronic cocaine users. The aims of the present study were to (1) pinpoint the specific neuropsychological characteristics of chronic cocaine abusers, (2) analyze their personality profile, and (3) explore the association between personality traits and neuropsychological test performance. A sample of 42 drug-abusers (mean age = 34.15; SD = 6.73; mean educational level = 11.44; SD = 2.01) was selected from a state rehabilitation facility and was compared to a control group (mean age = 34.53; SD = 9.01; mean educational level = 12.29; SD = 1.31). The following information was collected for each subject: (1) A clinical history adapted from Horton (1996). (2) The Personality Assessment Inventory (PAI) (Morey, 1991). (3) A neuropsychological test battery including: Arithmetic and Digits subtests from the WAIS-R, California Verbal Learning Test, Trial Making Test, Verbal Fluency tests, Rey-Osterrieth Complex Figure, Wisconsin Card Sorting Test, Benton Visual Retention Test, Stroop Neurological Screening Test and Hooper Visual Organization. Thirty-seven of the drug-dependent subjects obtained an abnormal score in at least one PAI scale. The personality profile of the drug-dependent subjects found via the PAI pointed to a Borderline/Antisocial personality, frequently associated with mania features. In six of the drug-abusers, a normal personality profile was observed. Neuropsychological test performance scores were within the low average or borderline range. The most abnormal scores were observed in attention, memory, and executive functioning tests. The results did not show any robust association between personality profile and neuropsychological test performance.

Single-donor platelets reduce the risk of septic platelet transfusion reactions

BACKGROUND

Septic platelet transfusion reactions (SPTRs) are the most common, serious risk of transfusion. Because SPTRs result from donor skin flora or asymptomatic bacteremia, the use of single-donor platelets (SDPs) has been proposed to reduce the risk of SPTRs from the risks with pools of platelet concentrates (PCs).

STUDY DESIGN AND METHODS

Beginning in 1986, all febrile transfusion reactions were evaluated by culture of the platelet bag. Confirmed SPTRs were identified by isolation of the same bacteria from the bag and the patient's blood or by positive Gram's stain of the bag that confirmed a positive platelet culture. In 1987, a program to minimize PC use in favor of SDP use was initiated as a means of reducing SPTRs.

RESULTS

In 12 years, the use of SDPs increased from 51.7 percent to 99.4 percent of all platelet transfusions at one institution. SPTRs fell from three events in 1 year to the current rate of one event per year. The incidence of SPTRs decreased from 1 in 4,818 transfusions to 1 in 15,098 transfusions. The rate of SPTRs due to PCs was 5.39 times higher than that of SPTRs due to SDPs (95% CI, 1.89,12.9).

CONCLUSION

The use of SDPs is a simple means of reducing SPTRs. Other measures such as sterilization will be required to eliminate all SPTRs.

Association between insertion mutation in NOD2 gene and Crohn's disease in German and British populations

Background Genetic predisposition to inflammatory bowel disease (IBD) has been shown by epidemiological and linkage studies. Genetic linkage of IBD to chromosome 16 has been previously observed and replicated in independent populations. The recently identified NOD2 gene is a good positional and functional candidate gene since it is located in the region of linkage on chromosome 16q12, and activates nuclear factor (NF) kappaB in response to bacterial lipopolysaccharides. Methods We sequenced the coding region of the NOD2 gene and genotyped an insertion polymorphism affecting the leucine-rich region of the protein product in 512 individuals with IBD from 309 German or British families, 369 German trios (ie, German patients with sporadic IBD and their unaffected parents), and 272 normal controls. We then tested for association with Crohn's disease and ulcerative colitis. Findings Family-based association analyses were consistently positive in 95 British and 99 German affected sibling pairs with Crohn's disease (combined p<0.0001); the association was confirmed in the 304 German trios with Crohn's disease. No association was seen in the 115 sibling pairs and 65 trios with ulcerative colitis. The genotype-specific disease risks conferred by heterozygous and homozygous mutant genotypes were 2.6 (95% CI 1.5-4.5) and 42.1 (4.3-infinity), respectively. Interpretation The insertion mutation in the NOD2 gene confers a substantially increased susceptibility to Crohn's disease but not to ulcerative colitis.

Results of a phase-I/II randomized, masked, placebo-controlled trial of recombinant human interleukin-11 (rhIL-11) in the treatment of subjects with active rheumatoid arthritis

Interleukin-11 (IL-11) is a pleiotropic cytokine that regulates the growth and development of hematopoietic stem cells and decreases the proinflammatory mediators of cytokine and nitric oxide production. In animal models of arthritis, treatment with recombinant human IL-11 (rhIL-11) reduces both the level of synovitis and the histologic lesion scores in the joints. The goal of this phase-I/II study in adults with rheumatoid arthritis (RA) was to evaluate the safety and clinical activity of different doses and schedules of rhIL-11 in patients with active RA for whom treatment with at least one disease-modifying antirheumatic drug had failed. This was a multicenter, randomized, placebo-controlled trial that evaluated the safety and tolerability of rhIL-11 in 91 patients with active RA. rhIL-11 was administered subcutaneously; patients were randomized into one of five treatment groups (ratio of rhIL-11 to placebo, 4:1). Patients were treated for 12 weeks with either 2.5 or 7.5 microg/kg of rhIL-11 or placebo twice per week or 5 or 15 microg/kg of rhIL-11 or placebo once per week. The status of each subject's disease activity in accordance with the American College of Rheumatology (ACR) criteria was assessed before, during, and after completion of administration of the study drug. Administration of rhIL-11 was well tolerated at all doses and schedules. The most frequent adverse event was a reaction at the injection site. The data suggest a statistically significant reduction in the number of tender joints (P < 0.008) at the 15 microg/kg once-weekly dose schedule but showed no overall significant benefit at the ACR criterion of a 20% response. The trial showed rhIL-11 to be safe and well tolerated at a variety of doses and schedules over a 12-week treatment period in patients with active RA. The only adverse event clearly associated with rhIL-11 administration was reaction at the injection site.

An efficacy and cost-effectiveness analysis of combination hepatitis B immune globulin and lamivudine to prevent recurrent hepatitis B after orthotopic liver transplantation compared with hepatitis B immune globulin monotherapy

Orthotopic liver transplantation (OLT) for hepatitis B virus (HBV) infection was limited until recently by poor graft and patient outcomes caused by recurrent HBV. Long-term immunoprophylaxis with hepatitis B immune globulin (HBIG) dramatically improved post-OLT survival, but recurrent HBV still occurred in up to 36% of the recipients. More recently, combination HBIG and lamivudine has been shown to effectively prevent HBV recurrence in patients post-OLT. The aim of the current study is to determine long-term outcome and cost-effectiveness of using combination HBIG and lamivudine compared with HBIG monotherapy in patients who undergo OLT for HBV. A retrospective chart review identified 59 patients administered combination HBIG and lamivudine and 12 patients administered HBIG monotherapy as primary prophylaxis against recurrent HBV. Lamivudine, 150 mg/d, was administered orally indefinitely. HBIG was administered under a standard protocol (10,000 IU intravenously during the anhepatic phase, then 10,000 IU/d intravenously for 7 days, then 10,000 IU intravenously monthly) indefinitely. A decision-analysis model was developed to evaluate the potential economic impact of prophylaxis against HBV with combination therapy compared with monotherapy. Recurrent HBV was defined as the reappearance of hepatitis B surface antigen (HBsAg) after its initial disappearance post-OLT. In the combination-therapy group, no patient redeveloped serum HBsAg or HBV DNA during mean follow-ups of 459 and 416 days, respectively. In the monotherapy group, 3 patients (25%) had reappearance of HBsAg in serum during a mean follow-up of 663 days. Combination therapy resulted in a dominant, cost-effective strategy with an average cost-effectiveness ratio of $252,111/recurrence prevented compared with $362,570/recurrence prevented in the monotherapy strategy. Combination prophylaxis with HBIG and lamivudine is highly effective in preventing recurrent HBV, may protect against the emergence of resistant mutants, and is significantly more cost-effective than HBIG monotherapy with its associated rate of recurrent HBV.

Thoracoscopic sympathectomy

The objective was to evaluate the safety and effectiveness of endoscopic thoracic sympathectomy (ETS) for treatment of a variety of sympathetic disorders, including hyperhidrosis, splanchnic pain, reflex sympathetic dystrophy, and Raynaud upper extremity ischemia. Sixty-three ETS procedures were performed in 34 patients at the University of Maryland Medical System between March 1992 and August 1999 (14 male patients, 20 female patients; mean age 22 years). The indications for surgery were hyperhidrosis in 26 patients, upper extremity ischemia in 3 patients, splanchnic pain and reflex sympathetic dystrophy in 2 patients each, and facial blushing in 1 patient. Preoperative symptoms resolved completely or improved significantly in 97.1% (33/34) of patients. One patient with left reflex sympathetic dystrophy had symptoms that recurred shortly after surgery. There were no major complications; one patient with hyperhidrosis reported significant compensatory hyperhidrosis. These findings suggest that ETS is a safe and effective procedure for treatment of a variety of sympathetic disorders. Its application for hyperhidrosis is very effective, and its treatment of splanchnic pain, reflex sympathetic dystrophy, and Raynaud syndrome are rewarding. With increasing experience, ETS should become established in the repertoire of the thoracic surgeon.

Patients' perspective of factors affecting modality selection: a National Kidney Foundation patient survey

The National Kidney Foundation undertook a survey of individuals with chronic renal failure to assess factors that may have influenced their treatment selection. Areas examined included demographic data, patient education, movement between modalities, patient satisfaction with treatment, and sense of well-being. The results point to a need for additional patient education and assurance that every ESRD patient is informed about all treatment options that are not medically contraindicated. There is an additional need for enhanced treatment decision making that involves both the patient and the nephrologist. Respondents were highly satisfied with their current treatment modality although 17% had previously changed treatment owing to personal dissatisfaction. Center hemodialysis patients identified staff performance of treatment and dialyzing only 3 times weekly as the main advantages of that modality. Those on peritoneal dialysis identified its flexibility that allows control over one's personal schedule as important. Transplant recipients stressed the importance of living a more normal life than that afforded by dialysis. Most respondents expressed a positive sense of well-being. While transplant patients expressed a higher sense of well-being than individuals on dialysis, it is important to note that approximately 70% of those on dialysis reported a positive sense of well-being.

Probeliatrade mark PCR system for rapid detection of Salmonella in milk powder and ricotta cheese

The Probeliatrade mark Salmonella sp. PCR amplification and detection kits (Sanofi Diagnostics Pasteur, Marnes La Coquette, France) were evaluated for the rapid and specific detection of Salmonella agona artificially inoculated into skim milk powder and ricotta cheese. The Probeliatrade mark results were compared with those obtained using the Australian Standard Method. Using a pure culture of Salm. agona, the detection limit of Probeliatrade mark was between 8 and 79 cfu ml-1, equivalent to 0.2-2 cfu per PCR reaction. Detection of Salm. agona inoculated in skim milk powder (at 5-10 cfu g-1, stored at 5, 15 or 25 degrees C) and ricotta cheese (at 1-2, 10-20 and 100-200 cfu per 25 g) was effected by using non-selective enrichment prior to the PCR determinations. For all of the 40 milk powder samples and 12 ricotta cheese samples, the Probeliatrade mark results were consistent with those using the Australian Standard Method. Using Probeliatrade mark, Salmonella was detected to genus level in the dairy products within 24-28 h, whereas the cultural technique required 3-4 d for presumptive positive isolates and further time for confirmation.

Racial differences in response to acute dosing with hydrochlorothiazide

Blacks demonstrate a higher response rate to diuretic therapy for hypertension than do whites. This study examined the pharmacokinetic (PK), pharmacodynamic, and neurohumoral effects of hydrochlorothiazide (HCTZ) administration in a matched group of 9 black and 9 white hypertensive patients (mean +/- SD for black and white). After a 4-week washout period and 7-day control diet, subjects received a single dose of HCTZ (25 mg at 8 AM) with serial blood and urine collections for 36 hours. After HCTZ sodium excretion increased comparably in both groups (blacks: 122 +/- 42 pre to 265 +/- 49 mEq/24 hours post; whites: 117 +/- 29 pre to 255 beta 39 mEq/24 hrs post). Potassium excretion tended to be higher at baseline and was significantly higher following HCTZ in whites (blacks: 45 beta 20 pre to 66 beta 13 mEq at 24 hours post; blacks: 57 +/- 9 pre to 86 +/- 14 mEq at 24 hours post) with most of the post-dosing difference being observed in the hours 0 to 12 after HCTZ. There were no between group PK differences for urinary HCTZ. Aldosterone excretion followed a normal circadian pattern in the whites but did not show this pattern in the blacks. Aldosterone excretion (0 to 12 hours) was generally lower post-dosing in blacks. In conclusion, whereas the PK and single-dose natriuretic response for HCTZ were not racially distinct, potassium excretion was notably less in blacks. Aldosterone excretion was also lower in blacks and without its normal circadian pattern which may, in part, explain their altered potassium excretion pattern.

High dose rate brachytherapy to prevent recurrent benign hyperplasia in lung transplant bronchi: theoretical and clinical considerations

BACKGROUND

Significant anastomotic stenosis and malacia is reported to affect 7% to 15% of lung transplant recipients. Laser debridement, dilation and stenting can be used effectively to treat the majority of these patients. However, persistent, as well as reactive hyperplastic tissue reaction, will occur in some of these patients, requiring multiple bronchoscopic interventions. The experience of 2 patients who received intraluminal brachytherapy irradiation to prevent recurrence of hyperplastic tissue causing airway obstruction is reported. Both had failed multiple attempts of local control, including wall stent, laser ablation and balloon dilation. They suffered from shortness of breath and progressive decrease in quality of life because of airway obstruction.

METHODS

Two patients received intraluminal irradiation immediately following removal of severe post-lung transplant obstruction. Both patients developed airway obstruction 3 to 4 months after left lung transplantation. High Dose Rate (HDR) brachytherapy (192Ir). Afterloader was used to treat Patient 1 on two occasions. Patient 2 required a single treatment. The radiation dose of 3Gy/fraction was calculated at 1 cm from the catheter for all applications.

RESULTS

Follow up for both patients included bronchoscopy at 3 weeks, 3 months and 6 months after radiation therapy. Follow up for Patient 1 is 7 months, and patient 2 is 6 months. Each patient had an initial complete response after radiation. There were no treatment-related complications, and both patients experienced significant improvement in respiratory function.

CONCLUSIONS

Symptomatic benign airway obstruction from hyperplastic tissue in the bronchus after lung transplantation can be successfully treated with intraluminal radiation therapy. Patients who develop recurrent benign granulation tissue after stent and laser therapy may be considered for this type of treatment.

Ifosfamide- and paclitaxel-based treatment of relapsed and refractory lymphoma

Several trials of new salvage therapies for relapsed and refractory non-Hodgkin's lymphoma are based on ifosfamide and paclitaxel. These programs variably Induce clinical remissions and prepare patients for stem cell and bone marrow transplantations. Ifosfamide-containing regimens are also being evaluated in the treatment of newly diagnosed patients. However, no data exist with regard to paclitaxel-containing regimens outside salvage settings. This report reviews the effects of these compounds in the treatment of relapsed and refractory non-Hodgkin's lymphoma and proposes likely directions for future study.

Quantifying the sustainability of grazed pastures on the Northern Tablelands of New South Wales

An experiment was conducted to examine the effect of deep-rooted perennial grasses on the water and nitrogen economy of 3 mature pasture communities with different botanical compositions but the same fertiliser history. One pasture was dominated by volunteer naturalised pasture grasses (Eleusine tristachya and Danthonia spp.) (termed ‘degraded’), another was phalaris (Phalaris aquatica) dominant (phalaris), and a third was dominated by phalaris into which white clover (Trifolium repens) had been recently sown (phalaris–white clover). Two replicates of each pasture type were grazed continuously over 4 years with young weaner sheep changed each year. Measurements of hydrology, nutrient cycling, botanical composition and animal production were made in order to quantify the sustainability characteristics of each of the pasture types. Data are summarised as absolute measures at various points in time and also as trends over time. The ranking of standardised treatment measures was then summed to provide an index of sustainability with or without a weighting assumed to be representative of the relative importance of various layers of sustainability viewed from the perspective of a hypothetical ‘typical’ grazier. The results show that the phalaris–white clover treatment was substantially more sustainable, in both ecological and economic terms, than either of the other treatments. The unweighted index for the phalaris–white clover pasture was 3.61 compared to 2.08 and 1.98 for the phalaris and ‘degraded’ pastures, respectively.

Factors relating to readmission of term and near-term neonates in the first two weeks of life. Early Discharge Survey Group of the Health Professional Advisory Board of the Greater New York Chapter of the March of Dimes

AIMS

A multisite study of term and near term infants readmitted in the first two weeks of life to 9 New York City area hospitals in 1995 was conducted to evaluate factors related to readmission, including length of newborn stay.

RESULTS

Of the 30,884 infants born at the 9 study hospitals 391 newborns were readmitted. The major admission diagnoses were infection, 40.7%, hyperbilirubinemia, 39.1%, and feeding and/or gastrointestinal problems, 10.5%. In the first week, 65.1% of readmissions were for hyperbilirubinemia and 19.1% were for infection or suspected sepsis. In the second week, 67.8% of readmissions were for infection and 7.6% were for hyperbilirubinemia. Hyperbilirubinemia was the most frequent diagnosis for White and Asian infants, while infection was most frequent for African-American and Hispanic infants. Age at readmission was younger and the interval from discharge was shorter for infants with hyperbilirubinemia. Abnormalities which should have precluded early discharge included feeding difficulties, cyanotic congenital heart defects, hemolytic disease of the newborn, early jaundice or early high bilirubin levels.

CONCLUSION

Attention to identification of infants at risk and programs such as lactation counseling and universal screening for bilirubin (with appropriate interpretation) prior to discharge could have reduced the necessity for readmission regardless of the newborn length of stay.

Antivascular endothelial growth factor receptor (fetal liver kinase 1) monoclonal antibody inhibits tumor angiogenesis and growth of several mouse and human tumors

Tumor angiogenesis is mediated by tumor-secreted angiogenic growth factors that interact with their surface receptors expressed on endothelial cells. Vascular endothelial growth factor (VEGF) and its receptor [fetal liver kinase 1 (Flk-1)/kinase insert domain-containing receptor] play an important role in vascular permeability and tumor angiogenesis. Previously, we reported on the development of anti-Flk-1 and antikinase insert domain-containing receptor monoclonal antibodies (mAbs) that potently inhibit VEGF binding and receptor signaling. Here, we report the effect of anti-Flk-1 mAb (DC101) on angiogenesis and tumor growth. Angiogenesis in vivo was examined using a growth factor supplemented (basic fibroblast growth factor + VEGF) Matrigel plug and an alginate-encapsulated tumor cell (Lewis lung) assay in C57BL/6 mice. Systemic administration of DC101 every 3 days markedly reduced neovascularization of Matrigel plugs and tumor-containing alginate beads in a dose-dependent fashion. Histological analysis of Matrigel plugs showed reduced numbers of endothelial cells and vessel structures. Several mouse tumors and human tumor xenografts in athymic mice were used to examine the effect of anti-Flk-1 mAb treatment on tumor angiogenesis and growth. Anti-Flk-1 mAb treatment significantly suppressed the growth of primary murine Lewis lung, 4T1 mammary, and B16 melanoma tumors and growth of Lewis lung metastases. DC101 also completely inhibited the growth of established epidermoid, glioblastoma, pancreatic, and renal human tumor xenografts. Histological examination of anti-Flk-1 mAb-treated tumors showed evidence of decreased microvessel density, tumor cell apoptosis, decreased tumor cell proliferation, and extensive tumor necrosis. These findings support the conclusion that anti-Flk-1 mAb treatment inhibits tumor growth by suppression of tumor-induced neovascularization and demonstrate the potential for therapeutic application of anti-VEGF receptor antibody in the treatment of angiogenesis-dependent tumors.