Bivalent Omicron BA.1-Adapted BNT162b2 Booster in Adults Older than 55 Years

BACKGROUND

The emergence of immune-escape variants of severe acute respiratory syndrome coronavirus 2 warrants the use of sequence-adapted vaccines to provide protection against coronavirus disease 2019.

METHODS

In an ongoing phase 3 trial, adults older than 55 years who had previously received three 30-μg doses of the BNT162b2 vaccine were randomly assigned to receive 30 μg or 60 μg of BNT162b2, 30 μg or 60 μg of monovalent B.1.1.529 (omicron) BA.1-adapted BNT162b2 (monovalent BA.1), or 30 μg (15 μg of BNT162b2 + 15 μg of monovalent BA.1) or 60 μg (30 μg of BNT162b2 + 30 μg of monovalent BA.1) of BA.1-adapted BNT162b2 (bivalent BA.1). Primary objectives were to determine superiority (with respect to 50% neutralizing titer [NT50] against BA.1) and noninferiority (with respect to seroresponse) of the BA.1-adapted vaccines to BNT162b2 (30 μg). A secondary objective was to determine noninferiority of bivalent BA.1 to BNT162b2 (30 μg) with respect to neutralizing activity against the ancestral strain. Exploratory analyses assessed immune responses against omicron BA.4, BA.5, and BA.2.75 subvariants.

RESULTS

A total of 1846 participants underwent randomization. At 1 month after vaccination, bivalent BA.1 (30 μg and 60 μg) and monovalent BA.1 (60 μg) showed neutralizing activity against BA.1 superior to that of BNT162b2 (30 μg), with NT50 geometric mean ratios (GMRs) of 1.56 (95% confidence interval [CI], 1.17 to 2.08), 1.97 (95% CI, 1.45 to 2.68), and 3.15 (95% CI, 2.38 to 4.16), respectively. Bivalent BA.1 (both doses) and monovalent BA.1 (60 μg) were also noninferior to BNT162b2 (30 μg) with respect to seroresponse against BA.1; between-group differences ranged from 10.9 to 29.1 percentage points. Bivalent BA.1 (either dose) was noninferior to BNT162b2 (30 μg) with respect to neutralizing activity against the ancestral strain, with NT50 GMRs of 0.99 (95% CI, 0.82 to 1.20) and 1.30 (95% CI, 1.07 to 1.58), respectively. BA.4-BA.5 and BA.2.75 neutralizing titers were numerically higher with 30-μg bivalent BA.1 than with 30-μg BNT162b2. The safety profile of either dose of monovalent or bivalent BA.1 was similar to that of BNT162b2 (30 μg). Adverse events were more common in the 30-μg monovalent-BA.1 (8.5%) and 60-μg bivalent-BA.1 (10.4%) groups than in the other groups (3.6 to 6.6%).

CONCLUSIONS

The candidate monovalent or bivalent omicron BA.1-adapted vaccines had a safety profile similar to that of BNT162b2 (30 μg), induced substantial neutralizing responses against ancestral and omicron BA.1 strains, and, to a lesser extent, neutralized BA.4, BA.5, and BA.2.75 strains. (Funded by BioNTech and Pfizer; ClinicalTrials.gov number, NCT04955626.).

A phase 3 trial of safety, tolerability, and immunogenicity of V114, 15-valent pneumococcal conjugate vaccine, compared with 13-valent pneumococcal conjugate vaccine in adults 50 years of age and older (PNEU-AGE)

BACKGROUND

Pneumococcal conjugate vaccines (PCVs) have greatly reduced the incidence of pneumococcal disease, yet unmet medical need remains due to increased disease caused by non-vaccine serotypes (STs). V114 (VAXNEUVANCE^TM, Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA) is a 15-valent PCV containing 13 serotypes in licensed PCV13 and 2 additional serotypes (22F, 33F) which significantly contribute to pneumococcal disease burden. This phase 3 trial compared safety, tolerability, and immunogenicity of V114 to PCV13 in adults ≥50 years of age.

METHODS

Adults were randomized 1:1 to receive a single dose of V114 or PCV13; randomization was stratified by age (50-64 years, 65-74 years, and ≥75 years). Adverse events (AEs) were collected following vaccination. Serotype-specific opsonophagocytic activity (OPA) and immunoglobulin G (IgG) antibodies were measured prior to and 30 days after vaccination (Day 30). Primary objectives included assessing noninferiority of V114 to PCV13 for the 13 shared serotypes and superiority of V114 to PCV13 for the two unique serotypes. Superiority of V114 to PCV13 for shared serotype 3 was assessed as a secondary objective.

RESULTS

Overall, 1,202 participants were vaccinated (V114 N = 602, PCV13 N = 600). The most commonly reported AEs across both groups were injection-site pain, fatigue, and myalgia. V114 met noninferiority criteria compared to PCV13 for the 13 shared serotypes (using a 2-fold non-inferiority margin for the ratio of OPA geometric mean titers [GMTs] [V114/PCV13] at Day 30) and met superiority for the 2 unique serotypes (using a 2-fold super-superiority margin for the ratio of OPA GMTs [V114/PCV13] at Day 30 and a 0.10 super-superiority margin for the difference in proportions of participants with ≥4-fold rise from prevaccination to Day 30). V114 met superiority criteria compared to PCV13 for serotype 3 (based on a super-superiority margin of 1.2 for the ratio of the OPA GMTs [V114/PCV13] and a superiority margin of 0 for the difference in proportions of participants with ≥4-fold rise). [NCT03950622, EudraCT#2018-004316-22, Japic-CTI#194845].

Determining Feeding Tube Location by Gastric and Intestinal pH Values

BACKGROUND

The purpose of this study was to evaluate a series of pH values of aspirates from feeding tubes to differentiate between gastric and intestinal tube placement.

METHODS

One hundred ventilator-supported subjects, with an order for nasoduodenal feeding tube placement were randomly selected. The feeding tube was placed into the stomach, verified by auscultation, and 2 pH measurements were obtained. After the pH measurements were taken, tube location was then verified by fluoroscopy. When the tube was advanced into the small intestine, location was verified by fluoroscopy, and 2 additional pH measurements were obtained.

RESULTS

From the selected subjects, both a gastric and intestinal aspirate were obtained from 82 subjects. For the 82 subjects, the mean gastric and intestinal pH values were 4.8 +/- 2.3 and 7.1 +/- 1.0, respectively. For patients receiving acid-suppressing agents, these values were 5.0 +/- 2.3 and 7.2 +/- 1.0, respectively. For subjects not receiving acid-suppressing agents, these pH values were 4.0 +/- 2.5 and 6.7 +/- 1.1, respectively. For all patients, using a pH value of 6.5 as a predictor of feeding tube location, the sensitivity and specificity were 0.66 and 0.90. In addition, when an increase in pH > or = 1.0 was used as a predictor of location change for all patients, the sensitivity was 0.58.

CONCLUSIONS

The pH value was a reliable predictor of nasoduodenal tube placement. However, radiographic confirmation of location could not be excluded because of the low sensitivity using pH measurements alone. An increase of > or = 1.0 in gastric vs intestinal pH specimens could be useful to determine use of radiography confirmation of tube placement.

Next-day residual effects of gabapentin, diphenhydramine, and triazolam on simulated driving performance in healthy volunteers: a phase 3, randomized, double-blind, placebo-controlled, crossover trial

OBJECTIVE

Next-day residual effects of a nighttime dose of gabapentin 250 mg were evaluated on simulated driving performance in healthy participants in a randomized, placebo-controlled, double-blind, multicenter, four-period crossover study that included diphenhydramine citrate 76 mg and triazolam 0.5 mg.

METHODS

At treatment visits, participants (n = 59) were dosed at ~23:30, went to bed immediately, and awakened 6.5 h postdose for evaluation. The primary endpoint was the standard deviation of lateral position for the 100-km driving scenario. Additional measures of driving, sleepiness, and cognition were included.

RESULTS

Study sensitivity was established with triazolam, which demonstrated significant next-day impairment on all driving endpoints, relative to placebo (p < 0.001). Gabapentin demonstrated noninferiority to placebo on standard deviation of lateral position and speed deviation but not for lane excursions. Diphenhydramine citrate demonstrated significant impairment relative to gabapentin and placebo on speed deviation (p < 0.05). Other comparisons were either nonsignificant or statistically ineligible per planned, sequential comparisons. Secondary endpoints for sleepiness and cognitive performance were supportive of these conclusions.

CONCLUSIONS

Together, these data suggest that low-dose gabapentin had no appreciable next-day effects on simulated driving performance or cognitive functioning. Copyright © 2016 John Wiley & Sons, Ltd.

A Phase IIa, randomized, double-blind study of remimazolam (CNS 7056) versus midazolam for sedation in upper gastrointestinal endoscopy

BACKGROUND

This exploratory study was the first study of remimazolam in patients to assess the safety and efficacy of different single doses for procedural sedation.

METHODS

Patients scheduled to undergo a diagnostic upper gastrointestinal endoscopy were randomized to receive 1 of 3 doses of remimazolam or midazolam (25 per group) in a double-blind manner. After a single dose of study drug to achieve sedation, patients underwent gastroscopy. We assessed the success of the procedure, sedation levels, recovery from sedation, and safety.

RESULTS

A single dose of remimazolam resulted in a successful procedure in 32%, 56%, and 64% of patients in the low (0.10), middle (0.15), and high (0.20 mg/kg) dose groups compared with 44% of patients in the midazolam (0.075 mg/kg) dose group. The onset of sedation was 1.5 to 2.5 minutes in the remimazolam dose groups compared with 5 minutes for midazolam. Because this was a single administration study, sedation could be maintained for as long as necessary to complete the procedure, using rescue midazolam or propofol. Recovery from sedation was rapid for all treatment groups but was influenced by the choice of rescue medication. There were no obvious differences in the safety profiles of remimazolam and midazolam.

CONCLUSIONS

This exploratory dose-finding study showed that a single administration of remimazolam (0.10-0.20 mg/kg) was capable of inducing rapid sedation with a quick recovery profile in patients undergoing a diagnostic upper gastrointestinal endoscopy. The safety profile was favorable and appeared to be similar to that of midazolam, warranting further development of this short-acting compound.

Efficacy and safety of Elaeis guineensis and Ficus deltoidea leaf extracts in adults with pre-diabetes

Background

Individuals with pre-diabetes (fasting glucose 100–125 mg/dl) are at increased risk of developing diabetes; 50% of U.S. adults aged ≥65 y had pre-diabetes in 2005–08. Extracts of the leaves of E. guineensis (a tropical plant producing edible oil), and F. deltoidea (a traditional tea) contain phenolic compounds that have hypoglycemic effects in vitro and in vivo. Therefore, a study of the efficacy and safety of these leaf extracts was undertaken.

Methods

Otherwise healthy adults with pre-diabetes (15m/15f; aged 21 to 65 y; BMI ≥25 and < 40 kg/m²) were assigned to one of 3 groups for 8 weeks: E. guineensis leaf extract 500 mg or 1000 mg or F. deltoidea leaf extract 1000 mg. Assessments at baseline and throughout the study included: fasting plasma glucose, insulin, OGTT, and HOMA-IR; body weight and waist circumference; vital signs, comprehensive metabolic and lipid panels. Statistical analyses included paired Student’s t-test and ANCOVA or non-parametric tests when indicated.

Results

E. guineensis intervention for 8 weeks decreased fasting plasma glucose and insulin levels, glucose and insulin areas under the curve, and insulin resistance, and increased insulin sensitivity. The 500 mg dose of E. guineensis had a more consistent effect on reducing glycemia than the 1000 mg dose and the insulin findings at the two dose levels were somewhat inconsistent. Differences in the distribution of baseline insulin levels in the low and high dose groups may explain some of these observed differences in responses. F. deltoidea leaf extract had no effect on glycemia variables but both total and LDL cholesterol concentrations were significantly decreased in this group. There were no significant differences in change of weight; however waist circumference was significantly lower in the E. guineensis groups after intervention. At baseline and after 8 weeks of intervention, vital signs and safety lab tests were within normal limits and not significantly different between groups or due to intervention.

Conclusions

These results suggest that the leaf extracts of E. guineensis and F. deltoidea may have positive effects on glucose and lipid levels and are safe for use in humans. Further study is required to determine the maximum effective dosages and the mechanisms of action.

In a randomized, double-blinded, placebo-controlled trial, the single oral dose typhoid vaccine, M01ZH09, is safe and immunogenic at doses up to 1.7 x 10(10) colony-forming units

M01ZH09, S. Typhi (Ty2 Delta aroC Delta ssaV) ZH9, is a single oral dose typhoid vaccine with independently attenuating deletions. A phase II randomized, double-blind, placebo-controlled, dose-escalating trial evaluated the safety and immunogenicity of M01ZH09 to 1.7 x 10(10) colony-forming units (CFU). 187 Healthy adults received vaccine or placebo in four cohorts. Serologic responses and IgA ELISPOT were measured. At all doses, the vaccine was well tolerated and without bacteremias. One subject had a transient low-grade fever. 62.2-86.1% of subjects seroconverted S. Typhi-specific LPS IgG and 83.3-97.4% IgA; 92.1% had a positive S. Typhi LPS ELISPOT. M01ZH09 is safe and immunogenic up to 1.7 x 10(10)CFU. Efficacy testing of this single-dose oral typhoid vaccine is needed.

A prospective, randomized, double-blind, placebo-controlled parallel-group dual site trial to evaluate the effects of a Bacillus coagulans-based product on functional intestinal gas symptoms

Background

This randomized double blind placebo controlled dual site clinical trial compared a probiotic dietary supplement to placebo regarding effects on gastrointestinal symptoms in adults with post-prandial intestinal gas-related symptoms (abdominal pain, distention, flatulence) but no gastrointestinal (GI) diagnoses to explain the symptoms.

Methods

Sixty-one adults were enrolled (age 36.5 ± 12.6 years; height 165.1 ± 9.2 cm; weight 75.4 ± 17.3 kg) and randomized to either Digestive Advantage™ Gas Defense Formula - (GanedenBC³⁰ Bacillus coagulans GBI-30, 6086): n = 30; or Placebo: n = 31. Study subjects were evaluated every two weeks over a four-week period using validated questionnaires and standard biochemical safety testing. Outcome criteria of interest included change from baseline in Gastrointestinal Symptom Rating Scale (GSRS) abdominal pain, abdominal distention, flatus, and the Severity of Dyspepsia Assessment (SODA) bloating and gas subscores over four weeks of product use.

Results

Measured against the placebo, subjects in the probiotic group achieved significant improvements in GSRS abdominal pain subscore (p = 0.046) and the GSRS total score (p = 0.048), with a strong trend for improvement on the GSRS abdominal distension subscore (p = 0.061). A strong placebo effect was evident which could explain the lack of statistical significant differences between the groups for many of the efficacy variables.

Conclusion

In conclusion, the Bacillus coagulans-based product was effective in improving the quality of life and reducing gastrointestinal symptoms in adults with post prandial intestinal gas-related symptoms and no GI diagnoses.

Trial Registration

ClinicalTrials.gov Identifier: NCT00881322

The impact of low-dose aspirin on endoscopic gastric and duodenal ulcer rates in users of a non-selective non-steroidal anti-inflammatory drug or a cyclo-oxygenase-2-selective inhibitor

BACKGROUND

The effect of low-dose aspirin on endoscopic ulcer incidence in cyclo-oxygenase-2-selective inhibitor or non-selective non-steroidal anti-inflammatory drug users remains controversial.

AIM

To compare prospectively the incidence of endoscopic ulcers in healthy subjects receiving low-dose aspirin plus celecoxib or naproxen.

METHODS

In this double-blind, placebo-controlled, 1-week study, subjects (50-75 years) were randomized to receive aspirin 325 mg o.d. plus either celecoxib 200 mg o.d., naproxen 500 mg b.d., or placebo. Baseline and end of study endoscopies were performed. The primary end point was incidence of one or more gastric and duodenal ulcers.

RESULTS

A lower incidence of gastric and duodenal ulcers was seen in celecoxib/aspirin-treated subjects (19%) vs. naproxen/aspirin (27%; RR: 0.63, 95% CI: 0.44-0.92). Both naproxen/aspirin and celecoxib/aspirin groups demonstrated a higher incidence of gastric and duodenal ulcers vs. placebo/aspirin (8%; RR: 3.7, 95% CI: 1.8-7.6 and RR: 2.6, 95% CI: 1.2-5.8, respectively).

CONCLUSIONS

Fewer endoscopic ulcers were observed in patients treated with celecoxib/aspirin vs. naproxen/aspirin. However, celecoxib/aspirin was associated with a significantly higher incidence of gastric and duodenal ulcers than aspirin alone. Further studies are required to determine the generalizability of these findings in the aspirin users and to determine the appropriate strategy to minimize risk in susceptible patients.

Physicians' voices on physician-assisted suicide: looking beyond the numbers

Most empirical research examining physician views on physician-assisted suicide (PAS) has used quantitative methods to characterize positions and identify predictors of individual attitudes. This approach has generated limited information about the nature and depth of sentiments among physicians most impassioned about PAS. This study reports qualitative data provided by 909 physicians as part of a larger survey (N = 2,805) regarding attitudes toward and experiences with PAS and palliative care. Emergent themes illustrate important clinical, social, and ethical considerations in this area. The data illustrate the diverse and ardent responses that PAS evokes among certain physicians. The role of physicians' personal values is central to discussions about legalization of PAS. Polarized views such as those expressed by physicians in this study are not likely to be reconciled, thereby constraining the development of public policy regarding PAS.

Instability of attitudes about euthanasia and physician assisted suicide in depressed older hospitalized patients

The objective of this study was to examine the interest of non-terminally ill hospitalized elderly patients in euthanasia and physician assisted suicide (PAS) and to determine the stability of these interests over time. Patients age 60 or older (n=158), including both a depressed sample and non-depressed control sample, underwent a structured interview evaluating their interest in euthanasia and PAS in the event of a series of hypothetical outcome scenarios. Substantial proportions of subjects (varying from 13.3%-42% depending on the scenario) expressed hypothetical acceptance of euthanasia and PAS. After six months a subset of patients changed their minds about euthanasia and PAS (8% - 26% depending on the scenario), most often in the direction of initial acceptance to later rejection. Patients depressed in the hospital and interested in PAS for the outcome of their current (non-terminal) condition were significantly more likely express unstable opinions, with most rejecting it six months later. Other correlations of instability, in specific scenarios, included being male, experiencing higher baseline suffering, poorer subjective health and lower instrumental support. Because euthanasia and PAS actions are irreversible, findings of instability have important implications both clinically and for design of PAS legislation.

Life-sustaining treatment and assisted death choices in depressed older patients

OBJECTIVES

The major purpose of this study was to examine the effect of depressed mood in older, medically ill, hospitalized patients on their preferences regarding life-sustaining treatments, physician-assisted suicide (PAS), and euthanasia and to determine the degree to which financial constraints affected their choices.

DESIGN

Cross-sectional study.

SETTING

General medical hospital.

PARTICIPANTS

One hundred fifty-eight medically hospitalized, nondemented patients age 60 or older, mean age 74.1 (range 60-94). The sample was divided, based on Center for Epidemiologic Studies-Depression (CES-D) scores, into a depressed group (n = 71) and a nondepressed control group.

MEASUREMENTS

Subjects underwent a structured interview evaluating their life-sustaining treatment choices and whether they would accept or refuse PAS or euthanasia under a variety of hypothetical conditions. These choices were reevaluated with the introduction of financial impact. In addition, assessment included measures of depression, suicide, cognition, social support, functioning, and religiosity.

RESULTS

Depression was found to be highly associated with acceptance of PAS and euthanasia in most hypothetical clinical scenarios in addition to patients' current condition. Compared with nondepressed people, depressed respondents were 13 times as likely to accept PAS when considering their current condition (95% confidence interval [CI] 1.68-110.98), and over twice as likely to accept PAS when facing a hypothetical terminal illness or coma. Depression alone was weakly associated with life-sustaining treatment choices but, when financial impact was introduced, significantly more depressed subjects refused treatment options they had previously desired than did nondepressed subjects. The presence of suicidal ideation, even passive ideation, was strongly predictive of life-sustaining treatment refusals and increased interest in PAS and euthanasia. Depression's effect on acceptance of PAS was confirmed by logistic regression, which also showed that religious coping was significantly correlated with less interest in PAS in two hypothetical scenarios. CONCLUSION. Depressed subjects and even subjects with subtle, passive suicidal ideation were markedly more interested in PAS and euthanasia than nondepressed subjects in hypothetical situations. Depressed subjects were also particularly vulnerable to rejecting treatments if financial consequences might have resulted.

Physician-assisted suicide in Connecticut: physicians' attitudes and experiences

OBJECTIVE

This study examined aspects of physician attitudes toward physician-assisted suicide (PAS) not fully examined to date: evaluation of risks related to PAS, particularly the presence of depression, and the influence of religious and professionally-based values.

DESIGN

Anonymous, self-administered mailed questionnaire using Dillman methodology.

PARTICIPANTS

Targeted sample of physicians licensed by the Connecticut Department of Public Health in 1997 (n = 2,805 completed surveys; 40% response rate). DATA INCLUDE: Physician and patient characteristics, attitudes toward physician assisted suicide, and confidence in treating depression.

RESULTS

Religious affiliation, religiosity, ethnicity and medical specialty were strongly associated with views on PAS. Seven percent of respondents had been asked to write a lethal prescription during the past year, 15% of whom (n = 24) had complied with at least one request.

CONCLUSIONS

Most respondents expressed concern regarding certain risks associated with PAS, including movement toward involuntary euthanasia and the influence of undetected depression. Findings raise practical issues to be addressed through statutory or professional safeguards if PAS were to be legalized.

When consultants write orders: physicians' attitudes, beliefs, and practices

The process by which a consultation is performed may significantly impact the extent to which the content of the consultation contributes positively to patient care. The practice of consultants writing orders independent of the explicit permission of the consultation requester is a common event. A survey of 211 multispecialty physicians on the medical staff of a large, urban, Northeastern, teaching hospital about their attitudes, beliefs, and practices regarding consultation on the inpatient service reveal that the majority of respondents in all specialties were unaware of departmental or hospital policy regarding the practice of consultant order writing. Significant differences between specialties existed in the perception of the impact of consultant order writing on patient outcomes, in the practice of discussion with the primary attending prior to order writing, and in the documentation practices. The authors discuss such results and their policy implications in light of important medico-legal and ethical principles, and best practice standards.

Twice-daily versus thrice-daily clarithromycin in combination with ranitidine bismuth citrate in the eradication of Helicobacter pylori

BACKGROUND

Ranitidine bismuth citrate (RBC), 400 mg bid for 4 weeks, plus clarithromycin, 500 mg tid, is a regimen approved by the US Food and Drug Administration for the eradication of Helicobacter pylori in patients with duodenal ulcers. Proof that the clarithromycin portion of the regimen could be given twice daily without loss of efficacy would reduce cost and improve patient compliance. The objective of this study was to compare the H. pylori eradication rates in patients who had duodenal ulcer and were randomly assigned to 4 weeks of treatment with RBC, 400 mg bid, in conjunction with 2 weeks of therapy with either clarithromycin, 500 mg tid, or clarithromycin, 500 mg bid.

PATIENTS AND METHODS

Patients who had a duodenal ulcer and were H. pylori-positive by at least two tests were randomly assigned to (1) RBC, 400 mg bid for 4 weeks, plus clarithromycin, 500 mg tid for 2 weeks, or (2) RBC, 400 mg bid for 4 weeks, plus clarithromycin, 500 mg bid for 2 weeks. H. pylori eradication was assessed 4 weeks after completion of RBC plus clarithromycin.

RESULTS

Three hundred eighty-three patients from 78 centers had a duodenal ulcer and were H. pylori-positive. The modified intent-to-treat (MITT) and the per-protocol (PP) eradication rates were statistically equivalent between the twice-daily (65% MITT, 74% PP) and thrice-daily (63% MITT, 73% PP) clarithromycin treatment regimens. Incidence and types of adverse events did not differ between the two groups.

CONCLUSIONS

For eradicating H. pylori in patients with duodenal ulcer, clarithromycin, 500 mg bid for 2 weeks, with RBC, 400 mg bid for 4 weeks, is equivalent to clarithromycin, 500 mg tid with RBC. The potential enhancement of patient compliance, reduced cost of clarithromycin, and equivalent efficacy would support the use of twice-daily clarithromycin in triple-therapy regimens with RBC.

The physician-assisted suicide policy dilemma: a pilot study of the views and experiences of Connecticut physicians

Development of fully informed public policy regarding physician-assisted suicide (PAS) requires a thorough understanding of the experiences, attitudes, and beliefs of physicians with respect to this issue. This study gathered data on physician characteristics, attitudes toward PAS, factors influencing attitudes toward PAS, and sensitivity to the role of depression in a sample of 397 psychiatrists, internists, and family practitioners in Connecticut. Central considerations included: the influence of religious values, professional discipline and practice patterns, and ability to diagnose depression in a single evaluation. Psychiatrists were significantly more likely to be supportive of PAS than were internists or family practitioners. Most respondents expressed concern regarding the influence of depression on PAS requests. A subset of physicians endorse PAS yet do not share such concern about risks, suggesting substantial challenges for policy-makers.

Physician compliance with practice guidelines

BACKGROUND

Physician adherence to established practice standards has become an important national issue. Despite the proliferation of formal standards of practice, there is little evidence that the mere availability of guidelines results in changes in physician practices. This paper presents the results of a study of the effectiveness of a computerized monitoring and notification system in increasing physician compliance with treatment guidelines.

METHODS

This study prospectively compared medical staff practices in two one-year periods utilizing a computer system which tabulated noncompliance and provided reminders.

RESULTS

Overall, there was a statistically-significant decrease in the number of alerts issued in year two compared to year one; alerts were issued on 15% vs 29% of all patients (P < .001). The average number of alerts per patient decreased to .20 from .41.

CONCLUSIONS

The study results indicate that a clinical decision support system such as that described can improve adherence to treatment guidelines.

An Empirical Review of the Impact of Triplicate Prescription of Benzodiazepines

In 1989 New York became the first state to add benzodiazepines to the list of controlled substances requiring a triplicate prescription, allowing the state to track prescribing patterns and target providers, pharmacies, and patients for investigation when misuse is suspected. Studies by the state reporting that regulation has significantly reduced inappropriate prescribing and illicit diversion of benzodiazepines without affecting legitimate prescribing practices are being challenged by other studies showing that patients with legitimate needs for benzodiazepines are being denied them, often after abrupt discontinuation. Several reports indicate a significant increase in the prescribing of benzodiazepine substitutes that are less safe and effective, along with increased overdoses of some substitute drugs. Changes in physicians' legitimate prescribing practices may reflect their fears of the damage to career and peace of mind that follows investigations by regulatory agencies.

A rating inventory for resident case presentations

We devised a rating scale, the Resident Case Presentation Inventory (RCPI), to evaluate psychiatry residents' case presentations at our hospital's disposition conference. A review of 69 inpatient cases presented prior to discharge revealed that residents' greatest deficiencies were in the following two areas: 1) knowing indications for specific outpatient treatments and 2) coordinating input from various clinical disciplines, both inpatient and outpatient. The RCPI allows early identification of residents' educational needs and can give ongoing feedback on their progress.

Regulation of benzodiazepine prescribing practices: clinical implications

In an effort to control prescription abuse of benzodiazepines, the New York State Department of Health (DOH) enacted a regulation requiring the use of triplicate prescriptions for these medications. DOH predicted that this regulation would reduce the overall abuse of benzodiazepines and eliminate widescale organized fraud and abuse without any negative impact or reduced availability to patients. Following implementation of the regulation, the authors reviewed all psychiatric emergency room cases and outpatient clinic walk-in evaluations over a 3-month period in an urban medical center and identified 59 cases in which the use of benzodiazepines was a significant presenting problem. Of these, 24 (41%) were judged to be directly related to the new triplicate regulation. In all but one of these cases the patient presented because of symptoms or concerns directly stemming from the refusal by a clinician to continue prescribing a benzodiazepine in a previously established pattern. Typically, abrupt discontinuation of benzodiazepine treatment led to a withdrawal syndrome and/or the unmasking of a previously treated anxiety disorder. In attempting to redress what are essentially criminal substance abuse problems through the regulation of legitimate clinical practice, regulatory agencies may ultimately deprive patients of appropriate, legitimate, and efficacious treatments.

Psychiatric commitment of the elderly

Involuntary hospitalization of the elderly has been the focus of controversy. In many jurisdictions, commitment criteria are stringently and narrowly defined, require a showing of "dangerousness," and are difficult to apply toward securing proper treatment for the elderly. In other areas, broader criteria apply, but some authors argue that such criteria are inappropriately used with the elderly and leave them vulnerable to the abuse of unnecessary institutionalization. The authors examined 274 consecutive admissions aged 55 years and over, comparing voluntary and involuntary patients. Patients admitted involuntarily were significantly more likely to have organic mental disorders, be violent before admission, and be disoriented, withdrawn, and apathetic. Voluntary patients were significantly more likely to have major mood disorders. Patients who lived with others were more likely to be committed than those living alone. The authors discuss these findings with attention to the appropriateness of broader commitment standards and the more stringent dangerousness criteria as they apply to the geriatric population.

Autonomy and the right to refuse treatment: patients' attitudes after involuntary medication

The courts' assumption that patients' refusals of treatment are based on autonomous decision making was evaluated by examining the opinions of 24 involuntarily medicated patients about their treatment. At discharge 17 patients felt that their treatment refusal had been correctly overridden by staff and that they should be treated against their will again if necessary. Patients who persistently disapproved of the decision to override their treatment refusal were highly grandiose, engaged in denial of psychotic proportions, and responded poorly to treatment. The results suggest that, for most patients, the decision to refuse psychotropic medication is a manifestation of the patient's illness and does not reflect autonomous functioning or consistent beliefs about mental illness or its treatment. Consequently treatment refusal should be considered primarily a psychotherapeutic issue and, in most cases, should be subject to clinical rather than judicial review.

The presence of counsel at forensic psychiatric examinations

In virtually all situations involving forensic psychiatric assessments, the patient is represented by counsel. But does this fact entitle the lawyer to be present at the clinical evaluation? In a series of New York cases spanning a generation, judges have allowed presence of counsel at the psychiatric examination. The most common reason given for such a conclusion is to assure better cross-examination of the expert witness. Psychiatric evaluations mandated by law necessitate several guidelines different from those of the usual doctor/patient relationship. While we may have to accept the presence of attorneys in our consulting rooms, they should be observers only. To allow active intervention would distort the clinical process.

Neuroleptic malignant syndrome following amoxapine overdose

The case of a patient who developed the neuroleptic malignant syndrome following an overdose of amoxapine is presented. It is suggested that amoxapine, an antidepressant structurally related to the neuroleptic loxapine, be added to the list of medications that can cause this potentially lethal syndrome. This case illustrates the need for careful evaluation and attention to differential diagnosis when psychiatric patients develop physical signs and symptoms.

Legal and ethical pitfalls in family practice psychiatry

Family physicians provide a significant amount of mental health care in the form of psychotropic medication and supportive psychotherapy. Providers of primary psychiatric care face a number of legal dangers and ethical pitfalls. Most often, these derive from negligent diagnosis or treatment, failure to prevent suicide and exploitation of the patient. By adhering to sound clinical guidelines and ethical principles, physicians can both protect themselves and provide better care for their patients.

Shifting competency during hospitalization: a model for informed consent decisions

The demonstration of factual understanding should be sought when determining a patient's ability to give informed consent, but a patient's failure to demonstrate understanding should not always be equated with an inability to competently consent to or refuse treatment. The authors demonstrate the clinical use of a number of standards other than factual understanding. Judgments about competency are derived both from the patient's clinical condition and the risks and benefits inherent in the decision the patient is asked to make. Since both of these conditions may shift during the course of treatment, clinical competency is subject to continual reassessment using a variety of competency standards. The authors demonstrate the use of their model of shifting competency at five junctures in the treatment of a delusional patient.

Unforeseeable liability for patients' violent acts

Psychiatrists have been held liable for violent acts committed by their patients when more than an error in professional judgment could be demonstrated. The authors describe several recent court cases in which judges have ignored or distorted acceptable clinical practices, conceivably creating a new liability standard whereby a tragic outcome is considered the result of failure to apply appropriate judgment. Following discussion of the cases are recommendations for managing the risks attendant to psychiatric decision making today, such as gathering as much of the patient's history as possible, obtaining previous records, documenting clinical reasoning, and consulting colleagues. Reforms for the legal process are also suggested.

Catatonic reaction to accidental haloperidol overdose: an unrecognized drug abuse risk

A case is reported in which a patient was hospitalized with a severe mixed extrapyramidal symptoms-catatonic reaction after ingestion of three 10-mg tablets of haloperidol that he had purchased on the street, believing them to be Valium and intending to "get high." The diagnosis was initially missed because the patient and family reported no history of neuroleptic treatment. The syndrome resolved quickly with supportive care. Clinicians must consider this possibly underrecognized syndrome in patients presenting with sudden onset of parkinsonian and catatonic symptoms, particularly when substance abuse may have occurred.

Determining resuscitation status: a survey of medical professionals

Regarding the determination of resuscitation status (RS) and the writing of do-not-resuscitate orders, we compared the recent Presidential Guidelines with the attitudes and perceptions of 143 medical professionals in a major medical center. Seventy-four percent of respondents believed that RS was primarily determined by the physician. Only 1% believed the patient decides and a minority (40%) believed the patient should decide; 61% would want to decide for themselves if they were ill. Most respondents agreed that neither patients nor staff were well-informed about the individual patient's RS. When presented case vignettes requiring a decision about RS, the respondents frequently chose a RS contrary to the wishes of a competent patient. The findings of this survey point to the significant differences between the Presidential Commission's guidelines and the actual attitudes and perceived practices of clinicians.

Clinical judgments in the decision to commit. Psychiatric discretion and the law

Judicial decisions and statutory reforms point to a return to psychiatric discretion when clinical needs and patients' rights must be balanced. In seeking to commit patients, psychiatrists have been accused of contravening the legal rights of their patients by applying criteria other than those prescribed by law. This study examined the factors involved in the psychiatrists' decisions to seek commitment or to release 90 voluntarily hospitalized patients; we found psychiatrists' decisions to be appropriately correlated to legal criteria and legally relevant clinical and psychosocial factors. Interpersonal variables did not play a material role in the decision. Independent assessment of the patients' clinical status were consistent with clinicians' judgments of dangerousness. These findings indicate that this group of psychiatrists, faced with the decision to seek commitment, based their judgments on clinically relevant data rather than interpersonal factors and conformed to the dangerousness requirements of the commitment law.

Thyrotropin receptors in thyroid plasma membranes. Characteristics of thyrotropin binding and solubilization of thyrotropin receptor activity by tryptic digestion

Biologically active bovine 125I-thyrotropin preparations have been prepared, characterized, and used to evaluate the optimal conditions for thyrotropin binding to bovine thyroid plasma membranes in vitro. Binding of 125I-TSH has a pH optimum around 6.0 and is sensitive to the choice and concentration of buffer. Binding is inhibited by salts, especially those containing magnesium and calcium ions; magnesium concentrations optimal for adenylate cyclase assays (2 to 5 mM) result in 85 to 98% inhibition of binding. Binding is temperature sensitive. At 37 degrees binding has its highest initial level; however, instability of the membrane at this temperature causes a rapid loss of binding activity. Binding at 0 degrees is optimal in 30 min and at the same level as initial binding at 37 degrees; since there is no decrease in binding activity, it has been chosen as the optimal temperature. Thyrotropin, luteinizing hormone, the beta subunit of thyrotropin, and the alpha subunit of thyrotropin have relative binding affinities for the thyrotropin receptors of 100, 10, 2, and less than 0.5, respectively. In all of these characteristics, 125I-thyrotropin at 1.5 x 10(-5) M concentrations has the same properties of binding to bovine plasma membranes as do [3H]thyrotropin preparations which have been previously characterized (Amir, S.M., Carraway, T.F., Jr., Kohn, L.D., and Winand, R.V. (1973) J. Biol. Chem. 248, 4092-4100) and used to study binding at 5 x 10(-6) M concentrations. 125I-TSH binding as a function of hormone concentration results in curved Scatchard plots; however, Hill plots of these same binding data are linear and have a slope of 0.65. Taken together, these data suggest that the heterogeneity in thyrotropin binding constants which is evident in the Scatchard plot reflects a negatively cooperative relationship among the thyrotropin receptor sites, i.e. decreased hormonal affinity as hormone concentrations increase. Adenylate cyclase studies yield kinetic plots which also exhibit negative cooperativity; corrections for thyrotropin bound under the adverse binding conditions of the adenylate cyclase assays suggest that Km values for thyrotropin in this enzymatic assay are compatible with binding constants measured by the 125I-thyrotropin preparations. Tryptic digestion destroys binding activity on the thyroid plasma membrane but releases specific thyrotropin receptor activity into the supernatant phase. Chromatography on Sephadex G-100 indicates that this solubilized receptor fragment has a molecular weight between 15,000 and 30,000.