Diagnostic predictive values for sport-related concussions: a systematic review and diagnostic meta-analysis

OBJECTIVE

Sport-related concussions (SRCs) can cause significant neurological symptoms, and approximately 10%-15% of athletes with SRC experience a prolonged recovery. Given the lack of visible injury on brain imaging and their varied presentations, concussions can be difficult to diagnose. A variety of tests and examination methods have been used to elicit a concussion diagnosis; however, the sensitivity and specificity of these tests are variable. The authors performed a systematic review and meta-analysis to evaluate the sensitivity and specificity of standardized tests and visible signs like balance and vision changes in the diagnosis of SRC.

METHODS

A PRISMA-adherent systematic review of concussion diagnostic examinations was performed using the PubMed, MEDLINE, Scopus, Cochrane, Web of Science, and Google Scholar databases on December 1, 2022. Search terms included "concussion," "traumatic brain injury," "diagnosis," "sensitivity," and "specificity." Each method of examination was categorized into larger group-based symptomatologic presentations or standardized tools. The primary outcome was the diagnosis of concussion. Pooled specificity and sensitivity for each method were calculated using a meta-analysis of proportion and were hierarchically ranked using P-scores calculated from a diagnostic frequentist network meta-analysis.

RESULTS

Thirty full-length articles were identified for inclusion, 13 of which evaluated grouped symptomology examinations (balance and overall clinical presentation) and 17 of which evaluated established formalized tools (ImPACT, King-Devick [K-D] Test, Sport Concussion Assessment Tool [SCAT]). The pooled specificity of the examination methods differed minimally (0.8-0.85), whereas the sensitivity varied to a larger degree (0.5-0.88). In a random effects model, the SCAT had the greatest diagnostic yield (diagnostic OR 31.65, 95% CI 11.06-90.57). Additionally, P-score hierarchical ranking revealed SCAT as having the greatest diagnostic utility (p = 0.9733), followed sequentially by ImPACT, clinical presentation, K-D, and balance.

CONCLUSIONS

In deciphering which concussion symptom-focused examinations and standardized tools are most accurate in making a concussion diagnosis, the authors found that the SCAT examination has the greatest diagnostic yield, followed by ImPACT, clinical presentation, and K-D, which have comparable value for diagnosis. Given the indirect nature of this analysis, however, further comparative studies are needed to validate the findings.

Factors influencing geographic gender disparity in neurosurgery: a nationwide geospatial clustering analysis

OBJECTIVE

Women neurosurgeons (WNs) continue to remain a minority in the specialty despite significant initiatives to increase their representation. One domain less explored is the regional distribution of WNs, facilitated by the hiring practices of neurosurgical departments across the US. In this analysis, the authors coupled the stated practice location of WNs with regional geospatial data to identify hot spots and cold spots of prevalence and examined regional predictors of increases and decreases in WNs over time.

METHODS

The authors examined the National Provider Identifier (NPI) numbers of all neurosurgeons obtained via the National Plan and Provider Enumeration System (NPPES), identifying the percentage of WNs in each county for which data were appended with data from the US Census Bureau. Change in WN rates was identified by calculating a regression slope for all years included (2015-2022). Hot spots and cold spots of WNs were identified through Moran's clustering analysis. Population and surgeon features were compared for hot spots and cold spots.

RESULTS

WNs constituted 10.73% of all currently active neurosurgical NPIs, which has increased from 2015 (8.81%). Three hot spots were found-including the Middle Atlantic and Pacific divisions-that contrasted with scattered cold spots throughout the East Central regions that included Memphis as a major city. Although relatively rapidly growing, hot spots had significant gender inequality, with a median WN percentage of 11.38% and a median of 0.61 WNs added to each respective county per year.

CONCLUSIONS

The authors analyzed the prevalence of WNs by using aggregated data from the NPPES and US Census Bureau. The authors also show regional hot spots of WNs and that the establishment of WNs in a region is a predictor of additional WNs entering the region. These data suggest that female neurosurgical mentorship and representation may be a major driver of acceptance and further gender diversity in a given region.

Structural basis of a transcription pre-initiation complex on a divergent promoter

Most eukaryotic promoter regions are divergently transcribed. As the RNA polymerase II pre-initiation complex (PIC) is intrinsically asymmetric and responsible for transcription in a single direction, it is unknown how divergent transcription arises. Here, the Saccharomyces cerevisiae Mediator complexed with a PIC (Med-PIC) was assembled on a divergent promoter and analyzed by cryoelectron microscopy. The structure reveals two distinct Med-PICs forming a dimer through the Mediator tail module, induced by a homodimeric activator protein localized near the dimerization interface. The tail dimer is associated with ∼80-bp upstream DNA, such that two flanking core promoter regions are positioned and oriented in a suitable form for PIC assembly in opposite directions. Also, cryoelectron tomography visualized the progress of the PIC assembly on the two core promoter regions, providing direct evidence for the role of the Med-PIC dimer in divergent transcription.

Structure and noncanonical Cdk8 activation mechanism within an Argonaute-containing Mediator kinase module

The Cdk8 kinase module (CKM) in Mediator, comprising Med13, Med12, CycC, and Cdk8, regulates RNA polymerase II transcription through kinase-dependent and -independent functions. Numerous pathogenic mutations causative for neurodevelopmental disorders and cancer congregate in CKM subunits. However, the structure of the intact CKM and the mechanism by which Cdk8 is non-canonically activated and functionally affected by oncogenic CKM alterations are poorly understood. Here, we report a cryo-electron microscopy structure of Saccharomyces cerevisiae CKM that redefines prior CKM structural models and explains the mechanism of Med12-dependent Cdk8 activation. Med12 interacts extensively with CycC and activates Cdk8 by stabilizing its activation (T-)loop through conserved Med12 residues recurrently mutated in human tumors. Unexpectedly, Med13 has a characteristic Argonaute-like bi-lobal architecture. These findings not only provide a structural basis for understanding CKM function and pathological dysfunction, but also further impute a previously unknown regulatory mechanism of Mediator in transcriptional modulation through its Med13 Argonaute-like features.

A Quantitative Assessment of the Accuracy and Reliability of Robotically Guided Percutaneous Pedicle Screw Placement: Technique and Application Accuracy

BACKGROUND

Minimally invasive surgery (MIS) and anterior (ALIF), transforaminal (TLIF), or lateral lumbar interbody fusion (LLIF) often require percutaneous pedicle screw fixation (PSF) to achieve circumferential fusion. Robotic guidance technology may augment workflow to improve screw placement and decrease operative time.

OBJECTIVE

To report surgical experience with robotically assisted percutaneous screw placement following LLIF.

METHODS

Data from fusions with robotically assisted PSF in prone or lateral decubitus positions was reviewed. A CT-guided robotic guidance arm was used for screw placement (Excelsius GPS™, Globus Medical Inc, Audubon, Pennsylvania). Postoperative CT imaging facilitated screw localization. 3-dimensional and 2-dimensional coordinates of the screw tip and tail were calculated and compared with a target trajectory to calculate targeting errors. Breach was defined as a violation of the lateral or medial pedicle wall.

RESULTS

Robotic-guided screw placement was successful in 28/31 patients. In those patients, 116/116 screws were successfully implanted. The breach rate was 3.4% (4/116). Across 17 patients (70 screws), mean 3-D accuracy was 5.0 ± 2.4 mm, mean 2-D accuracy was 2.6 ± 1.1 mm, and mean angular offset was 5.6 ± 4.3° with corresponding intraclass correlation coefficients (ICC) of 0.775 and 0.693. 3-dimensional accuracy correlated with age (R = 0.306, P = .011) and BMI (R = 0.252, P = .038). Accuracy did not significantly differ among vertebral body levels (P > .22). Mean operative time for MIS-TLIF and percutaneous screws was 277 ± 52 and 183 ± 54 min, respectively. Operative time did not significantly decrease across either group (P > .187).

CONCLUSION

The Excelsius GPS™ robotic guidance system allows accurate PSF in most cases with 2 mm 2-D accuracy. Future studies are needed to demonstrate the utility of this novel guidance system and workflow improvement.

Adaptive behavior in autism: Minimal clinically important differences on the Vineland-II

Autism Spectrum Disorder (ASD) is associated with persistent impairments in adaptive abilities across multiple domains. These social, personal, and communicative impairments become increasingly pronounced with development, and are present regardless of IQ. The Vineland Adaptive Behavior Scales, Second Edition (Vineland-II) is the most commonly used instrument for quantifying these impairments, but minimal clinically important differences (MCIDs) on Vineland-II scores have not been rigorously established in ASD. We pooled data from several consortia/registries (EU-AIMS LEAP study, ABIDE-I, ABIDE-II, INFOR, Simons Simplex Collection and Autism Treatment Network [ATN]) and clinical investigations and trials (Stanford, Yale, Roche) resulting in a data set of over 9,000 individuals with ASD. Two approaches were used to estimate MCIDs: distribution-based methods and anchor-based methods. Distribution-based MCID [d-MCID] estimates included the standard error of the measurement, as well as one-fifth and one-half of the covariate-adjusted standard deviation (both cross-sectionally and longitudinally). Anchor-based MCID [a-MCID] estimates include the slope of linear regression of clinician ratings of severity on the Vineland-II score, the slope of linear regression of clinician ratings of longitudinal improvement category on Vineland-II change, the Vineland-II change score maximally differentiating clinical impressions of minimal versus no improvement, and equipercentile equating. Across strata, the Vineland-II Adaptive Behavior Composite standardized score MCID estimates range from 2.01 to 3.2 for distribution-based methods, and from 2.42 to 3.75 for sample-size-weighted anchor-based methods. Lower Vineland-II standardized score MCID estimates were observed for younger and more cognitively impaired populations. These MCID estimates enable users of Vineland-II to assess both the statistical and clinical significance of any observed change. Autism Res 2018, 11: 270-283. © 2017 International Society for Autism Research, Wiley Periodicals, Inc.

LAY SUMMARY

The Vineland Adaptive Behavior Scales (2nd edition; Vineland-II) is the most widely used scale for assessing day-to-day "adaptive" skills. Yet, it is unknown how much Vineland-II scores must change for those changes to be regarded as clinically significant. We pooled data from over 9,000 individuals with ASD to show that changes of 2-3.75 points on the Vineland-II Composite score represent the "minimal clinically-important difference." These estimates will help evaluate the benefits of potential new treatments for ASD.

Bevacizumab or laser for aggressive posterior retinopathy of prematurity

PURPOSE

The purpose of this study was to report the rate of reactivation and structural outcome, after the laser or bevacizumab treatment for aggressive posterior retinopathy of prematurity (APROP).

METHODS

Retrospective chart review was conducted on consecutive infants with APROP treated with (1) laser or (2) bevacizumab, followed by fluorescein angiography and prophylactic laser to the persistent avascular retina.

RESULTS

Thirty-six eyes of 19 patients were included in this study. The mean gestational age was 24.5 weeks with a mean birth weight of 632 g in the bevacizumab group and 24.7 weeks and 777 g in the laser group. Unfavorable outcome occurred in 1 of 22 eyes treated with bevacizumab and in 5 of 14 eyes in the laser group (P = 0.002). Reactivation requiring treatment was common in both groups, 9/22 after bevacizumab and 6/14 after laser (ns).

CONCLUSION

Regardless of the initial treatment reactivation requiring retreatment is common in eyes with APROP. The unfavorable structural outcome was significantly more common after initial laser treatment than after initial bevacizumab treatment.

Parasaccharibacter apium, gen. nov., sp. nov., Improves Honey Bee (Hymenoptera: Apidae) Resistance to Nosema

The honey bee, Apis mellifera L., is host to a variety of microorganisms. The bacterial community that occupies the adult worker gut contains a core group of approximately seven taxa, while the hive environment contains its own distribution of bacteria that is in many ways distinct from the gut. Parasaccharibacter apium, gen. nov., sp. nov., is a hive bacterium found in food stores and in larvae, worker jelly, worker hypopharyngeal glands, and queens. Parasaccharibacter apium increases larval survival under laboratory conditions. To determine if this benefit is extended to colonies in the field, we tested if P. apium 1) survives and reproduces in supplemental pollen patty, 2) is distributed throughout the hive when added to pollen patty, 3) benefits colony health, and 4) increases the ability of bees to resist Nosema. Parasaccharibacter apium survived in supplemental diet and was readily consumed by bees. It was distributed throughout the hive under field conditions, moving from the pollen patty to hive larvae. While P. apium did not significantly increase colony brood production, food stores, or foraging rates, it did increase resistance to Nosema infection. Our data suggest that P. apium may positively impact honey bee health.

Multicentre results of stereotactic body radiotherapy for secondary liver tumours

BACKGROUND

Surgical resection is the standard treatment for liver metastases, although for the majority of patients this is not possible. Stereotactic body radiotherapy (SBRT) is an alternative local-regional therapy. The purpose of this study was to evaluate the results of SBRT for secondary liver tumours from a combined multicentre database.

METHODS

Variables from patients treated with SBRT from four Academic Medical Centres were entered into a common database. Local tumour control and 1-year survival rates were calculated.

RESULTS

In total, 153 patients (91 women) 59 ± 8.4 years old with 363 metastatic liver lesions were treated with SBRT. The underlying primary tumour arose from gastrointestinal (GI), retroperitoneal and from extra-abdominal primaries in 56%, 8% and 36% of patients, respectively. Metastases, with a gross tumour volume (GTV) of 138.5 ± 126.8 cm(3) , were treated with a total radiation dose of 37.5 ± 8.2 Gy in 5 ± 3 fractions. The 1-year overall survival was 51% with an overall local control rate of 62% at a mean follow-up of 25.2 ± 5.9 months. A complete tumour response was observed in 32% of patients. Grade 3-5 adverse events were noted in 3% of patients.

CONCLUSION

Secondary liver tumours treated with SBRT had a high rate of local control with a low incidence of adverse events.

Multicenter results of stereotactic body radiotherapy (SBRT) for non-resectable primary liver tumors

BACKGROUND

An excess of 100 000 individuals are diagnosed with primary liver tumors every year in USA but less than 20% of those patients are amenable to definitive surgical management due to advanced local disease or comorbidities. Local therapies to arrest tumor growth have limited response and have shown no improvement on patient survival. Stereotactic body radiotherapy (SBRT) has emerged as an alternative local ablative therapy. The purpose of this study was to evaluate the tumor response to SBRT in a combined multicenter database.

STUDY DESIGN

Patients with advanced hepatocellular carcinoma (HCC, n = 21) or intrahepatic cholangiocarcinoma (ICC, n = 11) treated with SBRT from four Academic Medical Centers were entered into a common database. Statistical analyses were performed for freedom from local progression (FFLP) and patient survival.

RESULTS

The overall FFLP for advanced HCC was 63% at a median follow-up of 12.9 months. Median tumor volume decreased from 334.2 to 135 cm(3) (p < 0.004). The median time to local progression was 6.3 months. The 1- and 2-years overall survival rates were 87% and 55%, respectively. Patients with ICC had an overall FFLP of 55.5% at a median follow-up of 7.8 months. The median time to local progression was 4.2 months and the six-month and one-year overall survival rates were 75% and 45%, respectively. The incidence of grade 1-2 toxicities, mostly nausea and fatigue, was 39.5%. Grade 3 and 4 toxicities were present in two and one patients, respectively.

CONCLUSION

Higher rates of FFLP were achieved by SBRT in the treatment of primary liver malignancies with low toxicity.

Intraosseous maxillary hemangioma in an immature Bassett Hound

A 6-month-old Bassett Hound dog presented for evaluation of recurrent oral bleeding and a right maxillary swelling. Oral examination revealed right maxillary enlargement extending from the level of the right maxillary canine tooth to the area of the second and third premolar teeth. A discolored persistent right maxillary deciduous canine tooth and gingival inflammation was noted. Biopsies taken at the time of extraction of the persistent deciduous canine tooth resulted in significant hemorrhage and a biopsy report of reactive bone. The right maxillary enlargement did not resolve following the extraction procedure and empirical antimicrobial therapy. The owner elected euthanasia and post-mortem evaluation. Histopathologic assessment provided a diagnosis of maxillary hemangioma.

Cryoablation vs. radiofrequency ablation for small renal masses

RATIONALE AND OBJECTIVES

Cancer of the kidney is the third most common cancer of the urinary tract, and renal cell carcinoma is the most lethal of all genitourinary tumors. The incidental discovery of renal cell carcinoma has increased with increased use of cross-sectional imaging. Concomitantly, minimally invasive ablative technologies, including image-guided cryoablation, radiofrequency ablation, and others, have evolved as therapeutic options for small renal masses.

MATERIALS AND METHODS

Between 2006 and 2009, 111 patients (age range, 31-91 years; mean age, 70 years) underwent percutaneous computed tomography-guided thermal ablation for suspected renal cell carcinoma at two major academic centers. Outcomes data were retrospectively collected and analyzed to compare recurrence rates for patients undergoing radiofrequency ablation (n = 41) versus cryoablation (n = 70).

RESULTS

There were four cases of suspicious enhancement on follow-up computed tomography or magnetic resonance imaging in each group, with cumulative imaging recurrence rates of 11% and 7% for radiofrequency ablation and cryoablation, respectively. Log rank test analysis revealed no significant difference between rates of imaging recurrence between the two groups (P = .6044).

CONCLUSIONS

These results suggest that the use of cryoablative technology will result in similar outcomes compared with radiofrequency ablation.

Neutralizing CCL2 Inhibits Breast Tumor Growth Via Impact on the Tumor/Stroma Microenvironment

CCL2, (CC-chemokine ligand 2 or monocyte chemoattractant protein-1 (MCP-1)), is overexpressed in many human tumors and is believed to exert pro-tumor effects by recruiting monocytes to the tumor, where these cells become tumor associated macrophages (TAMs). TAMs secrete growth factors that stimulate angiogenesis and tumor growth, as well as proteases to promote tumor invasion and metastasis. CCL2 expression levels in primary breast tumors have been correlated with macrophage infiltration and blood vessel density, which in turn is correlated with disease stage and prognosis. These correlations indicate that CCL2 is a key player in tumor macrophage infiltration and/or tumor growth/invasion, and suggest that neutralizing CCL2 could be an effective form of therapy for breast cancer patients.The objective of these studies was to investigate whether CCL2 blockade could inhibit tumor growth in mice bearing human breast tumors. The human breast tumor cell lines MDA-MB-231 (ER-, PR-, Her2-) and MDA-MB-361 (ER+, PR+, Her2+) were implanted orthotopically in immunocompromised mice, and in both models the primary tumors metastasized to lungs and brain. Neutralizing antibodies to human CCL2 (CNTO 888) and to the mouse orthologs, MCP-1 and MCP-5, were administered therapeutically, either as a cocktail (termed CCL2 blockade) or individually to study the relative roles of host vs tumor derived CCL2 in promoting tumor growth.In both tumor models, CCL2 blockade significantly inhibited the growth of established primary tumors in the mammary fat pad. In addition, CCL2 blockade inhibited metastasis to distant sites. As measured by Taqman, visual inspection and immunohistochemistry, mice with MDA-MB-361 tumors treated with CCL2 blockade showed significantly reduced metastasis to lungs and brain, while mice bearing MDA-MB-231 tumors showed significantly reduced metastasis to lungs.To define the relative roles of human tumor-derived CCL2 vs mouse host-derived MCP-1/MCP-5, in vivo monotherapy tumor studies were conducted using the individual neutralizing antibodies. These studies included the mammary fat pad model and a tail vein metastasis model. In both cases, only the treatment with the anti-mouse MCP-1 antibody significantly inhibited primary tumor growth and distant metastasis, indistinguishable from the effect of CCL2 blockade treatment. In the tail vein metastasis model, the antibody treatment resulted in significantly fewer detectable lesions with these lesions showing a significant reduction in both tumor size and growth fraction, suggesting antibody treatment inhibits tumor seeding and growth. Mechanistic studies are in progress to further understand the basis of the anti-tumor effect mediated by the antibody treatment. These results demonstrate that host-derived MCP-1, produced from the tumor microenvironment, plays the critical role in tumor growth and metastasis in these models of human breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6095.

Nasal displacement of a tooth root in a dog

A ten-year-old miniature Dachshund dog was presented for chronic paroxysmal sneezing and unilateral nasal discharge. Extraction of the maxillary right fourth premolar tooth had been performed 2-weeks prior to the onset of clinical signs. Multiple diagnostic modalities were used to confirm the diagnosis and determine that the etiology was a nasally displaced mesiopalatal tooth root. A limited lateral rhinotomy was performed to remove the root. Postoperative examination 1-month following surgery indicated resolution of the clinical signs and uncomplicated healing of the surgery site. Oral examination indicated normal healing of the surgery site with continued absence of clinical signs 6-months after treatment.

Health-related quality of life assessment in adult haemophilia patients: a systematic review and evaluation of instruments

The objective of this study was to review and evaluate the performance of health-related quality of life (HRQL) and other health status measures used in studies of adult haemophilia and provide recommendations for future research. A systematic literature review was performed to identify HRQL and health status measures used in haemophilia. Literature was identified using medical databases, Internet and manual searches. The search was restricted to articles published in English since 1986. Ninety-six abstracts were located; 19 relevant articles were selected for detailed review. Three main types of HRQL measures were identified: generic psychometric-based HRQL (SF-36 and SF-12), utility-based HRQL [EQ-5D and Health Utilities Index (HUI)], and musculoskeletal-specific HRQL (Arthritis Impact Measurement Scale 2, AIMS 2) instruments. No patient-rated haemophilia-specific HRQL instrument was found. The SF-36, the EQ-5D, and the HUI were able to discriminate haemophilia patient subgroups with respect to disease severity and HIV comorbidity status. Sixteen additional scales were identified that were used to measure the different aspects of physical, psychological, and social functioning of patients. There were no clinical studies of haemophilia carried out that employed HRQL instruments, thus responsiveness of these instruments could not be evaluated. The variety of instruments used in haemophilia studies highlights the need for a tool that can capture the full impact of haemophilia and its treatment on patients' HRQL. Developing such a tool poses the unique challenge of accounting for common comorbidities, such as HIV and chronic hepatitis that may have a greater HRQL impact than the underlying disease.

Physician-assisted suicide

Medical professional codes have long prohibited physician involvement in assisting a patient's suicide. However, despite ethical and legal prohibitions, calls for the liberalization of this ban have grown in recent years. The medical profession should articulate its views on the arguments for and against changes in public policy and decide whether changes are prudent. In addressing such a contentious issue, physicians, policymakers, and society must fully consider the needs of patients, the vulnerability of particular patient groups, issues of trust and professionalism, and the complexities of end-of-life health care. Physician-assisted suicide is prominent among the issues that define our professional norms and codes of ethics. The American College of Physicians-American Society of Internal Medicine (ACP-ASIM) does not support the legalization of physician-assisted suicide. The routine practice of physician-assisted suicide raises serious ethical and other concerns. Legalization would undermine the patient-physician relationship and the trust necessary to sustain it; alter the medical profession's role in society; and endanger the value our society places on life, especially on the lives of disabled, incompetent, and vulnerable individuals. The ACP-ASIM remains thoroughly committed to improving care for patients at the end of life.

Pain assessment and management

Assessment and management of pain is crucial to the success of any program of care for dying patients and their families. With appropriate assessment and management, often using home health or hospice teams, pain can be controlled in more than 90% of patients. This article focuses on the symptomatic care of patients who are dying. The legal and regulatory issues that may inhibit delivery of adequate opioid therapy are also reviewed.

Care of patients with alzheimer's disease and their families

Although the medical management options in Alzheimer's disease are limited, physicians have a central role in addressing multiple associated care needs of these patients and their families. These needs change according to different stages of the disease. Sensitive disclosure of diagnosis and providing education, guidance, and appropriate referrals to community resources are essential components to an effective care plan. By making use of a multidisciplinary network of care providers, the physician can ensure the family of proactive management throughout the course of the disease.

Bioethics, assisted suicide, and the "right to die"

Physician-assisted suicide is much talked about. But confusion remains as to what precisely it is, and debate continues about its ethical implications. Is physician-assisted suicide distinguishable from refusal of treatment? Is there a "right to die?" Does assisted suicide necessarily have to mean physician-assisted suicide? What is the relationship of physician-assisted suicide to end-of-life care? How should physicians deal with a request for assisted suicide? These issues are explored in this paper, along with a review of the ethical arguments for and against physician-assisted suicide. The paper concludes that society should encourage individuals not to see assisted suicide as their best option. A better policy than widespread legalization of physician-assisted suicide is to provide the necessary social support, health care including mental health care, hospice care, and compassion to those who feel they face an undignified life, or an undignified painful death. This paper is based on a presentation made at the AACP 2000 Annual Meeting, October 14, 2000.

Seven legal barriers to end-of-life care: myths, realities, and grains of truth

OBJECTIVE

The American College of Physicians-American Society of Internal Medicine (ACP-ASIM) End-of-Life Care Consensus Panel was convened in 1997 to identify clinical, ethical, and policy problems in end-of-life care, to analyze critically the available evidence and guidelines, and to offer consensus recommendations on how to improve care of the dying. Topic selection and content presentation were carefully debated to maximize the project's focus on providing practical clinical and other guidance to clinicians who are not specialists in palliative care. This statement examines current legal myths, realities, and grains of truth in end-of-life care.

PARTICIPANTS

The Consensus Panel comprises 13 medical and bioethics experts, clinicians, and educators in care at the end of life selected by the Ethics and Human Rights Committee, College leadership, and the Center for Ethics and Professionalism at the ACP-ASIM.

EVIDENCE

A literature review including a MEDLINE search of articles from 1970-1998 and review of end-of-life care literature and organizational bibliographies was conducted. Unpublished sources were also identified by participants, as was anecdotal clinical experience.

CONSENSUS PROCESS

The draft statement was debated by panel members over a series of 3 to 4 meetings. For this statement, the initial draft and subsequent revised drafts were discussed in 1998-1999. The statement then underwent external peer review and revision before panel approval and the journal peer review process.

CONCLUSIONS

Legal myths about end-of-life care can undermine good care and ethical medical practice. In addition, at times ethics, clinical judgment, and the law conflict. Patients (or families) and physicians can find themselves considering clinical actions that are ethically appropriate, but raise legal concerns. The 7 major legal myths regarding end-of-life care are: (1) forgoing life-sustaining treatment for patients without decision-making capacity requires evidence that this was the patient's actual wish; (2) withholding or withdrawing of artificial fluids and nutrition from terminally ill or permanently unconscious patients is illegal; (3) risk management personnel must be consulted before life-sustaining medical treatment may be terminated; (4) advance directives must comply with specific forms, are not transferable between states, and govern all future treatment decisions; oral advance directives are unenforceable; (5) if a physician prescribes or administers high doses of medication to relieve pain or other discomfort in a terminally ill patient, resulting in death, he/she will be criminally prosecuted; (6) when a terminally ill patient's suffering is overwhelming despite palliative care, and he/she requests a hastened death, there are no legally permissible options to ease suffering; and (7) the 1997 Supreme Court decisions outlawed physician-assisted suicide. Many legal barriers to end-of-life care are more mythical than real, but sometimes there is a grain of truth. Physicians must know the law of the state in which they practice. JAMA. 2000;284:2495-2501.

The major head protein of bacteriophage T4 binds specifically to elongation factor Tu

The Lit protease in Escherichia coli K-12 strains induces cell death in response to bacteriophage T4 infection by cleaving translation elongation factor (EF) Tu and shutting down translation. Suicide of the cell is timed to the appearance late in the maturation of the phage of a short peptide sequence in the major head protein, the Gol peptide, which activates proteolysis. In the present work we demonstrate that the Gol peptide binds specifically to domains II and III of EF-Tu, creating the unique substrate for the Lit protease, which then cleaves domain I, the guanine nucleotide binding domain. The conformation of EF-Tu is important for binding and Lit cleavage, because both are sensitive to the identity of the bound nucleotide, with GDP being preferred over GTP. We propose that association of the T4 coat protein with EF-Tu plays a role in phage head assembly but that this association marks infected cells for suicide when Lit is present. Based on these data and recent observations on human immunodeficiency virus type 1 maturation, we speculate that associations between host translation factors and coat proteins may be integral to viral assembly in both prokaryotes and eukaryotes.