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Pahari H, Raj A, Sawant A, Ahire DS, Rathod R, Rathi C, Sankalecha T, Palnitkar S, Raut V. Liver transplantation for hepatocellular carcinoma in India: Are we ready for 2040? World J Transplant 2024; 14:88833. [PMID: 38576752 PMCID: PMC10989470 DOI: 10.5500/wjt.v14.i1.88833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/21/2023] [Accepted: 01/22/2024] [Indexed: 03/15/2024] Open
Abstract
BACKGROUND Liver transplantation (LT) for hepatocellular carcinoma (HCC) has been widely researched and is well established worldwide. The cornerstone of this treatment lies in the various criteria formulated by expert consensus and experience. The variations among the criteria are staggering, and the short- and long-term out comes are controversial. AIM To study the differences in the current practices of LT for HCC at different centers in India and discuss their clinical implications in the future. METHODS We conducted a survey of major centers in India that performed LT in December 2022. A total of 23 responses were received. The centers were classified as high- and low-volume, and the current trend of care for patients und ergoing LT for HCC was noted. RESULTS Of the 23 centers, 35% were high volume center (> 500 Liver transplants) while 52% were high-volume centers that performed more than 50 transplants/year. Approximately 39% of centers had performed > 50 LT for HCC while the percent distribution for HCC in LT patients was 5%-15% in approximately 73% of the patients. Barring a few, most centers were divided equally between University of California, San Francisco (UCSF) and center-specific criteria when choosing patients with HCC for LT, and most (65%) did not have separate transplant criteria for deceased donor LT and living donor LT (LDLT). Most centers (56%) preferred surgical resection over LT for a Child A cirrhosis patient with a resectable 4 cm HCC lesion. Positron-emission tomography-computed tomography (CT) was the modality of choice for metastatic workup in the majority of centers (74%). Downstaging was the preferred option for over 90% of the centers and included transarterial chemoembolization, transarterial radioembolization, stereotactic body radiotherapy and atezolizumab/bevacizumab with varied indications. The alpha-fetoprotein (AFP) cut-off was used by 74% of centers to decide on transplantation as well as to downstage tumors, even if they met the criteria. The criteria for successful downstaging varied, but most centers conformed to the UCSF or their center-specific criteria for LT, along with the AFP cutoff values. The wait time for LT from down staging was at least 4-6 wk in all centers. Contrast-enhanced CT was the preferred imaging modality for post-LT surveillance in 52% of the centers. Approximately 65% of the centers preferred to start everolimus between 1 and 3 months post-LT. CONCLUSION The current predicted 5-year survival rate of HCC patients in India is less than 15%. The aim of transplantation is to achieve at least a 60% 5-year disease free survival rate, which will provide relief to the prediction of an HCC surge over the next 20 years. The current worldwide criteria (Milan/UCSF) may have a higher 5-year survival (> 70%); however, the majority of patients still do not fit these criteria and are dependent on other suboptimal modes of treatment, with much lower survival rates. To make predictions for 2040, we must prepare to arm ourselves with less stringent selection criteria to widen the pool of patients who may undergo transplantation and have a chance of a better outcome. With more advanced technology and better donor outcomes, LDLT will provide a cutting edge in the fight against liver cancer over the next two decades.
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Affiliation(s)
- Hirak Pahari
- Department of Liver Transplant and HPB Surgery, Medicover Hospitals, Navi Mumbai 410210, Maharashtra, India
| | - Amruth Raj
- Department of Liver Transplant and HPB Surgery, Medicover Hospitals, Navi Mumbai 410210, Maharashtra, India
| | - Ambreen Sawant
- Department of Liver Transplant Anaesthesia, Medicover Hospitals, Navi Mumbai 410210, Maharashtra, India
| | - Dipak S Ahire
- Department of Gastroenterology and Hepatology, Medicover Hospitals, Navi Mumbai 410210, India
| | - Raosaheb Rathod
- Department of Gastroenterology and Hepatology, Medicover Hospitals, Navi Mumbai 410210, Maharashtra, India
| | - Chetan Rathi
- Department of Gastroenterology and Hepatology, Medicover Hospitals, Aurangabad 431003, India
| | - Tushar Sankalecha
- Department of Gastroenterology and Hepatology, Medicover Hospitals, Nashik 422009, India
| | - Sachin Palnitkar
- Department of Gastroenterology and Hepatology, Medicover Hospitals, Pune 411026, India
| | - Vikram Raut
- Department of Liver Transplant and HPB Surgery, Medicover Hospitals, Navi Mumbai 410210, Maharashtra, India
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Abstract
This paper is intended to discuss some of the scientific and ethical issues that are created by increased research efforts towards earlier diagnosis, as well as to treatment of, human prion diseases (and related dementias), including the resulting consequences for individuals, their families, and society. Most patients with prion disease currently are diagnosed when they are about 2/3 of the way through their disease course (Geschwind et al., 2010a; Paterson et al., 2012b), when the disease has progressed so far that even treatments that stop the disease process would probably have little benefit. Although there are currently no treatments available for prion diseases, we and others have realized that we must diagnose patients earlier and with greater accuracy so that future treatments have hope of success. As approximately 15% of prion diseases have a autosomal dominant genetic etiology, this further adds to the complexity of ethical issues, particularly regarding when to conduct genetic testing, release of genetic results, and when or if to implement experimental therapies. Human prion diseases are both infectious and transmissible; great care is required to balance the needs of the family and individual with both public health needs and strained hospital budgets. It is essential to proactively examine and address the ethical issues involved, as well as to define and in turn provide best standards of care.
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Affiliation(s)
- Kendra Bechtel
- Memory and Aging Center, University of California, San Francisco, United States
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Green TJ, Rochon PJ, Chang S, Ray CE, Winston H, Ruef R, Kreidler SM, Glueck DH, Shulman BC, Brown AC, Durham J. Downstaging disease in patients with hepatocellular carcinoma outside of Milan criteria: strategies using drug-eluting bead chemoembolization. J Vasc Interv Radiol 2013; 24:1613-22. [PMID: 24060436 DOI: 10.1016/j.jvir.2013.07.024] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 07/28/2013] [Accepted: 07/29/2013] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To assess downstaging rates in patients with United Network for Organ Sharing stage T3N0M0 hepatocellular carcinoma (HCC) treated with doxorubicin-eluting bead transarterial chemoembolization to meet Milan criteria for transplantation. MATERIALS AND METHODS A single-center retrospective review of 239 patients treated with doxorubicin-eluting bead (DEB) chemoembolization between September 2008 and December 2011 was undertaken. Baseline and follow-up computed tomography or magnetic resonance imaging was assessed for response based on the longest enhancing axial dimension of each tumor (ie, modified Response Evaluation Criteria In Solid Tumors measurements), and medical records were reviewed. Fisher exact tests and exact logistic regression were used to test the association of patient and disease characteristics with downstaging. RESULTS After exclusions, 22 patients remained in the analysis, 17 of whom (77%) had their HCC downstaged to meet Milan criteria. Among those whose disease was downstaged, seven underwent transplantation, one remained listed for transplantation, six had disease progression beyond Milan criteria, two underwent conventional transarterial chemoembolization, and one underwent radiofrequency ablation. The seven patients who received transplants were still living, but recurrent HCC developed in two. Baseline age (P = .25), Model for End-stage Liver Disease score (P = .77), and α-fetoprotein (AFP) level (P = 1.00) were similar between patients with and without downstaged HCC. No associations were observed between the odds of downstaging and sex (P = .21), Child-Pugh class (P = .14), Child-Pugh class controlling for baseline tumor multiplicity (P = .15), Eastern Cooperative Oncology Group performance status (P = 1.00), tumor burden (P = .31), multiple tumors (P = .31), or hepatitis C virus infection (P = 1.00). Fifteen patients who did not receive transplants were alive at 1 year, with two progression-free. Baseline AFP levels differed between those who survived 1 year and those who did not (P = .02), but did not differ by progression-free survival status (P = .62). CONCLUSIONS T3N0M0 HCC treatment with DEB chemoembolization has a high likelihood (77%) of downstaging the disease to meet Milan criteria.
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MESH Headings
- Aged
- Antibiotics, Antineoplastic/administration & dosage
- Antibiotics, Antineoplastic/adverse effects
- Carcinoma, Hepatocellular/blood
- Carcinoma, Hepatocellular/diagnostic imaging
- Carcinoma, Hepatocellular/mortality
- Carcinoma, Hepatocellular/pathology
- Carcinoma, Hepatocellular/surgery
- Carcinoma, Hepatocellular/therapy
- Catheter Ablation
- Chemoembolization, Therapeutic/adverse effects
- Chemoembolization, Therapeutic/mortality
- Chemotherapy, Adjuvant
- Colorado
- Disease Progression
- Disease-Free Survival
- Doxorubicin/administration & dosage
- Doxorubicin/adverse effects
- Female
- Humans
- Liver Neoplasms/blood
- Liver Neoplasms/diagnostic imaging
- Liver Neoplasms/mortality
- Liver Neoplasms/pathology
- Liver Neoplasms/surgery
- Liver Neoplasms/therapy
- Liver Transplantation/adverse effects
- Liver Transplantation/mortality
- Logistic Models
- Magnetic Resonance Imaging
- Male
- Middle Aged
- Neoadjuvant Therapy
- Neoplasm Recurrence, Local
- Neoplasm Staging
- Odds Ratio
- Retrospective Studies
- Risk Factors
- Time Factors
- Tomography, X-Ray Computed
- Treatment Outcome
- alpha-Fetoproteins/metabolism
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Affiliation(s)
- Tyler J Green
- Department of Radiology, University of Colorado Hospital, Aurora.
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Li BH, Guan X, Vittinghoff E, Gupta N. Comparison of the presentation and course of pediatric inflammatory bowel disease in South Asians with Whites: a single center study in the United States. J Pediatr 2013; 163:1211-3. [PMID: 23706360 DOI: 10.1016/j.jpeds.2013.04.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Revised: 02/06/2013] [Accepted: 04/10/2013] [Indexed: 12/17/2022]
Abstract
We compared the severity of pediatric inflammatory bowel disease in South Asians with Whites in the US. South Asians more commonly presented with poor weight gain, developed fistulas, and received treatment with antibiotics, methotrexate, adalimumab, and steroids. South Asians appear to have a more complicated presentation and course of pediatric inflammatory bowel disease.
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Affiliation(s)
- Benjamin H Li
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
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Peters MC, Mekonnen ZK, Yuan S, Bhakta NR, Woodruff PG, Fahy JV. Measures of gene expression in sputum cells can identify TH2-high and TH2-low subtypes of asthma. J Allergy Clin Immunol 2013; 133:388-94. [PMID: 24075231 DOI: 10.1016/j.jaci.2013.07.036] [Citation(s) in RCA: 210] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 07/15/2013] [Accepted: 07/30/2013] [Indexed: 01/22/2023]
Abstract
BACKGROUND The 3-gene signature of periostin, chloride channel accessory 1 (CLCA1), and Serpin β2 (SERPINB2) in airway epithelial brushings is used to classify asthma into TH2-high and TH2-low endotypes. Little is known about the utility of gene profiling in sputum as a molecular phenotyping method. OBJECTIVE We sought to determine whether gene profiling in sputum cells can identify T(H)2-high and T(H)2-low subtypes of asthma. METHODS In induced sputum cell pellets from 37 asthmatic patients and 15 healthy control subjects, PCR was used to profile gene expression of the epithelial cell signature of IL-13 activation (periostin, CLCA1, and SERPINB2), TH2 genes (IL4, IL5, and IL13), and other genes associated with airway TH2 inflammation. RESULTS Gene expression levels of CLCA1 and periostin, but not SerpinB2, were significantly higher than normal in sputum cells from asthmatic subjects. Expression levels of IL-4, IL-5, and IL-13 were also significantly increased in asthmatic patients and highly correlated within individual subjects. By combining the expression levels of IL-4, IL-5, and IL-13 in a single quantitative metric ("T(H)2 gene mean"), 26 (70%) of the 37 asthmatic patients had T(H)2-high asthma, which was characterized by more severe measures of asthma and increased blood and sputum eosinophilia. TH2 gene mean values tended to be stable when initial values were very high or very low but fluctuated above or below the T(H)2-high cutoff when initial values were intermediate. CONCLUSION IL-4, IL-5, and IL-13 transcripts are easily detected in sputum cells from asthmatic patients, and their expression levels can be used to classify asthma into T(H)2-high and T(H)2-low endotypes.
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Affiliation(s)
- Michael C Peters
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, Calif; Cardiovascular Research Institute, University of California, San Francisco, Calif
| | - Zesemayat K Mekonnen
- Cardiovascular Research Institute, University of California, San Francisco, Calif
| | - Shaopeng Yuan
- Cardiovascular Research Institute, University of California, San Francisco, Calif
| | - Nirav R Bhakta
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, Calif; Cardiovascular Research Institute, University of California, San Francisco, Calif
| | - Prescott G Woodruff
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, Calif; Cardiovascular Research Institute, University of California, San Francisco, Calif
| | - John V Fahy
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, Calif; Cardiovascular Research Institute, University of California, San Francisco, Calif.
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Betjemann JP, Thompson AC, Santos-Sánchez C, Garcia PA, Ivey SL. Distinguishing language and race disparities in epilepsy surgery. Epilepsy Behav 2013; 28:444-9. [PMID: 23891765 DOI: 10.1016/j.yebeh.2013.06.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 06/10/2013] [Accepted: 06/19/2013] [Indexed: 10/26/2022]
Abstract
This study aimed to identify whether race/ethnicity and limited English proficiency impact the likelihood of pursuing surgical treatment for medically refractory epilepsy. We conducted a retrospective cohort study of 213 patients with medically refractory epilepsy and mesial temporal sclerosis who were being considered for temporal lobectomy between January 1, 1993 and December 31, 2010 with follow-up through December 31, 2012. Demographic and clinical factors potentially associated with surgical utilization, including self-reported race/ethnicity and preferred language, were gathered from the medical record. Patients of Asian/Pacific Islander or African American race were significantly less likely to pursue surgical treatment of epilepsy compared with non-Hispanic whites in a multivariate logistic regression model (adjusted for nonconcordant ictal EEG, age, and limited English proficiency) (OR 0.20, p=0.003; OR 0.15, p=0.001, respectively). Limited English proficiency was also significantly associated with lower odds of surgery (OR 0.38, p=0.034). Both race and limited English proficiency contribute to disparities in the surgical management of medically refractory epilepsy, especially among Asian/Pacific Islanders and African Americans. Culturally sensitive patient-physician communication and patient education materials might aid in surgical decision-making among minority groups.
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Affiliation(s)
- John P Betjemann
- University of California, San Francisco, Department of Neurology, Box 0138, 521 Parnassus Ave, C-440, San Francisco, CA 94143, USA.
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Abstract
There is growing evidence that bisphenol A (BPA) may adversely affect humans. BPA is an endocrine disruptor that has been shown to be harmful in laboratory animal studies. Until recently, there were relatively few epidemiological studies examining the relationship between BPA and health effects in humans. However, in the last year, the number of these studies has more than doubled. A comprehensive literature search found 91 studies linking BPA to human health; 53 published within the last year. This review outlines this body of literature, showing associations between BPA exposure and adverse perinatal, childhood, and adult health outcomes, including reproductive and developmental effects, metabolic disease, and other health effects. These studies encompass both prenatal and postnatal exposures, and include several study designs and population types. While it is difficult to make causal links with epidemiological studies, the growing human literature correlating environmental BPA exposure to adverse effects in humans, along with laboratory studies in many species including primates, provides increasing support that environmental BPA exposure can be harmful to humans, especially in regards to behavioral and other effects in children.
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Key Words
- 17-beta estradiol
- 8-OHdG
- 8-hydoxydeoxyguanosine
- A European population representative sample (Chianti, Italy)
- AGD
- ANA
- BADGE
- BASC-2
- BMI
- BPA
- BRIEF-P
- Behavior Rating Inventory of Executive Function-Preschool
- Behavioral Assessment System for Children
- Bisphenol A
- C-reactive protein
- CAD
- CBCL
- CHAMACOS
- CHD
- CMV
- CRP
- CVD
- Child Behavior Checklist
- DBP
- DHEAS
- Development
- E2
- ECN
- EFS
- EH
- EPIC-Norfolk Study
- ER
- Endocrine-disrupting chemicals
- Epidemiology
- FAI
- FDA
- FSH
- FT
- Food and Drug Administration
- HDL
- HOMES
- HRV
- HbA1c
- Human
- IL-6
- ISCI
- IVF
- InCHIANTI
- LDL
- LH
- MDA
- MGH
- MaGiCAD
- Massachusetts General Hospital (United States)
- Metabolic disease
- NECAT
- NHANES
- NICU Network Neurobehavioral Scale
- NNNS
- National Health and Nutrition Examination Survey (United States)
- OHAT
- Office of Health Assessment and Translation
- PCOS
- PFOA
- PFOS
- PIVUS
- Reproduction
- SBP
- SCE
- SFF
- SHBG
- SRS
- Social Responsiveness Scale
- T
- T3
- T4
- TDI
- TSH
- The Center for the Health Assessment of Mothers and Children of Salinas, Salina, CA
- The European Prospective Investigation into Cancer and Nutrition Cohort Study, consisting of over 500,000 people (Denmark, France, Germany, Greece, Italy, the Netherlands, Norway, Spain, Sweden and the United Kingdom)
- The Health Outcomes and Measures of the Environment Study (United States)
- The Metabolomics and Genomics in Coronary Artery Disease Study (Denmark, France, Germany, Greece, Italy, the Netherlands, Norway, Spain, Sweden and the United Kingdom)
- The New England Children's Amalgam Trial (United States)
- The Study for Future Families, USA
- The Vasculature in Uppsala Seniors Study (Uppsala, Sweden)
- Thyroid
- UCSF
- USEPA
- United Sates Environmental Protection Agency
- University of California, San Francisco
- VCL
- anogenital distance
- antinuclear antibodies
- bisGMA
- bisphenol A
- bisphenol A diglycidyl ether
- bisphenol A-glycidyl methacrylate
- body mass index
- cardiovascular disease
- coronary artery disease
- coronary heart disease
- curvilinear velocity (μm/s)
- cytomegalovirus
- dehydroepiandrosterone sulfate
- diastolic blood pressure
- embryo cell number
- embryo fragmentation score
- endometrial hyperplasia
- estrogen receptor
- follicle-stimulating hormone
- free androgen index (total T divided by SHBG)
- free testosterone
- hCG
- heart rate variability
- hemoglobin A1c
- high-density lipoprotein
- human chorionic gonadotropin
- in vitro fertilization
- interleukin-6
- intracytoplasmic sperm injection
- low-density lipoprotein
- luteinizing hormone
- malondialdehyde
- perfluorooctane sulfonate
- perfluorooctanoic acid
- polycystic ovary syndrome
- reverse transcription polymerase chain reaction
- rtPCR
- sex hormone binding globulin
- sister chromatid exchange
- systolic blood pressure
- thyroid stimulating hormone
- thyroxine
- tolerable daily intake
- total testosterone
- triidothyronine
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Affiliation(s)
- Johanna R Rochester
- The Endocrine Disruption Exchange (TEDX), P.O. Box 1407, Paonia, CO 81428, United States.
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Smith A, Wu AH, Lynch KL, Ko N, Grenache DG. Multi-wavelength spectrophotometric analysis for detection of xanthochromia in cerebrospinal fluid and accuracy for the diagnosis of subarachnoid hemorrhage. Clin Chim Acta 2013; 424:231-6. [PMID: 23800427 DOI: 10.1016/j.cca.2013.06.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 06/12/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) was examined for bilirubin, an important indicator for diagnosis of subarachnoid hemorrhage (SAH). METHODS A multi-wavelength (340, 415, and 460 nm) spectrophotometric assay was developed for the quantitative measurement of bilirubin in CSF, enabling the mathematical correction for absorbance of hemoglobin and proteins. Bilirubin and hemoglobin results were correlated to HPLC and a standard colorimetric assay, respectively. A subset of samples was sent for an absorbance reading at 450 nm following baseline correction. The multi-wavelength bilirubin assay was validated on 70 patients with confirmed SAH and 70 patients with neurologic symptoms who ruled out for SAH. RESULTS The multi-wavelength spectrophometric assay demonstrated no interferences due to proteins (albumin) up to 30 g/l or oxyhemoglobin up to 260 mg/l. The assay limit of detection was 0.2 mg/l, linear to 20 mg/l, and CVs ranged from 1 to 6% at bilirubin concentrations of 0.84 and 2.1mg/l. The spectrophotometric assay correlated to HPLC and the colorimetric assay for bilirubin and hemoglobin, respectively. Results also correlated to the absorbance method (with removal of samples with high hemoglobin and proteins). The area under the ROC curve for diagnosis of SAH was 0.971 and 0.954 for the HPLC and spectrophotometric assay, respectively. At a cutoff of 0.2mg/l, the clinical specificity was 100% for both assays, and the clinical sensitivity was 94.3% and 88.6% for SAH for the HPLC and spectrophotometric asays, respectively. CONCLUSIONS The multi-wavelength spectrophotometric assay is an objective alternative to visual inspection, HPLC, and absorbance for CSF bilirubin.
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Cipriano SD, Dybbro E, Boscardin CK, Shinkai K, Berger TG. Online learning in a dermatology clerkship: piloting the new American Academy of Dermatology Medical Student Core Curriculum. J Am Acad Dermatol 2013; 69:267-72. [PMID: 23683728 DOI: 10.1016/j.jaad.2013.04.025] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 04/03/2013] [Accepted: 04/07/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND Multiple studies have shown that both current and future primary care providers have insufficient education and training in dermatology. To address the limitations and wide variability in medical student dermatology instruction, the American Academy of Dermatology (AAD) created a standardized, online curriculum for both dermatology learners and educators. OBJECTIVE We sought to determine the impact of the integration of the AAD online curriculum into a 2-week introductory dermatology clerkship for fourth-year medical students. METHODS In addition to their clinical duties, we assigned 18 online modules at a rate of 1 to 3 per day. We evaluated knowledge acquisition using a 50-item, multiple-choice pretest and posttest. Postmodule and end-of-course questionnaires contained both closed and open-ended items soliciting students' perceptions about usability and satisfaction. RESULTS All 51 participants significantly improved in their dermatology knowledge (P < .001). The majority of students found the modules easy to navigate (95%) and worth their time (93%). All respondents supported the continuation of the modules as part of the dermatology clerkship. LIMITATIONS Without a control group who did not experience the online curriculum, we are unable to isolate the specific impact of the online modules on students' learning. CONCLUSION This study demonstrates the successful integration of this educational resource into a 2-week, university-based dermatology clerkship. Students' perceptions regarding usability and satisfaction were overwhelmingly positive, suggesting that the online curriculum is highly acceptable to learners. Widespread use of this curriculum may be a significant advancement in standardized dermatology learning for medical students.
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Affiliation(s)
- Sarah D Cipriano
- Department of Dermatology, University of Utah, Salt Lake City, Utah, USA
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Abstract
As industry sponsorship of clinical research grows, investigators' personal financial relationships with those sponsors are under increasing scrutiny. The federal government, some states, and many universities have enacted conflict-of-interest policies to monitor and regulate investigators' financial relationships. Little is known, however, about investigators' awareness of or support for these policies or their attitudes toward regulatory efforts. To explore the possible implications of conflict-of-interest policies for clinical researchers, the authors interviewed active clinical investigators at two institutions where the conflict-of-interest policies differ. The most striking feature of the interviews was the range of perceptions and attitudes expressed by clinical investigators and their implications for administrators, professional societies, and policymakers concerned with conflicts of interest. Fewer than half of the interviewed investigators could accurately describe their campus' conflict-of-interest policy. Many investigators felt that professional societies, the public, and individual investigators were appropriate monitors of conflicts of interest. Many investigators recognized the general risks associated with conflicts of interest, but felt that they personally were not at risk. A fundamental challenge facing administrators and policymakers is to demonstrate to all investigators, both clinical and nonclinical, that the potential for bias, pressure and conflict is relevant to all investigators with industry relationships.
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Affiliation(s)
- Elizabeth A Boyd
- Department of Clinical Pharmacy, University of California, San Francisco, 94143, USA
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Glanz J. 1978 study had troubles like fatal Hopkins test. N Y Times Web 2001:A16. [PMID: 12159876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
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12
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Abstract
CONTEXT A growing number of academic researchers receive industry funding for clinical and basic research, but little is known about the personal financial relationships of researchers with their industry sponsors. OBJECTIVES To assess the extent to which faculty researchers have personal financial relationships with the sponsors of their research, the nature of those financial relationships, and efforts made at the institutional level to address disclosed financial relationships and perceived conflicts of interest. DESIGN AND SETTING Case study of the University of California, San Francisco (UCSF). Data sources included disclosure forms and official documents maintained by the UCSF Office of Research Administration from December 1980 to October 1999, including decisions made by the UCSF Chancellor's Advisory Panel on Relations with Industry. MAIN OUTCOME MEASURES Number and types of personal financial relationships with external sponsors (positive financial disclosures from all clinical, basic, or social science faculty who were principal investigators), amount of annual income received from sponsors, and decisions and management strategies used by the advisory panel. RESULTS By 1999, almost 7.6% of faculty investigators reported personal financial ties with sponsors of their research. Throughout the study period, 34% of disclosed relationships involved paid speaking engagements (range, $250-$20, 000 per year), 33% involved consulting agreements between researcher and sponsor (range, <$1000-$120,000 per year), and 32% involved the investigator holding a position on a scientific advisory board or board of directors. Fourteen percent involved equity ownership, and 12% involved multiple relationships. The advisory panel recommended managing perceived conflicts of interest in 26% of the cases, including recommending the sale of stock, refusing additional payment for talks, resigning from a management position, or naming a new principal investigator for a project. CONCLUSIONS Faculty researchers are increasingly involved in financial relationships with their research sponsors. Guidelines for what constitutes a conflict and how the conflict should be managed are needed if researchers are to have consistent standards of behavior among institutions. JAMA. 2000;284:2209-2214.
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Abstract
CONTEXT A growing number of academic researchers receive industry funding for clinical and basic research, but little is known about the personal financial relationships of researchers with their industry sponsors. OBJECTIVES To assess the extent to which faculty researchers have personal financial relationships with the sponsors of their research, the nature of those financial relationships, and efforts made at the institutional level to address disclosed financial relationships and perceived conflicts of interest. DESIGN AND SETTING Case study of the University of California, San Francisco (UCSF). Data sources included disclosure forms and official documents maintained by the UCSF Office of Research Administration from December 1980 to October 1999, including decisions made by the UCSF Chancellor's Advisory Panel on Relations with Industry. MAIN OUTCOME MEASURES Number and types of personal financial relationships with external sponsors (positive financial disclosures from all clinical, basic, or social science faculty who were principal investigators), amount of annual income received from sponsors, and decisions and management strategies used by the advisory panel. RESULTS By 1999, almost 7.6% of faculty investigators reported personal financial ties with sponsors of their research. Throughout the study period, 34% of disclosed relationships involved paid speaking engagements (range, $250-$20, 000 per year), 33% involved consulting agreements between researcher and sponsor (range, <$1000-$120,000 per year), and 32% involved the investigator holding a position on a scientific advisory board or board of directors. Fourteen percent involved equity ownership, and 12% involved multiple relationships. The advisory panel recommended managing perceived conflicts of interest in 26% of the cases, including recommending the sale of stock, refusing additional payment for talks, resigning from a management position, or naming a new principal investigator for a project. CONCLUSIONS Faculty researchers are increasingly involved in financial relationships with their research sponsors. Guidelines for what constitutes a conflict and how the conflict should be managed are needed if researchers are to have consistent standards of behavior among institutions. JAMA. 2000;284:2209-2214.
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Affiliation(s)
- E A Boyd
- Department of Clinical Pharmacy and Institute for Health Policy Studies, University of California, San Francisco, 3333 California St, Suite 265, San Francisco, CA 94143-0936, USA
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Showstack J, Katz PP, Lake JR, Brown RS, Dudley RA, Belle S, Wiesner RH, Zetterman RK, Everhart J. Resource utilization in liver transplantation: effects of patient characteristics and clinical practice. NIDDK Liver Transplantation Database Group. JAMA 1999; 281:1381-6. [PMID: 10217053 DOI: 10.1001/jama.281.15.1381] [Citation(s) in RCA: 167] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
CONTEXT Liver transplantation is among the most costly of medical services, yet few studies have addressed the relationship between the resources utilized for this procedure and specific patient characteristics and clinical practices. OBJECTIVE To assess the association of pretransplant patient characteristics and clinical practices with hospital resource utilization. DESIGN Prospective cohort of patients who received liver transplants between January 1991 and July 1994. SETTING University of California, San Francisco; Mayo Clinic, Rochester, Minn; and the University of Nebraska, Omaha. PATIENTS Seven hundred eleven patients who received single-organ liver transplants, were at least 16 years old, and had nonfulminant liver disease. MAIN OUTCOME MEASURE Standardized resource utilization derived from a database created by matching all services to a single price list. RESULTS Higher adjusted resource utilization was associated with donor age of 60 years or older (28% [$53813] greater mean resource utilization; P=.005); recipient age of 60 years or older (17% [$32795]; P=.01); alcoholic liver disease (26% [$49596]; P=.002); Child-Pugh class C (41% [$67 658]; P<.001); care from the intensive care unit at time of transplant (42% [$77833]; P<.001); death in the hospital (35% [$67 076]; P<.001); and having multiple liver transplants during the index hospitalization (154% increase [$474 740 vs $186 726 for 1 transplant]; P<.001). Adjusted length of stay and resource utilization also differed significantly among transplant centers. CONCLUSIONS Clinical, economic, and ethical dilemmas in liver transplantation are highlighted by these findings. Recipients who were older, had alcoholic liver disease, or were severely ill were the most expensive to treat; this suggests that organ allocation criteria may affect transplant costs. Clinical practices and resource utilization varied considerably among transplant centers; methods to reduce variation in practice patterns, such as clinical guidelines, might lower costs while maintaining quality of care.
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Affiliation(s)
- J Showstack
- Department of Medicine, University of California, San Francisco 94143-0936, USA.
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Abstract
PURPOSE To determine what patients want to know regarding the participation of trainees in their care. METHOD In 1995, questionnaires were sent to 111 women who had undergone elective hysterectomies between September 1992 and June 1994 at two teaching hospitals at the University of California, San Francisco, School of Medicine. The questionnaires asked the women about their awareness of and attitudes toward the participation of residents and medical students in their care and about how they thought physicians should communicate information regarding residents to patients. RESULTS Fifty-nine women (68%) returned the questionnaire. Thirty-seven of them (63%) knew that a resident had been involved in their care. Eighty percent of the respondents felt it important to know how residents were supervised and what they would do during the operation. Nearly half did not know whether a medical student had been involved in their care. Over 90% agreed that the attending gynecologist should tell patients that a resident would participate in the operation as well as what the resident would do. Most believed that residents are adequately supervised and that medical students have time to provide more attention to patients. CONCLUSIONS Most of the women wanted to know about the participation and specific roles of residents and students. Attending physicians should take the initiative to talk with patients about the roles of trainees. Open discussions can promote patient autonomy, maintain public confidence in academic health institutions, and benefit future patients.
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Affiliation(s)
- H N Kim
- Department of Obstetrics and Gynecology, University of California, San Francisco, School of Medicine, USA
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Bell EA. Testimony of Elmerine Allen Whitfield Bell. Account Res 1998; 6:167-81. [PMID: 11660590 DOI: 10.1080/08989629808573925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Barinaga M. UCSF case raises questions about grant idea ownership. Science 1997; 277:1430-1. [PMID: 9304209 DOI: 10.1126/science.277.5331.1430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Marshall E. Publishing sensitive data: who calls the shots? Journals joust over conflict-of-interest rules. Science 1997; 276:524. [PMID: 9148406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Sternberg S. Release of study ends drug fracas. Sci News 1997; 151:236. [PMID: 11655105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/17/2023]
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Eckert CH. Bioequivalence of levothyroxine preparations: industry sponsorship and academic freedom. JAMA 1997; 277:1200-1. [PMID: 9103338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Altman LK. Drug firm, relenting, allows unflattering study to appear. N Y Times Web 1997:A1, A16. [PMID: 11647207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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Abstract
OBJECTIVE To determine the frequency of selective nontreatment of extremely premature, critically ill, or malformed infants among all infant deaths in a level III intensive care nursery (ICN) and to determine the reasons documented by neonatologists for their decisions to withdraw or withhold life support. METHODS This was a descriptive study based on review of the medical records of all 165 infants who died at a university-based level III ICN during 3 years. We determined whether each death had occurred despite the use of all available technologies to keep the infant alive or whether these were withheld or withdrawn, thereby leading to the infant's death. We also determined whether neonatologists documented either "futility" or "quality of life" as a reason to limit medical interventions. RESULTS One hundred sixty-five infants died among the 1609 infants admitted during the study period. One hundred eight infant deaths followed the withdrawal of life support, 13 deaths followed the withholding of treatment, and 44 deaths occurred while infants continued to receive maximal life-sustaining treatment. For 90 (74%) of the 121 deaths attributable to withholding of withdrawal of treatment, physicians cited that death was imminent and treatment was futile. Quality-of-life concerns were cited by the neonatologists as reasons to limit treatment in 62 (51%). Quality of life was the only reason cited for limiting treatment for 28 (23%) of the 121 deaths attributable to withholding or withdrawal of treatment. CONCLUSIONS The majority of deaths in the ICN occurred as a result of selective nontreatment by neonatologists, with few infants receiving maximal support until the actual time of death. Neonatologists often documented that quality-of-life concerns were considered in decisions to limit treatment; however, the majority of these decisions were based on their belief that treatment was futile. Prospective studies are needed to elucidate the determinants of neonatologists' practice decisions of selective nontreatment for marginally viable or damaged infants.
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Affiliation(s)
- S N Wall
- Department of Pediatrics, Northwestern University Medical School, Chicago, Illinois, USA
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Abstract
The Advisory Committee on Human Radiation Experiments has correctly argued that persons and institutions can sometimes be held responsible for actions taken more than a half-century ago, when practices and policies on the use of research subjects were strikingly different. In reaching its conclusions, the Committee did not altogether adhere to the language and commitments of its own ethical framework. In its Final Report, the Committee emphasizes judgments of wrongdoing, to the relative neglect of culpability; it discusses mitigating conditions that are exculpatory, but does not provide a thoroughgoing assessment of either culpability or exculpation. However, the Committee's shortcomings are mild in comparison to the deficiencies in the "Report of the UCSF Ad Hoc Fact Finding Committee on World War II Human Radiation Experiments" of the University of California at San Francisco. The latter report reaches no significant judgments of either wrongdoing or culpability. The findings that should have been reached by both committees are discussed.
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Dalton R. 'Fraud police' face dilemma over warning medical boards. Nature 1996; 379:480. [PMID: 8596620 DOI: 10.1038/379480b0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Kolata G. Transplant: urgent step or step off the edge? N Y Times Web 1996:16. [PMID: 11646330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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Eastwood S, Derish P, Leash E, Ordway S. Ethical issues in biomedical research: perceptions and practices of postdoctoral research fellows responding to a survey. Sci Eng Ethics 1996; 2:89-114. [PMID: 11657788 DOI: 10.1007/bf02639320] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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Altman LK. When doctors and patients decide to test the far limits of treatment. N Y Times Web 1995:C3. [PMID: 11647096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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Stryker J. Surgery gives man new best friends. N Y Times Web 1995:E3. [PMID: 11647272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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Palca J. Animal organs for human patients? Hastings Cent Rep 1995; 25:4. [PMID: 8530269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Steinauer J. Medical schools and abortion. Womens Health Issues 1993; 3:176-7. [PMID: 8274874 DOI: 10.1016/s1049-3867(05)80253-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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AIDS experiment is retracted after inquiry. N Y Times Web 1991;:D22. [PMID: 11646886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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Longaker MT, Golbus MS, Filly RA, Rosen MA, Chang SW, Harrison MR. Maternal outcome after open fetal surgery. A review of the first 17 human cases. JAMA 1991; 265:737-41. [PMID: 1990189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A few fetal diseases may benefit from surgical treatment before birth, but hysterotomy and subsequent delivery by cesarean section pose a risk to the otherwise unaffected mother. To assess maternal risk of mortality, morbidity, and reproductive potential after fetal surgery, we reviewed our experience with 17 highly selected women who underwent fetal surgery. Fifteen of these procedures were performed for one of two congenital anomalies: severe bilateral hydronephrosis and congenital diaphragmatic hernia. There were no deaths or serious maternal injuries. In the 14 women who continued pregnancy after hysterotomy, uterine irritability and preterm labor were frequent complications, requiring early confinement in most cases. There has been no detectable effect on future fertility, as indicated by eight subsequent normal pregnancies. We conclude that hysterotomy for fetal surgery can be accomplished without unduly endangering the mother's life or her future reproductive potential. However, morbidity related to premature labor remains a serious problem, and our ability to control uterine contractions after hysterotomy remains the limiting factor in human fetal surgery.
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Affiliation(s)
- M T Longaker
- Department of Surgery, University of California, San Francisco 94143-0570
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Kolata G. Lifesaving surgery on a fetus works for the first time. N Y Times Web 1990:A1, B8. [PMID: 11646767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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Abstract
STUDY OBJECTIVE To assess whether decisions about "do-not-resuscitate" (DNR) orders are made equitably in patients with different diseases but similar prognoses. DESIGN Retrospective cohort study. SETTING Three teaching hospitals: a university referral center, a county hospital serving a largely indigent population, and a Veterans Administration hospital. PATIENTS Consecutive patients with any of the four following discharge diagnoses: the acquired immunodeficiency syndrome (AIDS) (100 patients); unresectable non-small-cell lung cancer (51 patients); cirrhosis with esophageal varices (51 patients); and severe congestive heart failure with coronary artery disease (115 patients). MEASUREMENTS AND MAIN RESULTS Do-not-resuscitate orders were written for 52% of patients with AIDS and 47% of patients with cancer but for only 16% of patients with cirrhosis and 5% of patients with congestive heart failure (P less than 0.0001). Although DNR orders were associated with functional and mental status, reason for admission, and severity of illness, the strong association between DNR orders and disease category persisted after adjustment for these potential confounders by multiple logistic regression. A survey of housestaff showed that DNR orders were discussed more frequently with patients who had AIDS or lung cancer than with patients who had cirrhosis or heart failure, despite an accurate understanding of the generally similar prognoses among the four groups. CONCLUSIONS Despite relatively similar prognoses, patients with AIDS or lung cancer are much more likely to receive DNR orders than patients with cirrhosis or severe congestive heart failure. This discrepancy cannot be explained by differences in severity of illness among patients or by misunderstandings of prognosis by clinicians. From our data, we cannot determine if patients with cirrhosis or heart failure receive too few DNR orders or if patients with AIDS or lung cancer receive too many. Our findings should encourage physicians to determine the preferences of patients about life-sustaining treatments more equitably.
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Blakeslee S. Fetus returned to womb following surgery. N Y Times Web 1986:C1, C3. [PMID: 11646520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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Miller A, Lo B. How do doctors discuss do-not-resuscitate orders? West J Med 1985; 143:256-8. [PMID: 4036128 PMCID: PMC1306302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Although patient preferences are important in decisions about "do not resuscitate" (DNR) orders, little is known about how physicians discuss these orders with patients. We asked 15 physicians to simulate discussing such orders with a patient. We found a striking variation in whether physicians explicitly asked for patient preferences, how they described cardiopulmonary resuscitation (CPR) and its possible outcomes and whether they made a recommendation to the patient about DNR orders. There was no pattern to the different amounts of information presented about CPR. Physicians gave conflicting reasons for how they individualized discussions with patients. Awareness of such different behaviors may stimulate physicians to examine what they say to patients about this sensitive and important topic and why they say it.
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