Granted, undecided, withdrawn, and refused requests for euthanasia and physician-assisted suicide

BACKGROUND: The aims of this study were to obtain information about the characteristics of requests for euthanasia and physician-assisted suicide (EAS) and to distinguish among different types of situations that can arise between the request and the physician's decision. METHODS: All general practitioners in 18 of the 23 Dutch general practitioner districts received a written questionnaire in which they were asked to describe the most recent request for EAS they received. RESULTS: A total of 3614 general practitioners responded to the questionnaire (response rate, 60%). Of all explicit requests for EAS, 44% resulted in EAS. In the other cases the patient died before the performance (13%) or finalization of the decision making (13%), the patient withdrew the request (13%), or the physician refused the request (12%). Patients' most prominent symptoms were "feeling bad," "tiredness," and "lack of appetite." The most frequently mentioned reasons for requesting EAS were "pointless suffering," "loss of dignity," and "weakness." The patients' situation met the official requirements for accepted practice best in requests that resulted in EAS and least in refused requests. A lesser degree of competence and less unbearable and hopeless suffering had the strongest associations with the refusal of a request. CONCLUSIONS: The complexity of EAS decision making is reflected in the fact that besides granting and refusing a request, 3 other situations could be distinguished. The decisions physicians make, the reasons they have for their decisions, and the way they arrived at their decisions seem to be based on patient evaluations. Physicians report compliance with the official requirements for accepted practice.     

Attitudes and practices of U.S. oncologists regarding euthanasia and physician-assisted suicide

BACKGROUND: The practices of euthanasia and physician-assisted suicide remain controversial. OBJECTIVE: To achieve better understanding of attitudes and practices regarding euthanasia and physician-assisted suicide in the context of end-of-life care. DESIGN: Cohort study. SETTING: United States. PARTICIPANTS: 3299 oncologists who are members of the American Society of Clinical Oncology. MEASUREMENTS: Responses to survey questions on attitudes toward euthanasia and physician-assisted suicide for a terminally ill patient with prostate cancer who has unremitting pain, requests for and performance of euthanasia and physician-assisted suicide, and sociodemographic characteristics. RESULTS: Of U.S. oncologists surveyed, 22.5% supported the use of physician-assisted suicide for a terminally ill patient with unremitting pain and 6.5% supported euthanasia. Oncologists who were reluctant to increase the dose of intravenous morphine for terminally ill patients in excruciating pain (odds ratio [OR], 0.61 [95% CI, 0.48 to 0.77]) and had sufficient time to talk to dying patients about end-of-life care issues (OR, 0.79 [CI, 0.71 to 0.87]) were less likely to support euthanasia or physician-assisted suicide. During their career, 3.7% of surveyed oncologists had performed euthanasia and 10.8% had performed physician-assisted suicide. Oncologists who were reluctant to increase the morphine dose for patients in excruciating pain (OR, 0.58 [CI, 0.43 to 0.79]) and those who believed that they had received adequate training in end-of-life care (OR, 0.86 [CI, 0.79 to 0.95]) were less likely to have performed euthanasia or physician-assisted suicide. Oncologists who reported not being able to obtain all the care that a dying patient needed were more likely to have performed euthanasia (P = 0.001). CONCLUSIONS: Requests for euthanasia and physician-assisted suicide are likely to decrease as training in end-of-life care improves and the ability of physicians to provide this care to their patients is enhanced.     

Factors influencing death at home in terminally ill cancer patients

Aim: The purpose of this study is to investigate factors affecting terminally ill cancer patients dying at home. Material: Ninety‐two terminally ill cancer patients who were receiving home medical care services and died between April 2005 and December 2006 were included in the study. The data included patients' and caregivers' demographic characteristics, disease‐related information, place of death, and status of home care support. To identify the factors predicting the place of death, multivariate logistic regression analyses were performed. Results: Patients of families who had no preference regarding the place of death or a preference for death at home were more likely to die at home (vs preference for hospital death, odds ratio = 5.87, 95% confidence interval = 1.02–36.53; odds ratio = 90.35, 95% confidence interval = 8.15–1001.51, respectively) after adjusting for potential confounders. Meanwhile, if the patient's family preferred that the patient not die at home, the patient's place of death was not at his/her home irrespective of his/her preference. Conclusion: The results suggested the stronger involvement of families' preferences regarding the patients' place of death over patients' own preferences. Therefore, factors affecting families' preferences need to be clarified for the dissemination of death at home for terminally ill cancer patients.     

Terminal sedation and euthanasia: a comparison of clinical practices

BACKGROUND: An important issue in the debate about terminal sedation is the extent to which it differs from euthanasia. We studied clinical differences and similarities between both practices in the Netherlands. METHODS: Personal interviews were held with a nationwide stratified sample of 410 physicians (response rate, 85%) about the most recent cases in which they used terminal sedation, defined as administering drugs to keep the patient continuously in deep sedation or coma until death without giving artificial nutrition or hydration (n = 211), or performed euthanasia, defined as administering a lethal drug at the request of a patient with the explicit intention to hasten death (n = 123). We compared characteristics of the patients, the decision-making process, and medical care of both practices. RESULTS: Terminal sedation and euthanasia both mostly concerned patients with cancer. Patients receiving terminal sedation were more often anxious (37%) and confused (24%) than patients receiving euthanasia (15% and 2%, respectively). Euthanasia requests were typically related to loss of dignity and a sense of suffering without improving, whereas requesting terminal sedation was more often related to severe pain. Physicians applying terminal sedation estimated that the patient's life had been shortened by more than 1 week in 27% of cases, compared with 73% in euthanasia cases. CONCLUSIONS: Terminal sedation and euthanasia both are often applied to address severe suffering in terminally ill patients. However, terminal sedation is typically used to address severe physical and psychological suffering in dying patients, whereas perceived loss of dignity during the last phase of life is a major problem for patients requesting euthanasia.     

Clinician-patient interactions about requests for physician-assisted suicide: a patient and family view

BACKGROUND: Responding effectively to a patient request for physician-assisted suicide (PAS) is an important clinical skill that involves careful evaluation. Clinician responses to PAS requests, however, have only been described using data obtained from clinicians. OBJECTIVE: To describe qualities of clinician-patient interactions about requests for PAS that were valued by patients and their family members. PARTICIPANTS AND METHODS: Intensive qualitative case study involving multiple longitudinal interviews conducted prospectively with patients pursuing PAS and with their family members and retrospectively with family members of deceased patients who seriously pursued PAS. The study setting was community based. Participants were recruited through patient advocacy organizations, hospices, and grief counselors. A total of 35 cases were studied: 12 were prospective and 23 were retrospective. Study procedures involved semistructured interviews that were audiotaped, transcribed, reviewed, and analyzed by a multidisciplinary research team. RESULTS: Three themes were identified that describe qualities of clinician-patient interactions that were valued by patients and family members: (1) openness to discussions about PAS; (2) clinician expertise in dealing with the dying process; and (3) maintenance of a therapeutic clinician-patient relationship, even when clinician and patient disagree about PAS. CONCLUSIONS: These patient and family accounts reveal missed opportunities for clinicians to engage in therapeutic relationships, including discussions about PAS, dying, and end-of-life care. Clinicians responding to patients requesting PAS need communication skills enabling them to discuss PAS and dying openly, as well as expertise in setting reasonable expectations, individualizing pain control, and providing accurate information about the lethal potential of medications.     

Smoking and myocardial infarction case-fatality: hospital and population approach.

BACKGROUND: Smoking is a risk factor for coronary heart disease, but it has been associated with better short-term prognosis in hospitalized patients with acute myocardial infarction. The aims of this study were to determine the association between smoking and myocardial infarction 28-day case-fatality in hospitalized patients and at the population level; and, whether smokers presenting with fatal myocardial infarction are more likely to die before reaching a hospital. DESIGN AND METHODS: Population-based myocardial infarction registry, carried out in 1997-1998 in seven regions of Spain, used standardized methods to find and analyze suspected myocardial infarction patients (10 654 patients; 7796 hospitalized). Four categories of smoking status were defined: never-smokers, former smokers for more than 1 year, former smokers for less than 1 year, and current smokers. RESULTS: The main end-point was 28-day case-fatality, found to be 20.1, 17.1, 15.6, and 8.9%, in the four smoking status categories, respectively, for hospitalized patients; and 37.4, 33.0, 24.5, and 23.2%, respectively, at population level. Hospitalized current smokers had lower age, sex, and comorbidity-adjusted 28-day case-fatality than never-smokers (odds ratio=0.71; 95% confidence interval: 0.56-0.90). This association held at population level (odds ratio=0.68; 95% confidence interval: 0.60-0.76), in which former smoking was also associated with lower case-fatality. In fatal cases, recent former smokers presented a lower risk of out-of-hospital death than never-smokers (odds ratio=0.47; 95% confidence interval: 0.29-0.77), whereas current smoking was marginally associated with out-of-hospital death (odds ratio=1.22; 95% confidence interval: 0.99-1.50). CONCLUSIONS: Current smoking is associated with lower 28-day case-fatality in hospitalized myocardial infarction patients. This association held at population level. Among fatal cases, smoking is associated with higher and recent former smoking with lower risk of dying out-of-hospital.     

Patient attitudes toward physician financial incentives

BACKGROUND: Despite concern about the impact of financial incentives on physician behavior, little is known about patients' attitudes toward these incentives. OBJECTIVES: To assess patient attitudes toward physician compensation models and to explore patient characteristics associated with these attitudes. METHODS: We mailed a survey to 2000 adult patients in a large New England health maintenance organization. We asked about their trust in their primary care physician; discomfort with compensation models of salary with withhold (salary), fee-for-service with withhold, and group capitation (capitation). RESULTS: One thousand one hundred twenty-five (56%) of the 2000 patients who responded expressed varying levels of discomfort with the proposed compensation models: 16% for salary, 25% for fee-for-service with withhold, and 53% for capitation (P<.001). Patients who knew their primary care physician was paid through capitation did not report less trust in their primary care physician but still frequently expressed discomfort (46%) with capitation. Among all respondents, those who were younger, white, had better health, had a higher income, were more educated, and who lacked a very trusting relationship with a primary care physician were more likely to report discomfort with both capitation and fee-for-service with withhold. In multivariable analyses, discomfort with capitation was more common among white patients (odds ratio, 2.6; 95% confidence interval, 1.6-4.2), patients with incomes exceeding $20 000 (odds ratio, 3.7; 95% confidence interval, 2.3-6.1), and college-educated patients (odds ratio, 2.0; 95% confidence interval, 1.4-2.7). CONCLUSIONS: Most patients were uncomfortable with 1 or more of the 3 common methods used to pay physicians. Discomfort was highest with capitation and was more likely among wealthier, well-educated, white patients. With capitation increasing nationally, patients' concerns should be considered in the design of compensation agreements.     

Patient satisfaction with screening flexible sigmoidoscopy

BACKGROUND: Screening flexible sigmoidoscopy is an underused cancer prevention procedure. Physicians often cite patient discomfort as a reason for not requesting sigmoidoscopy, but patient experiences and attitudes toward sigmoidoscopy have not been well studied. OBJECTIVE: To measure patient satisfaction and the determinants of satisfaction with screening sigmoidoscopy. METHODS: An instrument to assess satisfaction with screening sigmoidoscopy was developed. Responses were evaluated with a factor analysis, tested for reproducibility and internal consistency, and validated against an external standard. RESULTS: A total of 1221 patients (666 men and 555 women; mean age, 61.8 years) were surveyed after sigmoidoscopy. Examinations were performed by a nurse practitioner (n = 668), internist (n = 344), or gastrointestinal specialist (n= 184). More than 93% of the participants strongly agreed or agreed they would be willing to undergo another examination, and 74.9% would strongly recommend the procedure to their friends. Regarding pain and discomfort, 76.2% strongly agreed or agreed that the examination did not cause a lot of pain, 78.1% stated that it did not cause a lot of discomfort, and 68.5% thought that it was more comfortable than they expected. Fifteen percent to 25% of the patients indicated they had a lot of pain, great discomfort, or more discomfort than expected. Women were more likely to have significant pain or discomfort than men (adjusted odds ratio, 2.9; 95% confidence interval, 1.9-4.3; P<.001). CONCLUSIONS: Approximately 70% of individuals who undergo screening sigmoidoscopy are satisfied and find the procedure more comfortable than expected, whereas only 15% to 25% find the procedure unpleasant. Physicians should not project discomfort onto patients as a reason for not requesting screening sigmoidoscopy.     

Hypertension and the risk of acute myocardial infarction in Argentina. The Argentine Factores de Riesgo Coronario en America del Sur (FRICAS) Investigators

The relationship between a history of hypertension and the quality of its control in routine clinical practice and the risk of acute myocardial infarction was examined in a multicenter, case-control study conducted in Argentina between November 1991 and August 1994, within the framework of the FRICAS study. The cases were 939 patients with acute myocardial infarction and without a history of ischemic heart disease. The controls were 949 subjects identified in the same centers as the cases and admitted with a wide spectrum of acute disorders unrelated to known or suspected risk factors for acute myocardial infarction. The odds ratios and the 95% confidence intervals were derived from multiple logistic regression equations, including terms for age, gender, education, social status, exercise, smoking status, cholesterolemia, history of diabetes, body mass index, and family history of myocardial infarction. The quality of hypertension control was assessed with the most recent blood pressure reading reported by the subjects. Seventy-two percent of hypertensive cases and 62.6% of hypertensive controls had a history of antihypertensive therapy by self-report, when admitted to the medical center. The adjusted odds ratio for acute myocardial infarction due to hypertension was 2.58 (95% confidence interval, 2.08-3.19). The odds ratio was 2.42 (95% confidence interval, 1.88-3.11) when hypertensives reported that their greatest systolic value was below 200 mm Hg (moderate status) and 4.12 (95% confidence interval, 2.87-5.89) when it was above 200 mm Hg (severe status). When the highest diastolic blood pressure value was below 120 mm Hg (moderate status), the risk increased to 2.48 (95% confidence intervals, 1.90-3.24) and to 4.12 (95% confidence interval, 2.83-5.99) when it was above 120 mm Hg (severe status). If the most recent systolic blood pressure was less-than-or-equal140 mm Hg, the odds ratio was 2.59 (95% confidence interval, 1.96-3.41), and it was 3.42 (95% confidence interval, 2.40-4.87) when the value was >140 mm Hg. If the most recent diastolic blood pressure was less-than-or-equal90 mm Hg, the risk increased more than two fold (odds ratio=2.48; 95% confidence interval, 1.91-3.22), and if it was >90 mm Hg, it increased nearly four-fold (odds ratio=3.72; 95% confidence interval, 2.33-5.96). In smokers, the odds ratio was 2.28 in the absence of hypertension and increased to 7.51 when hypertension was present. In this Argentine population, hypertension is a strong and independent risk factor for acute myocardial infarction. In routine clinical practice, the control of blood pressure to levels below 140/90 seems to be required in order to reduce part (but not all) of the risk of acute myocardial infarction in hypertensive patients. (c) 2001 by CHF, Inc.     

Clinical importance of delays in the initiation of appropriate antibiotic treatment for ventilator-associated pneumonia

STUDY OBJECTIVES: To determine the influence of initially delayed appropriate antibiotic treatment (IDAAT) on the outcomes of patients with ventilator-associated pneumonia (VAP). SETTING: Medical ICU of Barnes-Jewish Hospital, St. Louis, a university-affiliated urban teaching hospital. PATIENTS: One hundred seven consecutive patients receiving mechanical ventilation and antibiotic treatment for VAP. INTERVENTIONS: Prospective patient surveillance and data collection. MEASUREMENTS AND RESULTS: All 107 patients eventually received treatment with an antibiotic regimen that was shown in vitro to be active against the bacterial pathogens isolated from their respiratory secretions. Thirty-three patients (30.8%) received antibiotic treatment that was delayed for >or= 24 h after initially meeting diagnostic criteria for VAP. These patients were classified as receiving IDAAT. The most common reason for the administration of IDAAT was a delay in writing the antibiotic orders (n = 25; 75.8%). The mean time (+/- SD) interval from initially meeting the diagnostic criteria for VAP until the administration of antibiotic treatment was 28.6 +/- 5.8 h among patients classified as receiving IDAAT, compared to 12.5 +/- 4.2 h for all other patients (p < 0.001). Forty-four patients (41.1%) with VAP died during their hospitalization. Increasing APACHE (acute physiology and chronic health evaluation) II scores (adjusted odds ratio, 1.13; 95% confidence interval, 1.09 to 1.18; p < 0.001), presence of malignancy (adjusted odds ratio, 3.20; 95% confidence interval, 1.79 to 5.71; p = 0.044), and the administration of IDAAT (adjusted odds ratio, 7.68; 95% confidence interval, 4.50 to 13.09; p < 0.001) were identified as risk factors independently associated with hospital mortality by logistic regression analysis. CONCLUSION: These data suggest that patients classified as receiving IDAAT are at greater risk for hospital mortality. Clinicians should avoid delaying the administration of appropriate antibiotic treatment to patients with VAP in order to minimize their risk of mortality.     

Alcohol consumption and antiretroviral adherence among HIV-infected persons with alcohol problems

BACKGROUND: Alcohol abuse has been associated with poor adherence to highly active antiretroviral therapy (HAART). We examined the relative importance of varying levels of alcohol consumption on adherence in HIV-infected patients with a history of alcohol problems. METHODS: We surveyed 349 HIV-infected persons with a history of alcohol problems at 6-month intervals. Of these subjects, 267 were taking HAART at one or more time periods during the 30-month follow-up period. Interviews assessed recent adherence to HAART and past month alcohol consumption, defined as "none", "moderate", and "at risk". We investigated the relationship between adherence to HAART and alcohol consumption at baseline and at each subsequent 6-month follow-up interval using multivariable longitudinal regression models, while controlling for potential confounders. RESULTS: Among the 267 HIV-infected persons with a history of alcohol problems who were receiving HAART, alcohol consumption was the most significant predictor of adherence (p < 0.0001), with better adherence being associated with recent abstinence from alcohol, compared with at-risk level usage (odds ratio = 3.6, 95% confidence interval = 2.1-6.2) or compared with moderate usage (odds ratio = 3.0, 95% confidence interval = 2.0-4.5). CONCLUSIONS: Any alcohol use among HIV-infected persons with a history of alcohol problems is associated with worse HAART adherence. Addressing alcohol use in HIV-infected persons may improve antiretroviral adherence and ultimately clinical outcomes.     

Physician adoption of hyperbaric oxygen therapy in the treatment of chronic wounds

Hyperbaric oxygen therapy, a treatment alternative for chronic wounds, has been used for several decades yet little is known about factors that influence physicians to incorporate this therapy into practice. To assess wound care physician knowledge of, attitudes toward, and adoption of hyperbaric oxygen therapy and to identify factors associated with physician adoption of this therapy, a 23-item questionnaire, based on Rogers' diffusion of innovation model, was developed by the authors and distributed to 653 American Academy of Wound Management Board-certified physicians. Of the 246 (43%) physicians in the study population who responded to the study survey, 167 (68%) reported they had used or referred patients for hyperbaric oxygen therapy during the past 12 months. More than half of the respondents reported a relatively high level of familiarity with and a positive attitude toward the effects of hyperbaric oxygen therapy on wound healing. Physician adoption of hyperbaric oxygen therapy was significantly associated with a community of >100,000 residents (adjusted odds ratio = 2.29, 95% confidence interval = 1.05 to 5.04); patient request for hyperbaric oxygen therapy (adjusted odds ratio = 5.38, 95% confidence interval = 2.50 to 11.56); positive attitude toward (adjusted odds ratio = 3.38, 95% confidence interval = 1.49 to 7.66) and high level of familiarity with hyperbaric oxygen therapy (adjusted odds ratio = 5.33, 95% confidence interval = 1.72 to 6.49); and practice location in either Florida or Texas (adjusted odds ratio = 3.44, 95% confidence interval = 1.24 to 9.54). Although the majority of the respondents reported adoption of hyperbaric oxygen therapy, most adopters are concentrated only in a few geographic areas. Despite the limitations of this study, especially the potential effects of sampling and response bias, the results help explain factors that have facilitated and hindered the adoption of this technology into practice.     

Predictive factors of Doppler echocardiography in persistent pulmonary artery hypertension of the neonate

INTRODUCTION: echocardiographic evaluation in neonates with persistent pulmonary artery hypertension is often limited to pressure measurements and analysis of pulmonary artery blood flow. The prognostic significance of a more detailed analysis, in particular of the extra-pulmonary shunt, is not known. PATIENTS AND METHOD: we analysed retrospectively the echocardiographs of neonates with persistent pulmonary artery hypertension who were also entered in a randomised therapeutic trial of treatment with inhaled nitric oxide. Our aim was to identify the predictive echographic factors for extra-corporeal circulatory assistance, death and a good response to nitric oxide. RESULTS: out of the 85 neonates studied, an extra-pulmonary right-left shunt across the foramen ovale or the ductus arteriosus was present in 80 patients (94%). Biventricular function was normal in the majority of patients while the cardiac index was reduced (< 2L/min/m2) in 61% of cases. With multivariate analysis, an exclusively right-left ductal shunt was a predictive factor for death (odds ratio 7.8; 95% confidence interval 1.2 to 52.8; p=0.04) while an exclusively left-right ductal shunt was at the limit of significance for circulatory assistance (odds ratio 0.13; 95% confidence interval 0.01 to 1.22; p=0.07). In the 40 patients randomised to receive nitric oxide, 28 responded positively with a reduction of at least 20% in the oxygenation index measured by post-ductal arterial gasometry. The existence of a left-right atrial shunt increased the risk of a poor response to nitric oxide (odds ratio 7.46; 95% confidence interval 1.23 to 45.1; p=0.028). CONCLUSION: precise echocardiographic evaluation of these patients allows identification of prognostic factors and adjustment of vasodilator treatment.     

The value of disease severity in predicting patient readiness to address end-of-life issues

BACKGROUND: Although patient-physician discussion is the most important tool for end-of-life planning, less than 30% of seriously ill patients have held these discussions. While physicians use objective disease severity and recent clinical events to trigger end-of-life discussions, it is not known if such findings predict patient readiness. We evaluated the ability of disease severity measures and recent clinical events to predict patient readiness for end-of-life discussions in patients with chronic lung disease. METHODS: The desire for discussion about end-of-life care was evaluated in 100 outpatients with a diagnosis of chronic lung disease presenting for pulmonary function testing. Objective disease severity was indicated by the percentage of the predicted forced expiratory volume, use of oral corticosteroids, a functional status score, frequency of recent hospitalizations, and required use of mechanical ventilation. RESULTS: In multivariate analysis, patient desire for an end-of-life discussion with the physician was not associated with percentage of predicted forced expiratory volume in 1 second (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.96-1.03), oral corticosteroid use (OR, 1.34; 95% CI, 0.40-4.54), functional status score (OR, 1.37; 95% CI, 0.34-5.56), hospitalizations in the past year (OR, 0.33; 95% CI, 0.09-1.20), or previous mechanical ventilation (OR, 1.37; 95% CI, 0.34-5.56). CONCLUSIONS: Patients appear no more or less interested in end-of-life discussions at later stages of chronic lung disease. Physicians cannot use disease severity measures or recent clinical events to accurately predict when patients desire end-of-life discussions. Focusing on physician skill in using specific communication strategies for patients at all stages of illness may be the most promising approach to increasing end-of-life discussions.     

Risk factors for hepatitis C virus infection in individuals infected with the HIV

BACKGROUND: Except for injecting drug use, other routes of transmission for hepatitis C virus among HIV-AIDS patients have not been consistently described, and risk estimates are often not adjusted for confounding factors. AIMS: To evaluate characteristics associated with hepatitis C virus infection in individuals infected with the HIV. PATIENTS: Cases were patients co-infected by HIV and hepatitis C virus, and controls were infected only by HIV. METHODS: Cases and controls were consecutively enrolled at a public health care outpatient HIV-AIDS reference centre in Porto Alegre, Southern Brazil. RESULTS: A total of 227 cases (63% men; 40.3+/-8.7 years) and 370 controls (44.6% men; 38.9+/-9.8 years) were enrolled in the study. In a multiple logistic regression model, male gender (odds ratio 1.9; 95% confidence interval 1.3-2.7), age between 30 and 49 years (odds ratio 2.1; 95% confidence interval 1.2-3.7), elementary school education (odds ratio 4.2; 95% confidence interval 1.9-9.6), lower family income (odds ratio 1.7; 95% confidence interval 1.1-2.7), sharing personal hygiene objects (odds ratio 2.0; 95% confidence interval 1.3-3.3), using injected drugs (odds ratio 21.6; 95% confidence interval 10.8-43.0) and crack cocaine (odds ratio 2.8; 95% confidence interval 1.1-6.9) were independently associated with co-infection by hepatitis C virus. CONCLUSION: These results confirm the risk profile for hepatitis C virus-HIV infection and suggest that sharing personal hygiene objects might explain the transmission of virus C to those not infected by the usual routes, which may be of relevance for developing preventive strategies.     

Is exposure to sick or dead poultry associated with flulike illness?: a population-based study from a rural area in Vietnam with outbreaks of highly pathogenic avian influenza

BACKGROUND: The verified human cases of highly pathogenic avian influenza in Vietnam may represent only a selection of the most severely ill patients. The study objective was to analyze the association between flulike illness, defined as cough and fever, and exposure to sick or dead poultry. METHODS: A population-based study was performed from April 1 to June 30, 2004, in FilaBavi, a rural Vietnamese demographic surveillance site with confirmed outbreaks of highly pathogenic avian influenza among poultry. We included 45 478 randomly selected (cluster sampling) inhabitants. Household representatives were asked screening questions about exposure to poultry and flulike illness during the preceding months; individuals with a history of disease and/or exposure were interviewed in person. RESULTS: A total of 8149 individuals (17.9%) reported flulike illness, 38,373 persons (84.4%) lived in households keeping poultry, and 11,755 (25.9%) resided in households reporting sick or dead poultry. A dose-response relationship between poultry exposure and flulike illness was noted: poultry in the household (odds ratio, 1.04; 95% confidence interval, 0.96-1.12), sick or dead poultry in the household but with no direct contact (odds ratio, 1.14; 95% confidence interval, 1.06-1.23), and direct contact with sick poultry (odds ratio, 1.73; 95% confidence interval, 1.58-1.89). The flulike illness attributed to direct contact with sick or dead poultry was estimated to be 650 to 750 cases. CONCLUSIONS: Our epidemiological data are consistent with transmission of mild, highly pathogenic avian influenza to humans and suggest that transmission could be more common than anticipated, though close contact seems required. Further microbiological studies are needed to validate these findings.     

Diet habits, alcohol drinking, tobacco smoking, green tea drinking, and the risk of esophageal squamous cell carcinoma in the Chinese population

OBJECTIVE: This study aims to investigate the risk of esophageal squamous cell carcinoma in relation to exogenous factors in a rural area of China with a high incidence of esophageal squamous cell carcinoma. METHODS: A population-based case-control study was conducted in Yangzhong County, Jiangsu Province, China, with 355 histologically confirmed esophageal squamous cell carcinoma cases recruited between 1 January 2004 and 28 February 2006 and 408 controls matched by sex and age, randomly selected from the local population. RESULTS: Stratified logistic regression analysis by sex revealed that hot-temperature food items, pork braised in brown sauce and old stocked rice intake could increase the risk of esophageal squamous cell carcinoma with odds ratio of 2.127 (95% confidence interval: 1.394-3.245), 2.059 (95% confidence interval: 1.417-2.993) and 9.059 (95% confidence interval: 5.930-13.840), respectively, in men and 3.048 (95% confidence interval: 1.733-5.364), 1.914 (95% confidence interval: 1.159-3.162) and 14.532 (95% confidence interval: 7.816-27.019), respectively, in women, whereas diet high in salt and chili, tobacco smoking and alcohol drinking only showed possible risk effects in men with odds ratio 2.338 (95% confidence interval: 1.568-3.485), 3.378 (95% confidence interval: 2.117-5.389), 1.976 (95% confidence interval: 1.337-2.921) and 2.197 (95% confidence interval: 1.510-3.195), respectively. Green tea drinking showed a protective effect in women (odds ratio=0.257; 95% confidence interval: 0.070-0.941). CONCLUSIONS: Findings from this study provided evidence that dietary habits, tobacco-smoking and alcohol drinking contribute to the etiology of esophageal squamous cell carcinoma. A healthy dietary habit, with smoking cessation and alcohol controlling is of a great importance in the prevention of esophageal cancer.     

Comparison of outcomes of weekend versus weekday admissions for atrial fibrillation

Previous studies have identified a "weekend effect" in terms of a poor outcome for patients hospitalized with various acute medical conditions. The aim of our study was to investigate whether weekend admissions for atrial fibrillation (AF) result in worse outcomes than those admitted on weekdays. In the Nationwide Inpatient Sample 2008 database, we identified a total of 86,497 discharges with a primary discharge diagnosis of AF. The use of a cardioversion procedure for AF on weekends was lower than that on a weekday (7.9% vs 16.2%; p <0.0001; odds ratio 0.5, 95% confidence interval 0.45 to 0.55, p <0.0001). After adjusting for patient and hospital characteristics and disease severity, the adjusted in-hospital mortality odds were greater for weekend admissions (odds ratio 1.23, 95% confidence interval 1.03 to 1.51; p <0.0001). The length of stay was significantly longer for weekend admissions. In conclusion, patients admitted with AF on weekends had lower odds of undergoing a cardioversion procedure and greater odds of dying.     

Responding to intractable terminal suffering: the role of terminal sedation and voluntary refusal of food and fluids. ACP-ASIM End-of-Life Care Consensus Panel. American College of Physicians-American Society of Internal Medicine

When provided by a skilled, multidisciplinary team, palliative care is highly effective at addressing the physical, psychological, social, and spiritual needs of dying patients and their families. However, some patients who have witnessed harsh death want reassurance that they can escape if their suffering becomes intolerable. In addition, a small percentage of terminally ill patients receiving comprehensive care reach a point at which their suffering becomes severe and unacceptable despite unrestrained palliative efforts; some of these patients request that death be hastened. This paper presents terminal sedation and voluntary refusal of hydration and nutrition as potential last resorts that can be used to address the needs of such patients. These two practices allow clinicians to address a much wider range of intractable end-of-life suffering than physician-assisted suicide (even if it were legal) and can also provide alternatives for patients, families, and clinicians who are morally opposed to physician-assisted suicide. This paper will define the two practices, distinguish them from more standard palliative care interventions and from physician-assisted suicide, illustrate them with a real clinical scenario, provide potential guidelines and practicalities, and explore their moral and legal status. Although medicine cannot sanitize dying or provide perfect answers for all challenging end-of-life clinical problems, terminal sedation and voluntary refusal of hydration and nutrition substantially increase patients' choices at this inherently challenging time.