A Randomized Controlled Trial of a CPR and Intubation Video Decision Support Tool for Hospitalized Patients

BACKGROUND

Decisions about cardiopulmonary resuscitation (CPR) and intubation are a core part of advance care planning, particularly for seriously ill hospitalized patients. However, these discussions are often avoided.

OBJECTIVES

We aimed to examine the impact of a video decision tool for CPR and intubation on patients’ choices, knowledge, medical orders, and discussions with providers.

DESIGN

This was a prospective randomized trial conducted between 9 March 2011 and 1 June 2013 on the internal medicine services at two hospitals in Boston.

PARTICIPANTS

One hundred and fifty seriously ill hospitalized patients over the age of 60 with an advanced illness and a prognosis of 1 year or less were included. Mean age was 76 and 51 % were women.

INTERVENTION

Three-minute video describing CPR and intubation plus verbal communication of participants’ preferences to their physicians (intervention) (N = 75) or control arm (usual care) (N = 75).

MAIN MEASURES

The primary outcome was participants’ preferences for CPR and intubation (immediately after viewing the video in the intervention arm). Secondary outcomes included: orders to withhold CPR/intubation, documented discussions with providers during hospitalization, and participants’ knowledge of CPR/ intubation (five-item test, range 0–5, higher scores indicate greater knowledge).

RESULTS

Intervention participants (vs. controls) were more likely not to want CPR (64 % vs. 32 %, p <0.0001) and intubation (72 % vs. 43 %, p < 0.0001). Intervention participants (vs. controls) were also more likely to have orders to withhold CPR (57 % vs. 19 %, p < 0.0001) and intubation (64 % vs.19 %, p < 0.0001) by hospital discharge, documented discussions about their preferences (81 % vs. 43 %, p < 0.0001), and higher mean knowledge scores (4.11 vs. 2.45; p < 0.0001).

CONCLUSIONS

Seriously ill patients who viewed a video about CPR and intubation were more likely not to want these treatments, be better informed about their options, have orders to forgo CPR/ intubation, and discuss preferences with providers.Trial registration: Clinicaltrials.gov {"type":"clinical-trial","attrs":{"text":"NCT01325519","term_id":"NCT01325519"}}NCT01325519Registry Name: A prospective randomized trial using video images in advance care planning in seriously ill hospitalized patients.     

The influence of the media on COPD patients�� knowledge regarding cardiopulmonary resuscitation

Background

The decision whether or not to undertake cardiopulmonary resuscitation (CPR) is a major ethical challenge. Patient preferences may be influenced by multiple factors, including information given by the media.

Objectives

We wanted to assess whether patients’ knowledge about CPR survival and outcomes was related to presentation by the media.

Methods

100 consecutive patients with COPD and chronic respiratory failure (CRF) and 100 patients at their first hospital admission for respiratory problems were enrolled. A questionnaire was administered to the patients seeking to ascertain their exposure to health information from the media, and to obtain their opinions on 1) the probability of survival after CPR, 2) the maximal length of time from collapse to CPR that allows a reasonable chance of survival, and 3) long-term outcomes of CPR survivors.

Results

The patients overestimated the success rate of CPR (63% of them estimated a hospital survival >40%), while the estimate of long-term outcome and timing of the procedure were more realistic. Bivariate correlations analysis showed significant correlation between the rate of correct responses and the viewing of educational television programs (p = 0.039), but not medical stories, reading of health-oriented newspapers, use of the internet, age, educational level, and the presence of CRF.

Conclusions

In conclusion, we have shown that both COPD and “newly admitted” patients’ estimate of survival after CPR is much higher than reported by the current literature. A correct knowledge of CPR procedures and outcomes is significantly correlated with the exposure to “educational” medical TV programs, but not medical stories, newspapers, or internet sources.     

Bacterial communities in neonatal feces are similar to mothers’ placentae

BACKGROUND:

The gut microbiota plays an important role in human health. It is essential to understand how the composition of the gut microbiota in neonates is established.

OBJECTIVES:

To investigate the nature of the microbial community in the first feces of newborn infants compared with the mothers’ placentae and vaginas.

METHODS:

One infant who was delivered via Cesarean section was compared with an infant who was delivered vaginally. Bar-coded pyro-sequencing of 16S ribosomal RNA genes was used to investigate the bacterial community composition and structure of each site.

RESULTS:

Neonatal feces of both infants had similar bacterial communities, and they were similar to the mother’s placenta regardless of the method of delivery. The vaginal bacterial community differed between the two mothers, but not different sites within the vagina. The bacteria in the neonatal feces and the mothers’ placentae demonstrated considerably higher diversity compared with the vaginas. The family Lactobacillaceae dominated in the vaginal samples, while the most abundant family in the fecal and placental samples was Micrococcineae.

CONCLUSIONS:

These results may provide new directions for the study of infant gut microbial formation.     

Three-year data from the XIENCE V® INDIA study: Safety and efficacy of XIENCE V® in 1000 real world Indian patients

Background

Cardiovascular disease in Asia has reached epidemic proportions in recent years. Use of drug eluting stents in Asians has rapidly expanded with varying penetration rates across different countries. The XIENCE V^® INDIA Study included ‘real world’ patients who underwent XIENCE V^® stent implantation to assess short and intermediate term outcomes in Indian patients with diverse risk factors.

Objective

To evaluate 3-year clinical outcomes in a cohort of ‘real world’ Indian patients with CAD being treated with XIENCE V^® Everolimus Eluting Coronary Stent System.

Methods

1000 patients were enrolled from 18 sites in India between June 2008 and March 2009. Patients were included if their index procedures were completed using only XIENCE V^®. There were no clinical or angiographic exclusions. An independent Clinical Events Committee adjudicated all endpoint-related events. The primary endpoint was stent thrombosis rate annually through to 3 years as defined by the Academic Research Consortium criteria. The co-primary endpoint was the composite rate of cardiac death and myocardial infarction at 1 year.

Results

At 1-year the primary endpoint of definite/probable stent thrombosis rate was 0.51%. No additional very late stent thrombosis was reported through a 3-year follow up. The composite endpoint of cardiac death and any myocardial infarction was 1.9%, 2.7% and 3.1% at 1, 2 and 3 years respectively.

Conclusion

Despite the high risk population of coronary artery disease, the use of XIENCE V^® in ''real world'' Indian patients was associated with very low clinical event rates upto three years of follow up.     

Midterm results of “treat and repair” for adults with non-restrictive ventricular septal defect and severe pulmonary hypertension

Background

A non-restrictive ventricular septal defect (VSD) can cause intracardiac left to right shunt, which leads to increased pulmonary vascular resistance (PVR) and pulmonary hypertension causes bi-directional or even right-left shunt, namely the Eisenmenger’s syndrome. For patients with non-restrictive VSD with severe pulmonary hypertension at stage of near or to be Eisenmenger’s syndrome, traditional VSD repair carries high mortality and poor prognosis. Recently, targeted drug therapy was used to decrease pulmonary circulation resistance in these patients before they receive defect repair surgery, namely “treat and repair” strategy, however, there is few reports about the midterm result of this strategy in adults with non-restrictive VSD with severe pulmonary hypertension at stage of near or to be Eisenmenger’s syndrome.

Methods

In this study, we used this strategy to treat 41 adult VSD patients who received bosentan as the targeted therapy to decrease their PVR before and after repair surgery.

Results

A total of 39 patients were followed up for an average of 37 months. None of the patients died during follow-up. Among them, 36 cases continued targeted drug therapy, whose mean pulmonary artery pressure (mPAP) was significantly reduced, including 31 cases with mPAP <50 mmHg, and the valve of tap hole was closed. Besides, the SpO₂ was significantly elevated.

Conclusions

These results demonstrated that “treat-and-repair” strategy may be a viable approach for the adults with non-restrictive VSD with severe pulmonary hypertension at stage of near or to be Eisenmenger’s syndrome.     

Overlooked Management and Risk Factors for Anemia in Patients with Intestinal Beh?et’s Disease in Actual Clinical Practice

Background/Aims

Anemia in patients with inflammatory bowel disease significantly affects the quality of life. The aim of this study was to investigate the frequency of and risk factors for anemia and to describe the management of anemia in patients with intestinal Behçet’s disease (BD) in actual clinical practice.

Methods

We included 64 patients with intestinal BD who visited the outpatient clinic of a tertiary referral center in June 2011 and had available laboratory data for the subsequent 6 months.

Results

Anemia was detected in 26 patients (40.6%). After 6 months, anemia was still present in 14 of these patients (53.8%). The cause of anemia was investigated in eight patients (30.8%), and oral iron supplementation was prescribed to four patients (15.4%). Of these four patients, two (50%) recovered completely within 6 months. Anemia was associated with a high Disease Activity Index for Intestinal Behçet’s Disease (DAIBD, p=0.024), erythrocyte sedimentation rate (p=0.003), and C-reactive protein (p=0.049) in univariate analysis. In multivariate analysis, the factor predictive for anemia in patients with intestinal BD was a higher DAIBD (≥40; odds ratio, 4.08; 95% confidence interval, 1.21 to 13.71; p=0.023).

Conclusions

Although anemia is common in intestinal BD patients, its clinical importance is overlooked in daily practice. Moderate to severe disease activity is predictive of anemia.     

Low awareness but positive attitudes toward fecal transplantation in Ontario physicians

BACKGROUND:

Despite mounting evidence supporting fecal transplantation (FT) as a treatment for recurrent Clostridium difficile infection (CDI), adoption into clinical practice has been slow.

OBJECTIVE:

To determine the health literacy and attitudes of academic physicians in Toronto and infectious disease physicians in Ontario toward FT as a treatment for recurrent CDI, and to determine whether these are significant barriers to adoption.

METHODS:

Surveys were distributed to 253 general internists, infectious diseases specialists, gastroenterologists and family physicians.

RESULTS:

The response rate was 15%. More than 60% of physicians described themselves as being ‘not at all’ or ‘somewhat’ familiar with FT. Of the 76% of physicians who had never referred a patient for FT, the most common reason (50%) was lack of awareness of where to access the treatment. The ‘ick factor’ accounted for only 13% of reasons for not referring. No respondent believed that the procedure was too risky to consider.

CONCLUSION:

Despite general poor health literacy on FT, most physicians sampled share similar positive attitudes toward the treatment.     

Efficacy and safety of,and patient satisfaction with,colonoscopic-administered fecal microbiota transplantation in relapsing and refractory community- and hospital-acquired Clostridium difficile infection

OBJECTIVE:

To report the efficacy and safety of, and patient satisfaction with, colonoscopic fecal microbiota transplantation (FMT) for community- and hospital-acquired Clostridium difficile infection (CDI).

METHODS:

A retrospective medical records review of patients who underwent FMT between July 1, 2012 and August 31, 2013 was conducted. A total of 22 FMTs were performed on 20 patients via colonoscopy. The patients were divided into ‘community-acquired’ and ‘hospital-acquired’ CDI. Telephone surveys were conducted to determine procedure outcome and patient satisfaction. Primary cure rate was defined as resolution of diarrhea without recurrence within three months of FMT, whereas secondary cure rate described patients who experienced resolution of diarrhea and return of normal bowel function after a second course of FMT.

RESULTS:

Nine patients met the criteria for community-acquired CDI whereas 11 were categorized as hospital-acquired CDI. A female predominance in the community-acquired group (88.89% [eight of nine]) was found (P=0.048). The primary cure rate was 100% (nine of nine) and 81.8% (nine of 11 patients) in community- and hospital-acquired CDI groups, respectively (P=0.189). Two patients in the hospital-acquired group had to undergo a repeat FMT for persistent symptomatic infection; the secondary cure rate was 100%. During the six-month follow-up, all patients were extremely satisfied with the procedure and no complications or adverse events were reported.

CONCLUSION:

FMT was a highly successful and very acceptable treatment modality for treating both community- and hospital-acquired CDI.     

Appropriateness of diagnosis of unstable angina pectoris in patients referred for coronary arteriography

BACKGROUND

A diagnosis of unstable angina pectoris (UAP) often carries with it a decision to catheterize the patient promptly. However, UAP remains a clinical diagnosis, based mostly on a patient’s clinical history and electrocardiogram (ECG) findings.

OBJECTIVE

To evaluate whether the diagnosis of UAP is overused in patients referred for coronary arteriography.

METHODS

Ninety-six patients with a diagnosis of UAP who were referred for invasive studies were re-examined clinically before catheterization. Coronarography was independently reviewed for correlation with clinical findings.

RESULTS

Based on the patient’s history and ECG changes, UAP was classified by two independent cardiologists as ‘very likely’ in 58% and 49%, ‘possible’ in 19% and 30%, and of ‘low probability’ in 23% and 21%, respectively. Patients with ‘very likely’ UAP had a high incidence of significant coronary lesions (87% and 96% for each cardiologist) and complex lesions by angiography (41% and 49%, respectively). Patients with a diagnosis of ‘low probability’ UAP had a low incidence of significant coronary lesions (55% for each cardiologist) and a very low incidence of complex angiographic lesions (5% for each cardiologist). Patients with ‘possible’ UAP had intermediate results.

CONCLUSION

Because of a presumptive diagnosis of UAP, approximately 22% of all patients referred for coronarography have no clinical and/or ECG evidence for this diagnosis. The incidence of complex coronary lesions in this group is very low.     

Variant RH alleles and Rh immunisation in patients with sickle cell disease

Background

Alloimmunisation is a major complication in patients with sickle cell disease (SCD) receiving red blood cell (RBC) transfusions and despite provision of Rh phenotyped RBC units, Rh antibodies still occur. These antibodies in patients positive for the corresponding Rh antigen are considered autoantibodies in many cases but variant RH alleles found in SCD patients can also contribute to Rh alloimmunisation. In this study, we characterised variant RH alleles in 31 SCD patients who made antibodies to Rh antigens despite antigen-positive status and evaluated the clinical significance of the antibodies produced.

Materials and methods

RHD and RHCE BeadChip™ from BioArray Solutions and/or amplification and sequencing of exons were used to identify the RH variants. The serological features of all Rh antibodies in antigen-positive patients were analysed and the clinical significance of the antibodies was evaluated by retrospective analysis of the haemoglobin (Hb) levels before and after transfusion; the change from baseline pre-transfusion Hb and the percentage of HbS were also determined.

Results

We identified variant RH alleles in 31/48 (65%) of SCD patients with Rh antibodies. Molecular analyses revealed the presence of partial RHD alleles and variant RHCE alleles associated with altered C and e antigens. Five patients were compound heterozygotes for RHD and RHCE variants. Retrospective analysis showed that 42% of antibodies produced by the patients with RH variants were involved in delayed haemolytic transfusion reactions or decreased survival of transfused RBC.

Discussion

In this study, we found that Rh antibodies in SCD patients with RH variants can be clinically significant and, therefore, matching patients based on RH variants should be considered.     

Nutritional Status and Growth in Korean Children with Crohn’s Disease: A Single-Center Study

Background/Aims

Malnutrition and growth retardation are important issues in treating pediatric Crohn’s disease (CD). Thus, we aimed to investigate the prevalence of various nutritional and growth parameters at the time of diagnosis in Korean children with CD.

Methods

Seventy-one children (<18 years) were enrolled. We analyzed the Z-scores of height-for-age (HAZ), weight-for-height (WHZ), body mass index for age (BMIZ), bone mineral density for age (BMDZ), and the biochemical markers measured at the time of diagnosis.

Results

At diagnosis, HAZ <−2 was observed in three patients (4%), WHZ <−2 in 20 patients (28%), BMIZ <−2 in 19 patients (27%), and BMDZ <−2 in 11 patients (18%). The HAZ was significantly lower in females and patients with extraintestinal manifestations, and the WHZ and BMIZ were significantly lower in patients with stricturing and penetrating disease. Subnormal serum levels were highly prevalent for hemoglobin, albumin, iron, ferritin, calcium, magnesium, folate, vitamin B₁₂, and zinc. There was a significant correlation between nutritional status, growth retardation, and disease activity.

Conclusions

Abnormal nutritional status was highly prevalent in Korean children with CD at the time of diagnosis and was associated with the extent, behavior, and activity of the disease.     

The effect of Ligustrum delavayanum on isolated perfused rat heart

BACKGROUND:

Extract of ligustrum leaves (Ligustrum delavayanum Hariot [Oleaceae]) is well known in traditional Chinese medicine. One of the active components, oleuropein, displays vasodilating and hypotensive effects.

OBJECTIVE:

To analyze the effect of 0.008% lyophilized extract of ligustrum dissolved in 0.5% ethanol on heart function.

ANIMALS AND METHODS:

Experiments were done on isolated rat hearts perfused by the Langendorff method in control conditions and during ischemic-reperfusion injury.

RESULTS:

Application of ligustrum induced positive inotropic and vasodilating effects in spontaneously beating hearts. Pretreatment of the hearts with ligustrum reduced left ventricular diastolic pressure measured during reperfusion and improved left ventricular contraction compared with hearts without any pretreatment. Ligustrum significantly suppressed the incidence and duration of cardiac reperfusion arrhythmias, expressed as G-score, from 7.40±0.58 in nontreated rats to 1.97±0.50.

DISCUSSION:

Application of ligustrum or ethanol alone induced changes in coordination between atria and ventricles during ischemia-reperfusion injury. The ‘g-score’, a new parameter summing the incidence and duration of atrioventricular blocks, atrioventricular dissociation and cardiac arrest, is introduced. The g-scores with ligustrum pretreatment were higher during ischemia than during reperfusion. Ethanol significantly depressed myocardial contractility and coronary flow, and nonsignificantly decreased heart rate of isolated rat hearts. Electrical changes observed during coronary reperfusion in the presence of ethanol were accompanied by deterioration of contractile function.

CONCLUSIONS:

Ligustrum had a significant protective effect on rat myocardium against ischemic-reperfusion injury. Ethanol partially attenuated the protective effect of ligustrum.     

Barriers to the recognition and reporting of occupational asthma by Canadian pulmonologists

BACKGROUND:

Occupational asthma is a common, but probably under-recognized problem.

OBJECTIVE:

To identify the factors that suggest work-related asthma when a pulmonologist encounters an adult patient with new-onset asthma, and to identify the barriers to recognizing and reporting such cases.

METHODS:

A postal questionnaire was sent to all pulmonologists in Canada. The questionnaire asked participants to respond to several questions about recognizing, diagnosing and reporting occupational asthma. Answers were scored using visual analogue scales.

RESULTS:

A total of 201 eligible responses were received from 458 pulmonologists. Pulmonologists identified that the most important factor in initially considering the role of work in occupational asthma was having seen others affected at the same workplace, or exposed to the same agent. Important perceived barriers to considering a diagnosis of occupational asthma were physicians’ low awareness, lack of knowledge and time. The most important barriers to reporting cases were the pulmonologists’ perceived patient concerns regarding job security and income. Quebec pulmonologists generally perceived barriers to recognizing and reporting occupational asthma to be less important, and believed that the use of specific inhalation challenge was more important in considering a diagnosis.

CONCLUSIONS:

Pulmonologists most readily recognized occupational asthma caused by a substance or process that they previously encountered as a possible cause of asthma. Time constraints and knowledge may hamper their ability to recognize occupational asthma. Concerns regarding the effect of the diagnosis on the patient’s job and income may discourage reporting.     

Filing for workers’ compensation among Ontario cases of mesothelioma

BACKGROUND/OBJECTIVE:

For many types of cancer, disease attribution to occupational exposures is difficult. Mesothelioma, however, is a ‘sentinel’ occupational cancer associated with asbestos exposure. The present study linked workers’ compensation claims data with cancer registry data to explore the completeness of reporting of mesothelioma to the Ontario Workplace Safety and Insurance Board (WSIB) according to characteristics of cases diagnosed among Ontario residents.

METHODS:

Two data sources were linked at the person level: the WSIB Occupational Disease Information and Surveillance System and the Ontario Cancer Registry. Filing rates were calculated as the proportion of Ontario Cancer Registry mesothelioma cases (International Classification of Diseases – Oncology code 905) that linked to a WSIB-filed cancer claim. Filing rates were calculated for the period 1980 to 2002, and trends were calculated by year, age and county of residence at diagnosis.

RESULTS:

The filing rate for compensation has increased little over the past 20 years, reaching a high of 43% in 2000. Overall, filing rates were highest among pleural mesothelioma cases among men (range 27% to 57%). Filing rates were highest among individuals 50 to 59 years of age and declined substantially throughout the retirement years. There was substantial variation in filing rates by area of residence, with the highest rate being in Lambton County, Ontario.

CONCLUSION:

The filing rate for compensation in Ontario was much lower than the estimated proportion of cases eligible for compensation. The increased filing rate in Lambton County was likely related to this community’s awareness of the association between asbestos and mesothelioma. Physicians can play an important role in educating patients of their potential entitlement to compensation benefits.     

Predictors of medication adherence in pediatric inflammatory bowel disease patients at the Stollery Children’s Hospital

BACKGROUND:

Patients with inflammatory bowel disease (IBD) often do not take their medications as prescribed.

OBJECTIVE:

To examine self-reported adherence rates in IBD patients at the Stollery Children’s Hospital (Edmonton, Alberta) and to determine predictors of medication adherence.

METHODS:

A survey was mailed to 212 pediatric IBD patients of the Stollery Children’s Hospital. A chart review was completed for those who returned the survey.

RESULTS:

A total of 119 patients completed the survey. The nonresponders were significantly older than responders (14.5 years versus 13.2 years; P=0.032). The overall adherence rate was 80%. Nonadherence was associated with older age (14.6 years versus 13.0 years; P=0.04), longer disease duration (5.0 years versus 3.1 years; P=0.004) and reported use of herbal medications (40.0% versus 13.6%; P=0.029). The most common reasons reported for missing medications were forgetfulness, feeling better and too many medications. In addition, patients reported being more likely to take anti-inflammatory medications and less likely to take herbal medicines.

CONCLUSION:

Identified predictors of nonadherence such as age, disease duration and use of herbal treatments may enable the development of specific strategies to improve adherence in adolescents with IBD.     

The IFN-λ Genetic Polymorphism Association With the Viral Clearance Induced by Hepatitis C Virus Treatment in Pakistani Patients

Background

Polymorphisms in the interferon λ (INF λ) genes on chromosome 19 have been associated with clearance of hepatitis C virus (HCV) induced by interferon and ribavirin therapy however there is no such data available for Pakistani patients with HCV infection.

Objectives

In this study, the effects of single nucleotide polymorphisms (SNPs) have been investigated in response to treatment with interferon-α and ribavirin in a cohort of 75 HCV genotype 3a patients.

Patients and Methods

A total number of 50 SNPs from the Interferon λ region on chromosome 19 were genotyped to investigate allelic associations with the treatment response in HCV type 3a patients. Thirteen SNPs were associated with HCV clearance, with the most significant alleles being RS8109886 (Fisher’s P = 0.0001), RS8113007 (Fisher’s P = 0.0001) and RS12979860 (Fisher’s P = 0.0002).

Results

These SNPs were found to be the most suitable SNPs for predicting treatment response in the present study. These findings support those reported previously. This could be used to improve HCV treatment strategies and suggest that Pakistani patients should be genotyped for the relevant SNPs to identify the patients who are more likely to respond to interferon and ribavirin therapy.

Conclusions

This therapy is costly and can be accompanied by several adverse side-effects, hence pre-treatment prediction of patients who are most likely to benefit would have both economic and patient benefits in the long term.     

Efficacy and Safety of Ferric Chloride in Controlling Hepatic Bleeding; An Animal Model Study

Background:

Controlling parenchymal hemorrhage especially in liver parenchyma, despite all the progress in surgical science, is still one of the challenges surgeons face saving patients’ lives and there is a research challenge among researchers in this field to introduce a more effective method.

Objectives:

This study attempts to determine the haemostatic effect of ferric chloride and compare it with that of the standard method (suturing technique) in controlling bleeding from liver parenchymal tissue.

Materials and Methods:

In this animal model study 60 male Wistar rats were used. An incision, two centimeters (cm) long and half a cm deep, was made on each rat’s liver and the hemostasis time was measured once using ferric chloride with different concentrations (5%, 10%, 15%, 25% and 50%) and then using the control method (i.e. controlling bleeding by suturing). The liver tissue was examined for pathological changes.

Results:

The hemostasis time of ferric chloride concentration groups was significantly less than that of the control group (P value < 0.001). The pathologic examination showed the highest frequency of low grade inflammation based on the defined pathological grading.

Conclusions:

Ferric chloride is an effective haemostatic agent in controlling liver parenchymal tissue hemorrhage in an animal model.