The association of marital status and hospice use in the USA

BACKGROUND: Married individuals are more likely to use hospice than unmarried individuals. We examine this association and how it is influenced by gender. METHODS: Medicare beneficiaries dying of cancer were studied. RESULTS: Currently married (OR 1.36 95% C.I. 1.28-1.45) or ever married (OR 1.23 95% C.I. 1.16-1.31) subjects were more likely to use hospice than never married subjects. A significant interaction between marital status and gender (P < .001) was observed. CONCLUSIONS: Subjects likely to enroll in hospice are subjects likely to have greater supportive relationships.     

Newborn circumcision outcomes: Are parents satisfied with the results?

Background/purpose

Although physician-reported complications following circumcision are very low, parental satisfaction is not well documented. This study examined parental opinions and compared these with those of the medical professional.

Methods

Physicians independently assessed complications and cosmetic outcome following the circumcision. Six weeks post-circumcision, parental report of complications, cosmetic outcome, and overall satisfaction were assessed.

Results

Newborn infants (n = 710) were prospectively recruited and underwent either a Gomco [n = 552 (78 %)] or Plastibell^® [n = 158 (22 %)] circumcision. Physician assessed complication rates were equivalent (Gomco 4.3 % versus Plastibell 5.1 %; p = 0.67), however, parental assessment found a much lower complication rate for Gomco 5.6 % versus Plastibell 12.0 % (p < 0.001). There was no difference between who performed the procedure nor between the techniques in regards to parental rating of overall satisfaction (excellent/good: Gomco 96.9 % versus Plastibell 95.6 %, p = 0.45). However, perceived post-operative pain as scored by parents was significantly higher in patients undergoing Plastibell procedure (6.4 % too much pain) versus Gomco (2.7 %; p = 0.05). Gomco accounted for 72.7 % of parental cosmetically unsatisfactory cases.

Conclusions

Clinicians and parents differed considerably in terms of opinion of cosmetic outcome and occurrence of post-operative complications. This study emphasizes the need for clinicians to better understand and address parental concerns before and after circumcision.     

Hemoglobin Affinity for Oxygen in Chronic Renal Disease: The Effect of Hemodialysis

The affinity of hemoglobin for oxygen mayincrease significantly in subjects who arehypophosphatemic and alkalotic. Westudied the organic phosphate content andoxygen binding by hemoglobin of red cellsin subjects undergoing hemodialysis, during which time a decrease in plasma inorganic phosphate and an increase inblood pH may occur. Red cell 2,3-DPGwas not correlated with plasma inorganicphosphorus, whereas red cell ATP washighly correlated with plasma inorganicphosphorus when analyses were made onpredialysis samples. Predialysis red cellinorganic phosphorus was highly correlated with plasma inorganic phosphorus,supporting the concept that intraerythrocytic inorganic phosphorus is maintainedby a gradient from plasma to cell. Plasmainorganic phosphorus decreased by 45%during the period of hemodialysis, whereasred cell inorganic phosphorus did notchange. Red cell 2,3-DPG, ATP, and oxygen binding by hemoglobin at standardconditions of temperature, pH, and pCO₂were not altered after 6 hr of hemodialysis. Plasma pH and base excess increasedduring dialysis. The increase in base excess, an estimate of the non-pH-dependenteffect of CO₂ on oxygen binding by hemoglobin, counterbalanced a portion of theeffect of elevated pH on hemoglobin—oxygen affinity under in vivo conditions.Hence, only a slight increase in oxygenbinding by hemoglobin occurred. Moreover, late dialysis symptoms were notassociated with the degree of alkalosis orwith the extent of change in hemoglobin’saffinity for oxygen. Red cell 2,3-DPG content was lower and hemoglobin’s affinityfor oxygen was higher in subjects withchronic renal disease than in nonazotemicsubjects with similar hemoglobin deficits.Moreover, increased red cell ATP in chronicrenal disease patients did not influenceoxygen binding by hemoglobin.

Submitted on June 11, 1973 Revised on July 30, 1973 Accepted on September 13, 1973     

Relative contribution of cardiovascular risk factors and rheumatoid arthritis clinical manifestations to atherosclerosis

OBJECTIVE: To estimate the contribution of cardiovascular (CV) risk factors and rheumatoid arthritis (RA) disease manifestations to atherosclerosis in RA. METHODS: We used high-resolution carotid ultrasound to measure the carotid intima-media thickness (IMT) and plaque in 631 RA patients. Using R(2) measures from multivariable models, we estimated the contribution of demographic characteristics (age, sex, and ethnic group), CV risk factors (diabetes mellitus, hypercholesterolemia, cigarette smoking, hypertension, and body mass index, and RA manifestations (joint tenderness, swelling, and deformity, nodules, erythrocyte sedimentation rate [ESR], C-reactive protein, rheumatoid factor, the HLA-DRB1 shared epitope, and cumulative glucocorticoid dose) to each of the outcomes. Estimates were obtained in the full sample, and within strata defined by age, sex, and ethnic group. We tested for interaction between CV risk factors and RA manifestations. RESULTS: The contribution of demographic factors, CV risk factors, and RA manifestations to IMT and plaque R(2) varied depending on the patients' age stratum. Demographic features explained 11-16% of IMT variance, CV risk factors explained 4%-12%, and RA manifestations explained 1-6%. The greatest contribution of RA manifestations occurred in the youngest age group, while that of CV risk factors occurred in the older age groups. Results for carotid plaque were similar. There was a significant interaction between the number of CV risk factors present and the ESR, suggesting that the ESR's effect on IMT varied according to the number of CV risk factors. CONCLUSION: Both established CV risk factors and manifestations of RA inflammation contribute significantly to carotid atherosclerosis in RA, and may modify one another's effects. These findings may have implications regarding the prevention of atherosclerosis in RA.     

Comparison of IgA endomysium antibody and IgA tissue transglutaminase antibody in celiac disease.

The antigen for immunoglobulin (Ig) A endomysium antibody (EmA), a sensitive and specific serological marker for celiac disease, has recently been described as tissue transglutaminase (tTG). The aim of this study was to compare the assays used to measure IgA EmA and IgA tTG antibody in patients with celiac disease and disease control subjects. Sera from 21 patients with untreated celiac disease, 48 patients with treated celiac disease and 128 disease control subjects were tested both for IgA EmA with the use of indirect immunofluorescence against human umbilical cord and for IgA tTG antibody with the use of ELISA. Titres of IgA tTG antibody were significantly higher in both the untreated and treated celiac groups than in the disease control group. Titres in the treated group were, however, significantly lower than in the untreated group. A reference range was calculated to include 99.8% of the disease control group in whom small bowel biopsy showed no evidence of celiac disease. One patient from the disease control group with raised IgA tTG antibody titres and positive IgA EmA was found to have celiac disease on small bowel biopsy. The sensitivity, specificity, and positive and negative predictive values of the IgA EmA assay were all 100%. The sensitivity of the IgA tTG antibody assay was 95%, specificity 100%, positive predictive value 100% and negative predictive value 97.7%. An ELISA used to measure IgA tTG antibody is an excellent tool to screen for celiac disease and may prove useful for monitoring response to treatment.     

Left Ventricular Thrombus After Primary PCI for ST-Elevation Myocardial Infarction: 1-Year Clinical Outcomes

BackgroundLeft ventricular thrombus formation is a complication of acute myocardial infarction. However, the incidence and risk of systemic thromboembolism in the era of primary angioplasty for ST elevation myocardial infarction (STEMI) is unclear. This study aims to determine clinical outcomes in patients with STEMI treated with primary angioplasty and left ventricular thrombus at 1 year.MethodsPatients who underwent primary angioplasty for STEMI and had a transthoracic echocardiogram were recruited. The primary endpoint was a composite of all-cause mortality, stroke, and systemic thromboembolism at 1 year. For the primary endpoint, the difference between the presence and absence of left ventricular thrombus was compared using a logistic regression, adjusting for minimization variables including age, diabetes mellitus, hypertension, and previous stroke.ResultsOf 2608 patients who underwent primary angioplasty for STEMI, 1645 (63%) patients had a transthoracic echocardiogram performed during the index hospital admission. Forty patients (2.4%) had evidence of left ventricular thrombus on transthoracic echocardiography. Patients with left ventricular thrombus were more likely to develop atrial fibrillation in the immediate postinfarction period (6 [15%] vs 87 [5.4%], P = 0.025). At 1 year, the primary endpoint occurred in 4 (10%) patients with left ventricular thrombus and 146 (9.1%) who did not (logistic regression hazard ratio 0.79, 95% confidence interval 0.23-2.70).ConclusionsIn the contemporary era of mechanical reperfusion for STEMI, echocardiographic detection of left ventricular thrombus was observed in < 3% patients. The presence of left ventricular thrombus was not associated with an increased risk of systemic thromboembolism.