Clinical and laboratory factors contributing to uninterpretable beryllium lymphocyte proliferation tests (BeLPT)

Background

The beryllium lymphocyte proliferation test (BeLPT), has become the principal clinical test for detecting beryllium sensitization and chronic beryllium disease. Uninterpretable BeLPT results can occur in a small but significant proportion of tests from poor lymphocyte growth (PG) or over proliferation of lymphocytes (OP). The clinical and laboratory causes of uninterpretable results are not known.

Methods

BeLPT data from the US Department of Energy‐supported Former Worker Screening Program were analyzed for a 10‐year period. Drivers of uninterpretable BeLPTs were investigated using multivariable models and classification techniques.

Results

Three participant attributes were significantly associated with PG, while OP showed no significant associations. Serum lot for the lymphocyte growth medium accounted for 21% of the variation in PG and 16% in OP.

Conclusion

Serum lots influence the likelihood of having uninterpretable BeLPT. To better understand uninterpretable results and possibly reduce their occurrence, additional laboratory‐related factors should be addressed.

     

Impulse oscillometry measurement of distal airways obstruction in depleted uranium‐exposed Gulf War veterans

Introduction

A cohort of Gulf War I veterans who sustained exposure to depleted uranium undergoes biennial surveillance for potential uranium‐related health effects. We performed impulse oscillometry and hypothesized that veterans with higher uranium body burdens would have more obstructive abnormalities than those with lower burdens.

Methods

We compared pulmonary function of veterans in high versus low urine uranium groups by evaluating spirometry and oscillometry values.

Results

Overall mean spirometry and oscillometry resistance values fell within the normal ranges. There were no significant differences between the high and low uranium groups for any parameters. However, more veterans were classified as having obstruction by oscillometry (42%) than spirometry (8%).

Conclusions

While oscillometry identified more veterans as obstructed, obstruction was not uranium‐related. However, the added sensitivity of this method implies a benefit in wider surveillance of exposed cohorts and holds promise in identifying abnormalities in areas of the lung historically described as silent.

     

Acute cardiac ischemia in patients with syncope

Objective:To determine the prevalence of acute cardiac ischemia in emergency department (ED) syncope patients without chest pain and to determine which of these patients are at high risk for acute cardiac ischemia. Design:Data were collected prospectively during a study of ED triage of patients who had had possible acute cardiac ischemia. Supplemental retrospective review of records was performed to differentiate syncope from dizziness. Setting:Six hospital EDs in New England (two primary teaching hospitals in urban locations, two medical-school-affiliated teaching hospitals, and two nonteaching hospitals in rural settings). Patients:5,762 patients had presented to the ED with chief complaints consistent with acute cardiac ischemia, including chest pain, shortness of breath, dizziness, and syncope. The study sample consisted of 251 patients who had had syncope and no chest pain. Results:The prevalence of acute cardiac ischemia among the syncope patients was 7% (18 of the 251 patients). Univariate analysis revealed the following to have significant association with acute cardiac ischemia: ischemic abnormalities on the electrocardiogram (ECG) obtained in the ED (p<0.001), arm or shoulder pain on presentation (p<0.05), rales (p<0.1), and prior history of exercise-induced angina (p<0.05) or myocardial infarction (p<0.1). All 18 patients with acute cardiac ischemia had ischemic abnormalities (pathologic Q waves, ST-segment elevation or depression, or T-wave abnormalities) on their presenting ECGs. Conclusion:For syncope patients who have no chest pain or ischemic abnormality on the presenting ECG in the ED, acute ischemia appears to be unlikely. Admission to the cardiac care unit for these patients for possible myocardial ischemia is probably unnecessary. However, patients who have syncope and ischemic abnormalities on the ECG are at risk for acute cardiac ischemia, even in the absence of chest pain. Hospital admission to rule out myocardial infarction for these patients is prudent. Received from the Center for Cardiovascular Health Services Research, Divisions of Clinical Decision Making and General Medicine, Department of Medicine, New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts. Presented in part at the 40th Annual Scientific Session of the American College of Cardiology, Atlanta, Georgia, March 3–7, 1991. Supported by the Agency for Health Care Policy and Research grants #RO1HS02068 and RO1HS05549. Dr. Georgeson was supported by grants from the National Library of Medicine (5 RO1 LM04493-05 and 5 T15 LM07044-06) and from the John A. Hartford Foundation (87269-3H), New York, NY.     

Patients’ perceptions of physicians’ recommendations for comfort care differ by patient age and gender

OBJECTIVE: To determine patient characteristics associated with patient and proxy perceptions of physicians’ recommendations for life-prolonging care versus comfort care, and with acceptance of such recommendations. DESIGN: Cross-sectional. SETTING: Five teaching hospitals in Denver, Colo. PATIENTS: We studied 239 hospitalized adults believed by physicians to have a high likelihood of dying within 6 months. MEASUREMENTS AND MAIN RESULTS: Interviews with patients or proxies were conducted to determine perceptions of physicians’ recommended goal of care and roles in decision making. RESULTS: Patients’ mean age was 66.6 years; 44% were women. In adjusted analysis, age greater than 70 years and female gender were associated with a higher likelihood of believing that comfort care had been recommended by the physician (odds ratio [OR], 3.70; 95% confidence interval [CI], 1.89 to 7.24; OR, 1.99; 95% CI, 1.04 to 3.84, respectively). Patients and proxies gave substantial decision-making authority to physicians: 29% responded that physicians dominate decision making, 55% that decision making is equally shared by physicians and patients, and only 16% that patients make decisions, Increasing age was associated with an increased likelihood of believing that physicians should dominate decision making (P<.005). CONCLUSIONS: Among patients with advanced illness, perceived comfort care recommendations were related to patient age and gender, raising concern about possible gender and age bias in physicians’ recommendations. Although all patients and proxies gave significant decision-making authority to physicians, older individuals were more likely to give physicians decision-making authority, making them more vulnerable to possible physician bias. Presented at the annual meeting of the American Geriatrics Society, May 19, 1999. Financial support for this work was received from the Hartford/Jahnigen Center of Excellence in Geriatrics at the University of Colorado and the Colorado Collective for Medical Decisions, a nonprofit organization to improve care of the dying in the state of Colorado.     

Time to Standardize and Broaden the Criteria of Acute Coronary Syndrome Symptom Presentations in Women

Early recognition of the signs and symptoms of acute coronary syndromes (ACS) is essential to improving patient management and associated outcomes. It is widely reported that women might have a different ACS symptom presentation than men. Multiple review articles have examined sex differences in symptom presentation of ACS and these studies have yielded inconclusive results and/or inconsistent recommendations. This is largely because these studies have included diverse study populations, different methods of assessing the chief complaint and associated coronary symptoms, relatively small sample sizes of women and men, and lack of adequate adjustment for age or other potentially confounding differences between the sexes. There is a substantial overlap of ACS symptoms that are not mutually exclusive according to sex, and are generally found in women and men. However, there are apparent differences in the frequency and distribution of ACS symptoms among women and men. Women, on average, are also more likely to have a greater number of ACS-related symptoms contributing to the perception that women have more atypical symptoms than men. In this review, we address issues surrounding whether women should have a different ACS symptom presentation message than men, and provide general recommendations from a public policy perspective. In the future, our goal should be to standardize ACS symptom presentation and to elucidate the full range of ACS and myocardial infarction symptoms considering the substantial overlap of symptoms among women and men rather than use conventional terms such as “typical” and “atypical” angina.