Bedside ketone determination in diabetic children with hyperglycemia and ketosis in the acute care setting

Objective:  Diabetic ketoacidosis (DKA) is a serious complication of diabetes mellitus marked by characteristic biochemical derangements. Diagnosis and management involve frequent evaluation of these biochemical parameters. Reliable bedside equivalents for these laboratory studies may help reduce the time to treatment and reduce costs.
Methods:  We evaluated the precision and bias of a bedside serum ketone meter in the acute care setting. Serum ketone results using the Precision Xtra™ glucometer/ketone meter (Abbott Laboratories, MediSense Products Inc., Bedford, MA, USA) correlated strongly with the Children's Medical Center of Dallas' laboratory values within the meter's value range.
Results:  Meter ketone values steadily decreased during the treatment of DKA as pH and CO₂ levels increased and acidosis resolved.
Conclusion:  Therefore, the meter may be useful in monitoring therapy for DKA. This meter may also prove useful in identifying patients at risk for DKA in physicians' offices or at home.     

Cytotoxic T lymphocyte therapy for Epstein-Barr virus+ Hodgkin's disease

Epstein Barr virus (EBV)+ Hodgkin's disease (HD) expresses clearly identified tumor antigens derived from the virus and could, in principle, be a target for adoptive immunotherapy with viral antigen-specific T cells. However, like most tumor-associated antigens in immunocompetent hosts, these potential targets are only weakly immunogenic, consisting primarily of the latent membrane protein (LMP)1 and LMP2 antigens. Moreover, Hodgkin tumors possess a range of tumor evasion strategies. Therefore, the likely value of immunotherapy with EBV-specific cytotoxic effector cells has been questioned. We have now used a combination of gene marking, tetramer, and functional analyses to track the fate and assess the activity of EBV cytotoxic T lymphocyte (CTL) lines administered to 14 patients treated for relapsed EBV+ HD. Gene marking studies showed that infused effector cells could further expand by several logs in vivo, contribute to the memory pool (persisting up to 12 mo), and traffic to tumor sites. Tetramer and functional analyses showed that T cells reactive with the tumor-associated antigen LMP2 were present in the infused lines, expanded in peripheral blood after infusion, and also entered tumor. Viral load decreased, demonstrating the biologic activity of the infused CTLs. Clinically, EBV CTLs were well tolerated, could control type B symptoms (fever, night sweats, and weight loss), and had antitumor activity. After CTL infusion, five patients were in complete remission at up to 40 mo, two of whom had clearly measurable tumor at the time of treatment. One additional patient had a partial response, and five had stable disease. The performance and fate of these human tumor antigen-specific T cells in vivo suggests that they might be of value for the treatment of EBV+ Hodgkin lymphoma.     

The Health Insurance Portability and Accountability Act Privacy Rule: a practical guide for researchers

BACKGROUND: The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, intended to address potential threats to patient privacy posed by the computerization and standardization of medical records, provides a new floor level of federal protection for health information in all 50 states. In most cases, compliance with the Privacy Rule was required as of April 2003. Yet considerable confusion and concern remain about the Privacy Rule and the specific changes it requires in the way healthcare providers, health plans, and others use, maintain, and disclose health information. Researchers worry that the Privacy Rule could hinder their access to health information needed to conduct their research. OBJECTIVES: In this article, we explain how the final version of the Privacy Rule governs disclosure of health information, assess implications of the Privacy Rule for research, and offer practical suggestions for researchers who require access to health information. CONCLUSION: The Privacy Rule is fundamentally changing the way that healthcare providers, health plans, and others use, maintain, and disclose health information and the steps that researchers must take to obtain health data. The Privacy Rule requires researchers who seek access to identifiable health information to obtain written authorization from subjects, or, alternatively, to demonstrate that their research protocols meet certain Privacy Rule requirements that permit access without written authorization. To ensure continued access to data, researchers will need to work more closely than before with healthcare providers, health plans, and other institutions that generate and maintain health information.     

Are there race/ethnicity differences in outpatient congestive heart failure management, hospital use, and mortality among an insured population?

OBJECTIVE: The objective of this study was to assess the quality of outpatient care received by patients with congestive heart failure (CHF) and whether differences in care and outcomes exist by race/ethnicity. BACKGROUND: Appropriate outpatient CHF management can improve patient well-being and reduce the need for costly inpatient care. Yet, little is known regarding outpatient CHF management or whether differences in this care exist by race/ethnicity. METHODS: Using automated data sources, we identified a cohort of insured patients seen in an outpatient setting for CHF between September 1992 and August 1993. Medical record abstraction was used to confirm diagnosis of CHF. Patients (N = 566) were followed until September 1998. Race/ethnicity differences in outpatient management and medical care utilization were assessed using generalized estimating equations. Differences in mortality and hospitalization for CHF, controlling for patient characteristics and outpatient management, were assessed using Cox and Andersen-Gill models, respectively. RESULTS: With the exception of beta blocker use and primary care visit frequency, few differences by race/ethnicity in patient characteristics and CHF management were found. However, older black patients had more hospital use both at baseline and during follow up. These differences persisted after adjusting for patient characteristics and clinical management. No race/ethnicity differences were found in mortality. CONCLUSIONS: In an insured population, older black patients with CHF have substantially more hospital use than older white patients. This increased use was not explained by differences in CHF outpatient management. Further research is needed to understand why race/ethnicity differences in hospital use are observed among older patients with CHF.     

Trichofolliculoma with incidental focal acantholytic dyskeratosis

Incidental focal acantholytic dyskeratosis has been described in a variety of cutaneous lesions, including benign and malignant epithelial lesions, fibrohistiocytic lesions, inflammatory lesions, and melanocytic lesions. It has also been observed in follicular lesions such as comedones and ruptured follicles. We report the case of a 47-year-old man with a firm, flesh-colored 2-mm pruritic papule in the sun-exposed area above the left eyebrow. An excisional biopsy was performed, the tissue was processed, and the hematoxylin and eosin slides were evaluated. Microscopic examination showed a dilated cystic cavity filled with keratinous debris and scattered fragments of hair. Smaller secondary follicular structures branched from the primary cyst's walls into the adjacent dermis. Hyperkeratosis, acantholysis, dyskeratosis, and suprabasilar clefts were also focally present. Correlation of the lesion's clinical morphology and microscopic features established a diagnosis of trichofolliculoma with incidental focal acantholytic dyskeratosis. Hence, trichofolliculoma can be added to the list of follicular lesions in which focal acantholytic dyskeratosis may be observed as an incidental microscopic change.     

Physician orders for life-sustaining treatment form: honoring end-of-life directives for nursing home residents

Physician Orders for Life-Sustaining Treatment (POLST) form provides choices about end-of-life care and gives these choices the power of physician orders. The POLST form assures end-of-life choices can be implemented in all settings, from the home through the health-care continuum. The use of the POLST form was evaluated in a pilot study in nursing homes in two eastern Washington counties. Chart reviews and template analysis of interviews revealed the POLST form accurately conveyed end-of-life wishes in 19 of 21 cases. An informed consent process was evidenced in 16 of 21 cases, and the POLST form was congruent with residents' existing advance directives for health care. The findings support the continued use, development, and evaluation of this promising tool for improving end-of-life care.     

Effect of exogenous DMNPE-caged ATP on in vitro-matured bovine oocytes prior to parthenogenetic activation, fertilisation and nuclear transfer

Adenosine triphosphate (ATP) plays an important role during fertilisation of the mammalian oocyte through its ability to alter the frequency and duration of calcium oscillations. It has also been shown that higher ATP levels correlate with increased developmental competence in bovine and human oocytes. During somatic cell nuclear transfer (NT), the incoming nucleus is remodelled extensively, undoubtedly using a variety of ATP-dependent enzymes. The aim of the present study was to determine whether additional exogenous ATP influences activation of parthenogenetic (PA), in vitro-fertilised (IVF) or cloned (NT) in vitro-matured bovine oocytes. Blastocyst development and cell numbers in PA embryos were found to increase in a dose-dependent manner following the photorelease of 0, 50, 100, 500 and 1000 microm DMNPE-caged ATP (adenosine 5'-triphosphate, P3-(1-(4,5-dimethoxy-2-nitrophenyl)ethyl) ester, disodium salt). No cleavage was found following release of 2 and 5 mm DMNPE-caged ATP or with DMNPE-caged ATP (not photoreleased). There were also no differences in blastocyst rates or cell numbers between the control group and groups treated with caged, but not photoreleased, ATP. The addition of exogenous ATP before IVF or to NT couplets did not result in a significant increase in blastocyst development or cell number. Embryo transfer is necessary to determine whether exogenous ATP can positively affect reprogramming, resulting in higher cloned pregnancy rates or live-term births.     

Hispanic ethnicity and post-traumatic stress disorder after a disaster: evidence from a general population survey after September 11, 2001

PURPOSE: To assess ethnic differences in the risk of post-traumatic stress disorder (PTSD) after a disaster, and to assess the factors that may explain these differences. METHODS: We used data from a representative survey of the New York City metropolitan area (n=2,616) conducted 6 months after September 11, 2001. Linear models were fit to assess differences in the prevalence of PTSD between different groups of Hispanics and non-Hispanics and to evaluate potential explanatory variables. RESULTS: Hispanics of Dominican or Puerto Rican origin (14.3% and 13.2%, respectively) were more likely than other Hispanics (6.1%) and non-Hispanics (5.2%) to report symptoms consistent with probable PTSD after the September 11 terrorist attacks. Dominicans and Puerto Ricans were more likely than persons of other races/ethnicities to have lower incomes, be younger, have lower social support, have had greater exposure to the September 11 attacks, and to have experienced a peri-event panic attack upon hearing of the September 11 attacks; these variables accounted for 60% to 74% of the observed higher prevalence of probable PTSD in these groups. CONCLUSION: Socio-economic position, event exposures, social support, and peri-event emotional reactions may help explain differences in PTSD risk after disaster between Hispanic subgroups and non-Hispanics.     

Mass smallpox vaccination and cardiac deaths, New York City, 1947

In April 1947, during a smallpox outbreak in New York City (NYC), more than 6 million people were vaccinated. To determine whether vaccination increased cardiac death, we reviewed NYC death certificates for comparable periods in 1946, 1947, and 1948 (N = 81,529) and calculated adjusted relative death rates for the postvaccination period. No increases in cardiac deaths were observed.