Orders to limit emergency treatment for an ambulance service in a large metropolitan area

We describe a policy allowing paramedics and emergency physicians to honor orders from nursing home records not to perform resuscitation or endotracheal intubation. The policy was adopted by the regional body coordinating emergency medical care and endorsed by the county medical society. The policy establishes community-wide definitions for "do not resuscitate" and "do not intubate" orders. It requires physicians to write such directives in patient's medical records and to update them every two years. It urges long-term care facilities to adopt policies to help ensure good decision-making practices in the formulation of these directives. The policy intends to partially address the unnecessary loss of patient autonomy that occurs when emergency care is administered according to routine orders.     

Social and Self-Reflective Use of a Web-Based Personally Controlled Health Management System

Background

Personally controlled health management systems (PCHMSs) contain a bundle of features to help patients and consumers manage their health. However, it is unclear how consumers actually use a PCHMS in their everyday settings.

Objective

To conduct an empirical analysis of how consumers used the social (forum and poll) and self-reflective (diary and personal health record [PHR]) features of a Web-based PCHMS designed to support their physical and emotional well-being.

Methods

A single-group pre/post-test online prospective study was conducted to measure use of a Web-based PCHMS for physical and emotional well-being needs during a university academic semester. The PCHMS integrated an untethered PHR with social forums, polls, a diary, and online messaging links with a health service provider. Well-being journeys additionally provided information to encourage engagement with clinicians and health services. A total of 1985 students and staff aged 18 and above with access to the Internet were recruited online, of which 709 were eligible for analysis. Participants’ self-reported well-being, health status, health service utilization, and help-seeking behaviors were compared using chi-square, McNemar’s test, and Student’s t test. Social networks were constructed to examine the online forum communication patterns among consumers and clinicians.

Results

The two PCHMS features that were used most frequently and considered most useful and engaging were the social features (ie, the poll and forum). More than 30% (213/709) of participants who sought well-being assistance during the study indicated that other people had influenced their decision to seek help (54.4%, 386/709 sought assistance for physical well-being; 31.7%, 225/709 for emotional well-being). Although the prevalence of using a self-reflective feature (diary or PHR) was not as high (diary: 8.6%, 61/709; PHR: 15.0%, 106/709), the proportion of participants who visited a health care professional during the study was more than 20% greater in the group that did use a self-reflective feature (diary: P=.03; PHR: P<.001).

Conclusions

There was variation in the degree to which consumers used social and self-reflective PCHMS features but both were significantly associated with increased help-seeking behaviors and health service utilization. A PCHMS should combine both self-reflective as well as socially driven components to most effectively influence consumers’ help-seeking behaviors.     

Prolonged Elevated Heart Rate is a Risk Factor for Adverse Cardiac Events and Poor Outcome after Subarachnoid Hemorrhage

Introduction

Sympathetic nervous system hyperactivity is common after subarachnoid hemorrhage (SAH). We sought to determine whether uncontrolled prolonged heart rate elevation is a risk factor for adverse cardiopulmonary events and poor outcome after SAH.

Methods

We prospectively studied 447 SAH patients between March 2006 and April 2012. Prior studies define prolonged elevated heart rate (PEHR) as heart rate >95 beats/min for >12 h. Major adverse cardiopulmonary events were documented according to the predefined criteria. Global outcome at 3 months was assessed with the modified Rankin Scale (mRS).

Results

175 (39 %) patients experienced PEHR. Nonwhite race/ethnicity, admission Hunt–Hess grade ≥4, elevated APACHE-2 physiological subscore, and modified Fisher score were significant admission predictors of PEHR, whereas documented pre-hospital beta-blocker use was protective. After controlling for admission Hunt–Hess grade, Cox regression using time-lagged covariates revealed that PEHR onset in the previous 48 h was associated with an increased hazard for delayed cerebral ischemia, myocardial injury, and pulmonary edema. PEHR was associated with 3-month poor outcome (mRS 4–6) after controlling for known predictors.

Conclusions

PEHR is associated with major adverse cardiopulmonary events and poor outcome after SAH. Further study is warranted to determine if early sympatholytic therapy targeted at sustained heart rate control can improve outcome after SAH.     

Links Between Socio-Economic Circumstances and Changes in Smoking Behavior in the Mexican Population: 2002–2010

While deleterious consequences of smoking on health have been widely publicized, in many developing countries, smoking prevalence is high and increasing. Little is known about the dynamics underlying changes in smoking behavior. This paper examines socio-economic and demographic characteristics associated with smoking initiation and quitting in Mexico between 2002 and 2010. In addition to the influences of age, gender, education, household economic resources and location of residence, changes in marital status, living arrangements and health status are examined. Drawing data from the Mexican Family Life Survey, a rich population-based longitudinal study of individuals, smoking behavior of individuals in 2002 is compared with their behavior in 2010. Logistic models are used to examine socio-demographic and health factors that are associated with initiating and quitting smoking. There are three main findings. First, part of the relationship between education and smoking reflects the role of economic resources. Second, associations of smoking with education and economic resources differ for females and males. Third, there is considerable heterogeneity in the factors linked to smoking behavior in Mexico indicating that the smoking epidemic may be at different stages in different population subgroups. Mexico has recently implemented fiscal policies and public health campaigns aimed at reducing smoking prevalence and discouraging smoking initiation. These programs are likely to be more effective if they target particular socio-economic and demographic sub-groups.     

A retrospective analysis of revision endoscopic third ventriculostomy

Purpose  

Endoscopic third ventriculostomy (ETV) has gained favour as an effective treatment for obstructive hydrocephalus. However, the timing of ETV failure and the long-term efficacy of revision ETV remain poorly documented.     

Changes in biological markers of health: older Americans in the 1990s

BACKGROUND: Many studies that show improved health in older adults have relied on subjective measures of health. This article assesses changes in the physiological status of older Americans during the 1990s using biological measures of high-risk for morbidity and mortality. METHODS: Changes in the prevalence of clinically-defined, high risk for 10 biological markers were assessed in respondents age 65 years and older from National Health and Nutrition Examination Surveys (NHANES) III (1988-1994) and IV (1999-2000). RESULTS: Some changes in prevalence of high-risk values of biological markers indicate improved health among older adults in the 1990s: a 6% reduction in the prevalence of high-risk total cholesterol (p <.001) and a 7% reduction in the prevalence of high-risk homocysteine (p <.001). Other changes indicate worsening health: a 9% increase in the prevalence of high-risk systolic blood pressure (p <.01), a 10% increase in obesity (p <.001), and an 8% increase in the prevalence of high-risk C-reactive protein (p <.001). These changes remained significant after adjusting for age, sex, and education. Results of logistic regressions indicate that changes in the frequency of medication usage, medication efficacy, prevalence of chronic disease, and diet explained some of these changes. CONCLUSIONS: Changes in the prevalence of high-risk values of biological markers in the 1990s are mixed. Greater use and effectiveness of lipid-lowering medication has contributed to the reduction in percentage of the population with high-risk lipid levels, and folate supplementation accounted for a decline in the percentage with high-risk homocysteine. However, increases in the percentage with high-risk systolic blood pressure occurred despite an increase in the use of antihypertensive medications, in part because of the limited ability of antihypertensive medications to bring blood pressure below high-risk levels.     

Education and APOE-e4 in longitudinal cognitive decline: MacArthur Studies of Successful Aging

Longitudinal data from the MacArthur Study of Successful Aging were used to test for interactions between education and apolipoprotein E (APOE) genotype with respect to time trends in cognitive performance. Interactions between education, APOE-e4 status, and time were found for overall cognitive function, and for subscales measuring memory and naming: The presence of the e4 allele was associated with steeper declines in cognition for those with a greater than eighth-grade education. For those with an eighth-grade education or less, time trends did not differ by APOE genotype. A measure of cognitive impairment (i.e., scores of < or = 7 on the Short Portable Mental Status Questionnaire) yielded parallel though weaker evidence for a similar interaction with respect to risk of cognitive impairment. These findings suggest that the presence of at least one e4 allele appears to reduce the protective effects of education for those with at least a ninth-grade education or more, resulting in steeper cognitive declines with age.     

Isolation and characterization of rabbit single chain antibodies to human Reg Ialpha protein

To investigate the role of Reg Ialpha in human inflammatory bowel disease (IBD), we made two phage-displayed single chain variable fragment (scFv) libraries from rabbits immunized with recombinant or native human Reg Ialpha. After one to three rounds of panning, we were able to isolate phage-displaying scFvs, which bound to human Reg Ialpha. Anti-Reg Ialpha scFvs from both libraries showed similar immunoreactivity to different processed forms of the protein. Despite several DNA fingerprint patterns among these clones, their deduced amino acid sequences are highly homologous with 100% identity in the complementarity-determining regions (CDRs) of the variable segment of heavy chain (VH) region and a small variation in the CDR1 of the variable segment of light chain (VL) region. We also expressed and purified soluble myc-tagged or glutathione S-transferase (GST) fusion scFv proteins from bacteria. Immunohistochemical studies using one of our anti-Reg Ialpha scFv antibodies showed prominent staining in the metaplastic Paneth cell population and light staining in the lamina propria. This scFv antibody is now being used for studies of the role of Reg Ialpha in human IBD.