Assay interference as a cause of false positive troponin T elevation in emergency department patients.

BACKGROUND: Troponin assays are used in the diagnosis of myocardial injury and may show elevated results for a variety of reasons. However it is increasingly recognised that cardiac troponin elevation may in some cases be due to assay interference. This is of significant importance as a misdiagnosis of myocardial injury may lead to unnecessary and potentially harmful investigation and treatment for patients. We sought to confirm the accuracy of cardiac high sensitivity troponin T (chsTnT) elevation in an unselected group of patients presenting to the emergency department, by using a second confirmatory cardiac high sensitivity troponin I (chsTnI) assay. METHODS: We identified patients presenting to two local emergency departments over a five-day period who had chsTnT levels measured as part of routine clinical care. All samples with elevated chsTnT levels (above the 99% centile URL) were retested for chsTnI in order to confirm true myocardial injury. RESULTS: A total of 74 samples from 54 patients were analysed for chsTnT and chsTnI. 7 samples (9.5%) had chsTnI levels < 5 ng/L suggesting assay interference as the cause of chsTnT elevation. CONCLUSIONS: Assay interference leading to false positive troponin elevation may be more common than many physicians appreciate and can potentially lead to harmful investigation and treatment for patients. In cases where the diagnosis of myocardial injury is uncertain, a second alternative troponin assay should be performed to confirm true myocardial injury.

The Dental Amalgam Phasedown in New Zealand: A 20-year Trend.

BACKGROUND AND OBJECTIVES: Information on the choice of material and performance of restorations placed in a dental practice annually is limited. The Minamata Convention on Mercury is likely to affect the use of amalgam worldwide. The objective of this research was to investigate the use of restorative materials at the University of Otago Faculty of Dentistry in New Zealand from 1998 to 2017. METHODS: Data from the Faculty of Dentistry's database from the years of interest were compiled. These data included information on the characteristics of restorations, including information on the material used and number of surfaces involved for each restoration. The tooth in which each restoration was placed was categorized by arch, tooth type, and deciduous or permanent dentition. RESULTS: Records identified 227,514 permanent restorations placed from January 1998 to December 2017, of which 91.7% were direct restorations. Among direct restorations, composite resin was the most commonly used material, followed by amalgam, glass ionomer, and compomer. The use of amalgam for direct restorations decreased from 52.3% of direct restorations in 1998 to 7.1% in 2017. A corresponding increase was observed in the use of tooth-colored direct restorations, particularly composites. Among indirect restorations, porcelain fused to metal, gold, and stainless steel (in pediatric applications) were the materials most frequently used. CONCLUSIONS: Despite having no official policy on reducing the use of dental amalgam, the Faculty of Dentistry is following the global trend in reducing its use, with composite resin now well established as the predominant restorative material used. If the current rate of decline persists unchecked, the Faculty of Dentistry could transition to being amalgam free by 2020, although it seems likely that the characteristics and principles of use of the material (and its removal) will be taught for some time to come. This knowledge is important to planning curriculum changes needed to prepare graduates for clinical practice.

Statins: in the beginning.

Since the first human trial of a hydroxymethylglutaryl-coenzyme A (HMG CoA) reductase inhibitor in 1978, the growth in importance of this drug class, both financially and medically, has been staggering. The aim of this paper is to summarise how this drug class was developed, highlighting the role ofAkira Endo.

Depression symptom trends and health domains among lung cancer patients in the CanCORS study.

OBJECTIVES: Among lung cancer patients depression symptoms are common and impact outcomes. The aims of this study were to determine risk factors that contribute to persistent or new onset depression symptoms during lung cancer treatment, and examine interactions between depression symptoms and health domains that influence mortality. MATERIALS AND METHODS: Prospective observational study in five healthcare systems and 15 Veterans Affairs medical centers. Patients in the Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium with lung cancer were eligible. The 8-item Center for Epidemiologic Studies Depression (CES-D) scale was administered at baseline and follow-up. Scores ≥4 indicated elevated depressive symptoms. Health domains were measured using validated instruments. We applied logistic regression and Cox proportional hazards modeling to explore the association between depression symptoms, health domains, and mortality. RESULTS: Of 1790 participants, 38% had depression symptoms at baseline and among those still alive, 31% at follow-up. Risk factors for depression symptoms at follow-up included younger age (OR=2.81), female sex (OR=1.59), low income (OR=1.45), not being married (OR=1.74) and current smoking status (OR=1.80); high school education was associated with reduced odds of depression symptoms at follow-up, compared with lesser educational attainment (OR=0.74) (all p values <0.05). Patients with depression symptoms had worse health-related quality of life, vitality, cancer-specific symptoms, and social support than patients without depression symptoms (all p<0.001). The association between depression symptoms and increased mortality is greater among patients with more lung cancer symptoms (p=0.008) or less social support (p=0.04). CONCLUSIONS: Patient risk factors for depression symptoms at follow-up were identified and these subgroups should be targeted for enhanced surveillance. Patients with depression symptoms suffer across all health domains; however, only more lung cancer symptoms or less social support are associated with worse mortality among these patients. These potentially modifiable health domains suggest targets for possible intervention in future studies.

Pre-death grief in Parkinson's caregivers: a pilot survey-based study.

OBJECTIVE: To evaluate the evidence for pre-death grief in caregivers (CGs) of persons with Parkinson's disease (PD) and to compare non-motor PD symptoms (cognitive decline, depression, hallucinations) versus motor symptoms (fluctuations of mobility) for associations with CG grief reactions. BACKGROUND: Prolonged grief in response to loss has been associated with negative outcomes and decreased well-being in caregivers (i.e. spouse or adult child) of relatives with dementia. In Parkinson's disease (PD) the negative impact of providing care has been referred to as caregiver strain. Grief has not been explored in PD caregivers, and understanding grief may offer new insights for future intervention. METHODS: Volunteer caregivers (n = 74) filled out the Marwit and Meuser Caregiver Grief Inventory (MM-CGI-SF) which measures 3 types (i.e. subscales) of grief: Personal Sacrifice and Burden, Heartfelt Sadness and Longing, Worry and Felt Isolation. This scale also provided a total grief score. Volunteer caregivers also responded to self-reported UPDRS questions about the motor and non-motor symptoms of their PD relative (i.e. spouse or parent). T-tests were used to correlate CG subscales of grief with patient variables. A hierarchical regression analysis was used to determine the predictive contribution of motor and nonmotor symptoms to grief. RESULTS: Grief based on the total score was found in 17% of CGs. Grief was significantly higher in CG's whose relative had more severe symptoms. The type of grief experienced was similar across all three subscales. Hierarchical regression analysis revealed that nonmotor symptoms explained slightly more of the variance (14-23%) than motor symptoms (11-17%). CONCLUSIONS: This study revealed that pre-death grief is a significant finding in PD caregivers. The severity of symptoms and the presence of nonmotor symptoms, especially cognitive decline, predict caregivers who are at greatest risk of prolonged grief; however it should be kept in mind that motor symptoms also contribute.

Clinical trial to compare tinnitus masking and tinnitus retraining therapy.

CONCLUSION: Both tinnitus masking (TM) and tinnitus retraining therapy (TRT) can be effective therapies for amelioration of tinnitus. TM may be more effective for patients in the short term, but with continued treatment TRT may produce the greatest effects. OBJECTIVES: Although TM and TRT have been used for many years, research has not documented definitively the efficacy of these methods. The present study was a controlled clinical trial to prospectively evaluate the clinical efficacy of these two methods for US military veterans with severe tinnitus. SUBJECTS AND METHODS: Over 800 veterans were screened to ensure that enrolled patients had tinnitus of sufficient severity to justify 18 months of individualized treatment. Qualifying patients (n=123) were placed quasi-randomly (alternating placement) into treatment with either TM or TRT. Treatment was administered at 0, 3, 6, 12, and 18 months. Outcomes of treatment were evaluated primarily using three self-administered tinnitus questionnaires (Tinnitus Handicap Inventory, Tinnitus Handicap Questionnaire, Tinnitus Severity Index). RESULTS: Findings are presented from the three written questionnaires with respect to three categories of patients: describing tinnitus as a 'moderate,' 'big,' and 'very big' problem at baseline. Based on effect sizes, both groups showed considerable improvement overall. In general, TM effects remained fairly constant over time while TRT effects improved incrementally. For the patients with a 'moderate' and 'big' problem, TM provided the greatest benefit at 3 and 6 months; benefit to these TRT patients was slightly greater at 12 months, and much greater at 18 months. For patients with a 'very big' problem, TM provided the greatest benefit at 3 months. For these latter patients, results were about the same between groups at 6 months, and improvement for TRT was much greater at 12 months, with further gains at 18 months.

Using multilevel modeling in caregiving research.

Recently, caregiving research has moved towards a greater emphasis on the interactive and dynamic processes of the care situation. As a result, many of the questions are multilevel in nature, involving more than one unit of analysis and placing greater focus on the context of the care dyad. Nevertheless, most caregiving studies use methods that fail to address the hierarchical nature of the care dyad and consequently fail to illuminate variation both within and between dyad processes. The focus of this paper is to promote a dyad approach to the analysis of caregiving data and to highlight the advantages and appropriateness of multilevel modeling when dealing with clustered or hierarchical data. In particular, we discuss how multilevel modeling can be adapted to study change in the care dyad over time, improve the way we evaluate interventions, and enhance our understanding of dyad congruence.

Formal and informal support: the great divide.

As we approach the next century, it is clear that neither formal services nor informal family caregivers can meet the needs of a growing population. It is therefore pertinent to reconceptualize the linkages between formal and informal care and move towards an integrative model. This paper explores several models of such an interface that exist in the literature and proposes that many of these overlap. Various predictors of formal service use are also explored, with an emphasis on the outcomes of both the informal caregiver and the care recipient. Implications for future research include further exploring and understanding the link between formal and informal support and the need to increase receipt of formal care among family caregivers.