Legionnaires' Disease Outbreaks and Cooling Towers, New York City, New York, USA.

The incidence of Legionnaires' disease in the United States has been increasing since 2000. Outbreaks and clusters are associated with decorative, recreational, domestic, and industrial water systems, with the largest outbreaks being caused by cooling towers. Since 2006, 6 community-associated Legionnaires' disease outbreaks have occurred in New York City, resulting in 213 cases and 18 deaths. Three outbreaks occurred in 2015, including the largest on record (138 cases). Three outbreaks were linked to cooling towers by molecular comparison of human and environmental Legionella isolates, and the sources for the other 3 outbreaks were undetermined. The evolution of investigation methods and lessons learned from these outbreaks prompted enactment of a new comprehensive law governing the operation and maintenance of New York City cooling towers. Ongoing surveillance and program evaluation will determine if enforcement of the new cooling tower law reduces Legionnaires' disease incidence in New York City.

A detailed radiobiological and dosimetric analysis of biochemical outcomes in a case-control study of permanent prostate brachytherapy patients.

The purpose of this study is to determine dosimetric and radiobiological predictors of biochemical control after recalculation of prostate implant dosimetry using updated AAPM Task Group 43 (TG-43) parameters and the radiobiological parameters recommended by TG-137. All biochemical failures among patients implanted with 125I Or 103Pd sources between 1994 and March 2006 were matched 2:1 with nonfailure controls. The individual matching was by risk group, radionuclide, prescribed dose, and time of implant (one match before and one after the failed patient) resulting in a median follow-up of 10.9 years. Complete dose volume histogram (DVH) data were recalculated for all 55 cases and 110 controls after updating the original source strength by the retrospectively determined ratios of TG-43. Differential DVH data were acquired in 179 increments of prostate volume versus percentage prescribed dose. At each incremental dose level i, the biologically equivalent dose BEDi, equivalent uniform dose EUDi, and tumor control probability TCPi were calculated from the implant dose plus any external beam delivered to the patient. Total BED, EUD, and TCP were then derived from the incremental values for comparison with single point dosimetric quality parameters and DVH-based averages. There was no significant difference between failures and controls in terms of total BED (143 vs 142 Gy), EUD (95 vs 94 Gy), or TCP (0.87 vs 0.89). Conditional logistic regression analysis factored out the matching variables and stratified the cohort into each case and its controls, but no radiobiological parameter was predictive of biochemical failure. However, there was a significant difference between radiobiological parameters of 125I and 103Pd due to less complete coverage of the target volume by the former isotope. The implant BED and TCP were highly correlated with the D90 and natural prescription doses and a series of mean DVH-based doses such as the harmonic mean and expressions of the generalized EUD. In this case-control study of prostate brachytherapy biochemical failures and nonfailures, there were no radiobiological parameters derived from detailed DVH-based analysis that predicted for biochemical control. This may indicate that in our approach, implant dosimetry is at or near the limits of clinically effective dose escalation.

Multiple Sclerosis at Home Access (MAHA): An Initiative to Improve Care in the Community.

BACKGROUND: Caring for individuals with progressive, disabling forms of multiple sclerosis (MS) presents ongoing, complex challenges in health care delivery, especially access to care. Although mobility limitations represent a major hurdle to accessing comprehensive and coordinated care, fragmentation in current models of health care delivery magnify the problem. Importantly, individuals with disabling forms of MS are exceedingly likely to develop preventable secondary complications and to incur significant suffering and increased health care utilization and costs. METHODS: A house call program, Multiple Sclerosis at Home Access (MAHA), was implemented. The program was designed to provide comprehensive services and prevent common complications. Key aspects included monthly house calls, continuity among providers, and a multidisciplinary team led by a comprehensivist, a provider bridging subspecialty and primary care. A total of 21 adult patients (Expanded Disability Status Scale score ≥7.5) completed 1 full year of the program. RESULTS: During the 2-year preevaluation and postevaluation period, half of the hospital admissions were related to secondary and generally preventable complications. Aside from a single outlying individual important to the evaluation, in the year after program implementation, decreases were found in number of individuals hospitalized, hospitalizations/skilled facility admissions, and hospital days; the total number of overall emergency department (ED) visits decreased; and ED-only visits increased (ie, ED visits without hospital admission). Patient satisfaction reports and quality indicators were positive. Fifty percent of patients participated in supplementary televisits. CONCLUSIONS: This program evaluation suggests that a house call-based practice is a viable solution for improving care delivery for patients with advanced MS and disability.

An Analysis of Recruitment Efficiency for an End-of-Life Advance Care Planning Randomized Controlled Trial.

BACKGROUND:: Optimizing recruitment efficiency is an important strategy to address the resource limitations that typically constrain clinical research. Surprisingly, little empiric data exist to guide research teams attempting to recruit a difficult population into similar studies. Our objective was to investigate factors associated with enrollment into an advance care planning interventional trial. METHODS:: This study used secondary data of patients with advanced cancer receiving treatment at an academic medical center in central Pennsylvania who were referred to a randomized controlled trial of an advance care planning intervention. Enrolled participants were compared to nonparticipants with regard to age, gender, race, season of recruitment, elapsed time between recruitment stage, distance to study site, and number of recruitment calls. RESULTS:: Of the 1988 patients referred, 200 participants were enrolled yielding a recruitment efficiency of 10%. Two-thirds of all enrolled participants were recruited with 1 or less phone calls, whereas only 5% were enrolled after 3 calls. There were no statistically significant differences in enrollment based on gender ( P = .88) or elapsed time between recruitment contacts ( P = .22). However, nonparticipants were slightly older ( P = .02). CONCLUSIONS:: Our finding that individuals were more likely to enroll within the first 3 phone calls suggests that recruitment efforts should be focused on making initial contacts with potential participants, rather than continuing attempts to those who are unable to be contacted easily. Researchers could optimize their recruitment strategy by periodically performing similar analyses, comparing differences between participants and nonparticipants.

Family Caregivers' Characterization of Conversations Following an ACP Event.

BACKGROUND: Advance care planning (ACP) has been shown to benefit patients and families, yet little is known about how an ACP event impacts communication and conversation about end-of-life treatment wishes and the content of such conversations between patients and family caregivers. OBJECTIVE: To characterize post-ACP conversations regarding medical wishes between seriously ill patients and their family caregivers. PARTICIPANTS: Patients with advanced illness and family caregivers. OUTCOME MEASURED: Post-ACP conversations. DESIGN: As part of a larger randomized controlled trial, dyads consisting of seriously ill patients and their identified family caregiver engaged in ACP and created an advance directive for the patient. Approximately 4 to 6 weeks later, semistructured interviews were conducted with the family caregivers to elucidate the subsequent communications regarding medical wishes. If the dyad did not have any conversations post-ACP, reasons and barriers were explored. RESULTS: The majority of dyads (131/188, 69.7%) had 2 to 3 conversations lasting 3 to 5 minutes each in the weeks immediately following ACP. These conversations most commonly addressed general patient wishes about quality of life and specific medical treatments. The most common reasons for not having conversations were a general discomfort with the topic (13/57, 22.8%) and previously having discussed medical wishes (16/57, 28.1%). CONCLUSION: The ACP events promote conversation regarding quality of life, general wishes at the end of life, and specific medical wishes. Barriers to conversation following ACP were similar to barriers to ACP in general, suggesting that a more intentional focus on addressing these barriers pre- and post-ACP may be necessary to improve communication.

A Randomized Controlled Trial of Strategies to Improve Family Members' Preparedness for Surrogate Decision-Making.

OBJECTIVE: To evaluate 2 strategies for preparing family members for surrogate decision-making. DESIGN: A 2 × 2 factorial, randomized controlled trial testing whether: (1) comprehensive online advance care planning (ACP) is superior to basic ACP, and (2) having patients engage in ACP together with family members is superior to ACP done by patients alone. SETTING: Tertiary care centers in Hershey, Pennsylvania, and Boston, Massachusetts. PARTICIPANTS: Dyads of patients with advanced, severe illness (mean age 64; 46% female; 72% white) and family members who would be their surrogate decision-makers (mean age 56; 75% female; 75% white). INTERVENTIONS: Basic ACP: state-approved online advance directive plus brochure. Making Your Wishes Known (MYWK): Comprehensive ACP decision aid including education and values clarification. MEASUREMENTS: Pre-post changes in family member self-efficacy (100-point scale) and postintervention concordance between patients and family members using clinical vignettes. RESULTS: A total 285 dyads enrolled; 267 patients and 267 family members completed measures. Baseline self-efficacy in both MYWK and basic ACP groups was high (90.2 and 90.1, respectively), and increased postintervention to 92.1 for MYWK ( P = .13) and 93.3 for basic ACP ( P = .004), with no between-group difference. Baseline self-efficacy in alone and together groups was also high (90.2 and 90.1, respectively), and increased to 92.6 for alone ( P = .03) and 92.8 for together ( P = .03), with no between-group difference. Overall adjusted concordance was higher in MYWK compared to basic ACP (85.2% vs 79.7%; P = .032), with no between-group difference. CONCLUSION: The disconnect between confidence and performance raises questions about how to prepare family members to be surrogate decision-makers.

Pattern Recognition of the Multiple Sclerosis Syndrome.

During recent decades, the autoimmune disease neuromyelitis optica spectrum disorder (NMOSD), once broadly classified under the umbrella of multiple sclerosis (MS), has been extended to include autoimmune inflammatory conditions of the central nervous system (CNS), which are now diagnosable with serum serological tests. These antibody-mediated inflammatory diseases of the CNS share a clinical presentation to MS. A number of practical learning points emerge in this review, which is geared toward the pattern recognition of optic neuritis, transverse myelitis, brainstem/cerebellar and hemispheric tumefactive demyelinating lesion (TDL)-associated MS, aquaporin-4-antibody and myelin oligodendrocyte glycoprotein (MOG)-antibody NMOSD, overlap syndrome, and some yet-to-be-defined/classified demyelinating disease, all unspecifically labeled under MSsyndrome. The goal of this review is to increase clinicians' awareness of the clinical nuances of the autoimmune conditions for MS and NMSOD, and to highlight highly suggestive patterns of clinical, paraclinical or imaging presentations in order to improve differentiation. With overlay in clinical manifestations between MS and NMOSD, magnetic resonance imaging (MRI) of the brain, orbits and spinal cord, serology, and most importantly, high index of suspicion based on pattern recognition, will help lead to the final diagnosis.

Medical and physician assistant students' views on integrating comics into medical education.

This article was migrated. The article was marked as recommended. Purpose: This study explored comics as a tool for teaching medical and physician assistant (PA) students about end-of-life decisions and advance care planning. Methods: Using a mixed method convergent design, a survey (consisting of a five-point Likert scale and open-ended questions) was administered to second-year medical and first-year PA students enrolled in an Ethics and Professionalism class at a US medical school. The survey assessed students' perspectives on the addition of a comic "Betty P." to assigned readings and about the use of comics in the classroom. Quantitative results were compared by demographics, and open-ended responses were analyzed qualitatively for emergent themes. Quantitative and qualitative findings were compared for correspondence. Results: Of the 145 students who completed the survey (83%), 141 students (81%) had read the comic. The vast majority (89%) felt that "Betty P." helped them understand end of life care for patients, and 84% felt that the comic did not distract them from the seriousness of the subject. Qualitative analysis revealed 2 major themes: 1) comics were educational, and 2) comics engaged learners emotionally. We observed convergence between quantitative and qualitative results. Conclusion: Integrating comics as a supplemental teaching tool is an innovative way to engage medical students.

Advance care planning for patients with amyotrophic lateral sclerosis.

PURPOSE: To determine whether an advance care planning (ACP) decision-aid could improve communication about end-of-life treatment wishes between patients with amyotrophic lateral sclerosis (ALS) and their clinicians. METHODS: Forty-four patients with ALS (>21, English-speaking, without dementia) engaged in ACP using an interactive computer based decision-aid. Before participants completed the intervention, and again three months later, their clinicians reviewed three clinical vignettes, and made treatment decisions (n = 18) for patients. After patients indicated their agreement with the team's decisions, concordance was calculated. RESULTS: The mean concordance between patient wishes and the clinical team decisions was significantly higher post-intervention (post = 91.9%, 95% CI = 87.8, 96.1, vs. pre = 52.4%, 95% CI = 41.9, 62.9; p <0.001). Clinical team members reported greater confidence that their decisions accurately represented each patient's wishes post-intervention (mean = 6.5) compared to pre-intervention (mean = 3.3, 1 = low, 10 = high, p <0.001). Patients reported high satisfaction (mean = 26.4, SD = 3.2; 6 = low, 30 = high) and low decisional conflict (mean = 28.8, SD = 8.2; 20 = low, 80 = high) with decisions about end-of-life care, and high satisfaction with the decision-aid (mean = 52.7, SD = 5.7, 20 = low, 60 = high). Patient knowledge regarding ACP increased post-intervention (pre = 47.8% correct responses vs. post = 66.3%; p <0.001) without adversely affecting patient anxiety or self-determination. CONCLUSION: A computer based ACP decision-aid can significantly improve clinicians' understanding of ALS patients' wishes with regard to end-of-life medical care.

High satisfaction and low decisional conflict with advance care planning among chronically ill patients with advanced chronic obstructive pulmonary disease or heart failure using an online decision aid: A pilot study.

OBJECTIVE: Many patients with chronic illnesses report a desire for increased involvement in medical decision-making. This pilot study aimed to explore how patients with exacerbation-prone disease trajectories such as advanced heart failure or chronic obstructive pulmonary disease experience advance care planning using an online decision aid and to compare whether patients with different types of exacerbation-prone illnesses had varied experiences using the tool. METHODS: Pre-intervention questionnaires measured advance care planning knowledge. Post-intervention questionnaires measured: (1) advance care planning knowledge; (2) satisfaction with tool; (3) decisional conflict; and (4) accuracy of the resultant advance directive. Comparisons were made between patients with heart failure and chronic obstructive pulmonary disease. RESULTS: Over 90% of the patients with heart failure (n = 24) or chronic obstructive pulmonary disease (n = 25) reported being "satisfied" or "highly satisfied" with the tool across all satisfaction domains; over 90% of participants rated the resultant advance directive as "very accurate." Participants reported low decisional conflict. Advance care planning knowledge scores rose by 18% (p < 0.001) post-intervention. There were no significant differences between participants with heart failure and chronic obstructive pulmonary disease. DISCUSSION: Patients with advanced heart failure and chronic obstructive pulmonary disease were highly satisfied after using an online advance care planning decision aid and had increased knowledge of advance care planning. This tool can be a useful resource for time-constrained clinicians whose patients wish to engage in advance care planning.

Elevated expression of IFN-gamma in the HIV-1 infected brain.

We determined the extent of expression of three cytokines (IFN-gamma, IL-4, and TNF-alpha ) in brain tissue infected with human immunodeficiency virus-1 (HIV-1). The selections were IFN-gamma as a Th1 cytokine, IL- 4 as a Th2 cytokine, and TNF-alpha as a pro-inflammatory cytokine (and because of its prior implication in brain tissue damage due to HIV-1 infection). Based on current models for pathogenesis of HIV-1-associated dementia (HAD), in the periphery, Th1 cytokines are considered to be salutary, whereas Th2 cytokines are regarded as deleterious. However, we hypothesized that in the CNS these roles are reversed. Post-mortem temporal lobe tissue specimens from 16 HIV-1-seropositive patients and 11 HIV-1-seronegative controls were stained for IFN-gamma, IL-4, and TNF-alpha utilizing immunohistochemistry and alkaline phosphatase. HIV-1 infection causes alterations of brain cytokine expression that include increased IFN-gamma expression for HIV-1-seropositive vs. HIV-1-seronegative individuals. There was increased expression of IFN-gamma for HIV-1-seropositive individuals with or without HAD, with or without the broader category of neuropsychiatric impairment (NPI), and with or without opportunistic infections (OIs) compared to HIV-1-seronegatives. A significant inverse correlation between IFN-gamma vs. IL-4 in HIV-1-seropositives with HAD and in seronegative individuals was observed. There was an inverse correlation in seropositives between IFN-gamma vs. TNF-alpha, a positive trend with HAD, significant without HAD, significant with NPI and significant without OIs. Between IL-4 vs. TNF-alpha there was a correlation (trend) in seropositives, a trend with NPI, significant without NPI, and a trend without OI. Due to HIV-1 infection of the brain and neurological disease there is a prominent increased expression of IFN-gamma, an inverse expression of IFN-gamma vs. TNF-alpha, and TNF-alpha vs. IL-4. The inverse correlation between increased IFN-gamma and decreased IL-4 expression is consistent with the stimulation of activated macrophages, and T cells, greater toxicity in the HIV-1-infected brain, and is supportive of the significance of IFN-gamma in HIV-1-infected patients.

Evaluation of radiobiologic biochemical control in a large permanent prostate brachytherapy population from a single institution using AAPM TG-137 parameters.

PURPOSE: To re-evaluate prostate implant dosimetry using American Association of Physicists in Medicine Task Group 43 parameters and the radiobiologic approach of American Association of Physicists in Medicine Task Group 137. METHODS AND MATERIALS: Among 1473 consecutive patients implanted with iodine-125 or palladium-103 sources before March 2006, there have been 55 biochemical failures. The dosimetric quality parameter, D(90), was updated according to the radionuclide and dosimetric era of the implant. For each patient, biologically equivalent dose (BED) and tumor control probability (TCP) were calculated from the updated implant D(90) plus any external beam dose using recommended indices and equations. RESULTS: There was no significant difference in BED between biochemical failures and nonfailures, 148±27Gy and 145±24Gy, respectively (p=0.352). TCP was 0.90±0.26 for biochemical failures and 0.93±0.21 for nonfailures (p=0.414). Cox regression analysis found that neither BED nor TCP predicted for biochemical control either for the entire population or within each radionuclide-dependent dosimetric era. The only overall predictors of biochemical control were dosimetric era, Gleason score, and percent positive biopsies. Improvements in dosimetric quality over the first 300 patients were evident, but dosimetric era remained a better predictor of biochemical outcome than implant sequence number. CONCLUSION: In a large prostate implant population, dosimetric and derived radiobiologic parameters did not predict for failure. Apparently, too few patients had total BEDs below the level necessary for optimum biochemical control. A learning curve extended over hundreds of patients before plateauing but changes in seed characterization parameters also had a pronounced effect.

Obesity does not correlate with adverse pathologic findings on transperineal template-guided mapping biopsy of the prostate.

BACKGROUND: Obesity has correlated with adverse pathologic features on prostate biopsy and may predispose to a higher rate of prostate cancer-related death after radical prostatectomy. In this study, we examine the potential relationship between body mass index (BMI) and histopathologic findings on transperineal template-guided mapping biopsy of the prostate (TTMB). METHODS: From January 2005 to January 2008, 244 consecutive patients underwent TTMB using an anatomic-based technique. The criteria for TTMB included previously negative transrectal ultrasound (TRUS) biopsy with persistently elevated PSA and/or diagnosis of ASAP, or HG-PIN. The study population was divided into 4 different BMI cohorts (BMI < 25, BMI 25-29.9, BMI 30-34.9, and BMI ≥ 35 kg/m(2)). Biopsy findings were compared between the various BMI cohorts using one-way analysis of variance (ANOVA) and the χ(2) test. RESULTS: Pre-TTMB clinical parameters, including PSA and prostate volume, were not significantly different between the various BMI cohorts. On average, the study population had undergone 1.7 TRUS biopsies before TTMB. Of the 244 study patients, 112 (45.9%), were diagnosed with prostate adenocarcinoma on TTMB. There was no difference in the rate of cancer detection between the different BMI cohorts. Among patients diagnosed with prostate cancer, BMI did not correlate with Gleason score or percent of positive biopsy cores. When the geography of biopsy-positive cores was analyzed, there were no statistically significant differences in cancer location among the different BMI groups. CONCLUSIONS: In this study, obesity did not predispose toward higher Gleason score, larger cancer volume, or geographic cancer distribution on repeat biopsy with TTMB.

Brain macrophage surface marker expression with HIV-1 infection and drug abuse: a preliminary study.

GOAL: To determine the heterogeneity of surface marker expression of macrophages in the temporal lobe of patients who died with AIDS who were also Drug Abusers (DAs). We studied the expression of macrophage surface markers CD11c, CD14, CD68, and HLA-DR and T cell surface markers CD4, and CD8. BACKGROUND: The macrophage is the prime locus for HIV-1-associated pathology, is the most frequently infected cell in the brain, and has the highest virus load compared to other cells. We previously described the heterogeneity of macrophage surface marker expression and performed morphometric analysis in peripheral nerves of patients who died from AIDS compared to HIV-1 negative individuals. We showed that the HIV-related neuropathy in AIDS is a multifocal process. It is similarly important to determine the expression of macrophage surface markers in brain. Temporal lobe tissue was selected for this preliminary study because we previously found elevated HIV-1 proviral DNA load and inflammatory processes in this neuroanatomic location for subjects who died with AIDS. There is a high prevalence of Drug Abuse in Miami, Florida, associated with AIDS that may interactively affect HIV-associated pathology. METHODS: Temporal lobe tissue was examined from 17 HIV-1-seropositive patients (4 with Drug Abuse and 13 without Drug Abuse) and 11 HIV-seronegative individuals (5 with Drug Abuse and 6 without Drug Abuse). Standard immunohistochemistry utilized alkaline phosphatase conjugate secondary antibody and fuchsin substrate. RESULTS: We found that HIV-1 infection and the interaction of HIV-1 infection and Drug Abuse produced changes in macrophage surface marker expression. Macrophage surface markers, CD11c, CD14, CD68, and HLA-DR, and T-cell marker CD4 were increased with statistical significance due to HIV-1 infection (all p < .001) whereas CD8 remained unchanged. Changes due to Drug Abuse alone were not significant. Interaction of Drug Abuse and HIV-infected individuals showed increased expression of CD68 (p = .011), HLA-DR (p = .001), CD4 (p = .027), and CD8 (p = .016). CONCLUSION: Drug Abuse and HIV-1 infection are factors that differentially and interactively result in multiple macrophages surface marker effects. In HIV-1 infected individuals, Drug Abuse stimulates surface marker expression. Since brain macrophage surface makers do not change uniformly as a result of Drug Abuse and HIV infection, these cells may be heterogeneous and contain sub-types (sub-sets). It remains to be determined which macrophage sub-types may be most pathognomic for pathology.