Advanced Cancer Patients' Prognostic Awareness and Its Association With Anxiety, Depression and Spiritual Well-Being: A Multi-Country Study in Asia.

AIMS: The associations between prognostic awareness, acceptance of illness and psychological outcomes (anxiety, depression and spiritual well-being) remain unclear. This study examined the associations between prognostic awareness and various psychological outcomes and how they can be moderated by patient acceptance of illness (cancer). MATERIALS AND METHODS: In total, 1184 patients with stage IV solid cancer were recruited at major public hospitals across four Asian countries (China, India, Sri Lanka, Vietnam). Prognostic awareness and acceptance of illness were assessed through self-reported understanding of treatment intent and acceptance of illness, respectively. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale, whereas spiritual well-being was measured using the Functional Assessment of Chronic Illness Therapy - Spiritual Well-Being Scale. Multivariate regressions were used to estimate the associations while controlling for patient characteristics. RESULTS: Compared with being unaware of their prognosis (i.e. believing that their cancer is curable), being aware or unsure of their prognosis was associated with higher anxiety and depressive symptoms, and lower spiritual well-being scores. Acceptance of illness moderated these relationships and improved the psychological outcomes. CONCLUSIONS: The results suggest that disclosure of prognostic information should be provided in conjunction with psychological interventions that focus on acceptance of illness.

Strategies to improve survival outcomes of out-of-hospital cardiac arrest (OHCA) given a fixed budget: A simulation study.

BACKGROUND: Our study aimed to identify a strategy that maximizes survival upon hospital discharge or 30-days post out-of-hospital cardiac arrest (OHCA) in Singapore for fixed investments of S$1, S$5, or S$10 million. Four strategies were compared: (1) no additional investment; (2) reducing response time via leasing of more ambulances; (3) increasing number of people trained in cardiopulmonary resuscitation (CPR); and (4) automated external defibrillators (AED). METHODS: We estimated the effect of ambulance response time, bystander CPR and AED on survival based on Singapore's 2010-2015 OHCA registry data. We simulated the changes in ambulance response times and likelihood of (1) CPR and (2) AED usage as a function of their increased availability, which was then combined with the effect of each factor to determine the increase in survival for each strategy. RESULTS: Survival given no additional investment was 4.03% (95% CI: 3.96%, 4.10%). The investments in ambulances, CPR training and AEDs for a given budget of S$1M changed survival to 4.03% (95% CI: 3.96%, 4.10%), 4.04% (95% CI: 3.98%, 4.11%), and 4.44% (95% CI: 4.35%, 4.54%), respectively. This generated 0, 2 and 102 additional life years saved respectively. Given a budget of S$5M or S$10M, 509 or 886 additional life years could be saved, by investing in an additional 10,000 or 20,000 AEDs respectively. The strategies reached a saturation effect whereby improvement in survival was marginal when the budget was increased to ≥S$5M for investment in ambulances and CPR training. CONCLUSIONS: Investing in AEDs had the most gain in survival.

Incidence and lifetime costs of injuries in the United States.

BACKGROUND: Standardized methodologies for assessing economic burden of injury at the national or international level do not exist. OBJECTIVE: To measure national incidence, medical costs, and productivity losses of medically treated injuries using the most recent data available in the United States, as a case study for similarly developed countries undertaking economic burden analyses. METHOD: The authors combined several data sets to estimate the incidence of fatal and non-fatal injuries in 2000. They computed unit medical and productivity costs and multiplied these costs by corresponding incidence estimates to yield total lifetime costs of injuries occurring in 2000. MAIN OUTCOME MEASURES: Incidence, medical costs, productivity losses, and total costs for injuries stratified by age group, sex, and mechanism. RESULTS: More than 50 million Americans experienced a medically treated injury in 2000, resulting in lifetime costs of $406 billion; $80 billion for medical treatment and $326 billion for lost productivity. Males had a 20% higher rate of injury than females. Injuries resulting from falls or being struck by/against an object accounted for more than 44% of injuries. The rate of medically treated injuries declined by 15% from 1985 to 2000 in the US. For those aged 0-44, the incidence rate of injuries declined by more than 20%; while persons aged 75 and older experienced a 20% increase. CONCLUSIONS: These national burden estimates provide unequivocal evidence of the large health and financial burden of injuries. This study can serve as a template for other countries or be used in intercountry comparisons.

'Obesity paradox' misunderstands the biology of optimal weight throughout the life cycle.

The 'obesity paradox' refers to observations that run counter to the thesis that normal weight (BMI 18.5-24.9 g/m(2)) provides the lowest mortality and higher weight is associated with greater mortality. We argue that the weight of lowest mortality is influenced by aging and chronic disease, with mortality advantage extending into the overweight and even class I obese ranges under some circumstances. A focus on quality nutrition, physical activity, fitness, and maintaining function in these weight ranges may be preferable to a focus on intentional weight loss, which has uncertain effects. The 'obesity paradox' is no 'paradox' if one defines and interprets 'ideal' weight appropriately.

Comparison of measurements of time outdoors and light levels as risk factors for myopia in young Singapore children.

AIMS: To compare methods to measure time outdoor and light levels, two possible predictors of myopia, in Singapore children. METHODS: Outdoor time from a diary and portable light meter over a 1-week period was compared in 117 Singapore children aged 6-12 years with and without myopia. All children wore a (HOBO Pendant temp/light Part # UA-002-64) light meter for 1 week and the parents filled the 7-day outdoor diary to track the outdoor activity. RESULTS: Mean outdoor time from diary and time with light levels was 5.44 hours per week and 7.91 hours per week, respectively, during school term and school holidays. Time spent with light levels of >1000 Lux from the light meter were 7.08 h per week and 9.81 h per week, respectively, during school term and school holidays. The intraclass correlation coefficients were 0.21 and 0.28 for outdoor time from the diary and light meter (1000 Lux cut-off) during the school term and holidays, respectively. The correlation coefficient was 0.34 (95% CI 0.05, 0.58) for a weekday during school holidays, 0.17 (-0.14, 0.45) for a weekday during school term, 0.07 (-0.16, 0.29) for a weekday during school term, and 0.25 (0.02, 0.46) for a weekend during school term. CONCLUSIONS: The agreement between the light meter and 1-week diary was poor to fair. Both instruments measure different parameters, time outdoors and light intensity, and could therefore capture different aspects of risk in future myopia studies.

Impact of laparoscopic adjustable gastric banding on type 2 diabetes.

Bariatric surgery is becoming an accepted option for obese people with type 2 diabetes. Our aim was to assess the impact of laparoscopic adjustable gastric banding (LAGB) through a systematic review of the literature. Data was sourced from Scopus, MEDLINE and EMBASE published from 2000 through May 2011, and five unpublished studies that were performed by industry for regulatory approval were also included. Studies were selected on the basis that they provide some detail of diabetes status before and after LAGB. There were 35 studies meeting the inclusion criteria. There was considerable heterogeneity in study design, sample size, length of follow-up, attrition rates and classification of diabetes status. Weight loss was progressive over the first 2 years with a weighted average of 47% excess weight loss at 2 years. Remission or improvement in diabetes varied from 53% to 70% over different time periods. Results were broadly consistent, demonstrating clinically relevant improvements in diabetes outcomes with sustained weight loss in obese people with type 2 diabetes following LAGB surgery. However, there were significant shortcomings in the reviewed literature with few high-quality studies, inconsistent reporting of diabetes outcomes and high attrition rates. Long-term studies that address these limitations are needed.

Indirect costs of obesity: a review of the current literature.

This study reviews the recent literature on the relationship between obesity and indirect (non-medical) costs. Medline and Web of Science searches were conducted to identify published studies from 1992 to present that report indirect costs by obesity status; 31 studies were included. The indirect costs were grouped into six categories: costs associated with absenteeism, disability, premature mortality, presenteeism, workers' compensation, and total indirect costs. Compared with non-obese workers, obese workers miss more workdays due to illness, injury, or disability. Costs of premature mortality vary substantially across countries. The results for presenteeism and workers' compensation were mixed. More research is needed to determine obesity's causal role in increasing indirect costs, especially for workers' compensation and presenteeism. Cohort and longitudinal study designs should be a priority.

The costs of fatal and non-fatal falls among older adults.

OBJECTIVE: To estimate the incidence and direct medical costs for fatal and non-fatal fall injuries among US adults aged >or=65 years in 2000, for three treatment settings stratified by age, sex, body region, and type of injury. METHODS: Incidence data came from the 2000 National Vital Statistics System, 2001 National Electronic Injury Surveillance System-All Injury Program, 2000 Health Care Utilization Program National Inpatient Sample, and 1999 Medical Expenditure Panel Survey. Costs for fatal falls came from Incidence and economic burden of injuries in the United States; costs for non-fatal falls were based on claims from the 1998 and 1999 Medicare fee-for-service 5% Standard Analytical Files. A case crossover approach was used to compare the monthly costs before and after the fall. RESULTS: In 2000, there were almost 10 300 fatal and 2.6 million medically treated non-fatal fall related injuries. Direct medical costs totaled 0.2 billion dollars for fatal and 19 billion dollars for non-fatal injuries. Of the non-fatal injury costs, 63% (12 billion dollars ) were for hospitalizations, 21% (4 billion dollars) were for emergency department visits, and 16% (3 billion dollars) were for treatment in outpatient settings. Medical expenditures for women, who comprised 58% of the older adult population, were 2-3 times higher than for men for all medical treatment settings. Fractures accounted for just 35% of non-fatal injuries but 61% of costs. CONCLUSIONS: Fall related injuries among older adults, especially among older women, are associated with substantial economic costs. Implementing effective intervention strategies could appreciably decrease the incidence and healthcare costs of these injuries.

Incidence and lifetime costs of injuries in the United States.

BACKGROUND: Standardized methodologies for assessing economic burden of injury at the national or international level do not exist. OBJECTIVE: To measure national incidence, medical costs, and productivity losses of medically treated injuries using the most recent data available in the United States, as a case study for similarly developed countries undertaking economic burden analyses. METHOD: The authors combined several data sets to estimate the incidence of fatal and non-fatal injuries in 2000. They computed unit medical and productivity costs and multiplied these costs by corresponding incidence estimates to yield total lifetime costs of injuries occurring in 2000. MAIN OUTCOME MEASURES: Incidence, medical costs, productivity losses, and total costs for injuries stratified by age group, sex, and mechanism. RESULTS: More than 50 million Americans experienced a medically treated injury in 2000, resulting in lifetime costs of 406 billion dollars; 80 billion dollars for medical treatment and 326 billion dollars for lost productivity. Males had a 20% higher rate of injury than females. Injuries resulting from falls or being struck by/against an object accounted for more than 44% of injuries. The rate of medically treated injuries declined by 15% from 1985 to 2000 in the US. For those aged 0-44, the incidence rate of injuries declined by more than 20%; while persons aged 75 and older experienced a 20% increase. CONCLUSIONS: These national burden estimates provide unequivocal evidence of the large health and financial burden of injuries. This study can serve as a template for other countries or be used in intercountry comparisons.

Lichen amyloidosus treated by hydrocolloid dressings.

We hereby report a case of lichen amyloidosus in a 69-year-old man unresponsive to various treatments. The patient was treated by occlusion with hydrocolloid dressings. Considerable subjective and objective improvement was observed with respect to the pruritus and cosmetic appearance. We suggest this convenient and efficacious treatment as first line therapy.

Acrolein-induced cytotoxicity in cultured human bronchial epithelial cells. Modulation by alpha-tocopherol and ascorbic acid.

Acrolein is a highly reactive unsaturated hazardous air pollutant of human health concern, particularly as a component of cigarette smoke. In this study, the mechanisms of acrolein-induced cytotoxicity in human bronchial epithelial cells (HBE1) and the modulating effects of antioxidants were examined. Our results show that acrolein induces a cell death pathway in human bronchial epithelial cells, which retain key features of apoptosis, as indicated by phosphatidylserine (PS) externalization and DNA fragmentation. Acrolein-induced apoptosis was associated with depletion of cellular GSH and intracellular generation of oxidants. Supplementation of cells with either alpha-tocopherol or ascorbic acid was found to strongly inhibit acrolein-induced apoptosis and to prevent the increase in the generation of intracellular oxidants, although GSH depletion was unaffected. Moreover, recovery of cellular GSH levels after acrolein exposure was enhanced following either alpha-tocopherol or ascorbic acid supplementation. The intracellular generation of oxidants following acrolein exposure seems to be an important event triggering the apoptotic response in this model system.

Inhibition of neutrophil apoptosis by acrolein: a mechanism of tobacco-related lung disease?

Cigarette smoking is known to contribute to inflammatory diseases of the respiratory tract by promoting recruitment of inflammatory-immune cells such as neutrophils and perhaps by altering neutrophil functional properties. We investigated whether acrolein, a toxic unsaturated aldehyde found in cigarette smoke, could directly affect neutrophil function. Exposure of freshly isolated human neutrophils to acrolein markedly inhibited spontaneous neutrophil apoptosis as indicated by loss of membrane asymmetry and DNA fragmentation and induced increased neutrophil production of the chemokine interleukin-8 (IL-8). Acrolein (1--50 microM) was found to induce marked activation of extracellular signal-regulated kinase (ERK) and p38 mitogen-activated protein kinases (MAPKs), and inhibition of p38 MAPK activation by SB-203580 prevented acrolein-induced IL-8 release. However, inhibition of either ERK or p38 MAPK did not affect acrolein-dependent inhibition of apoptosis. Acrolein exposure prevented the activation of caspase-3, a crucial step in the execution of neutrophil apoptosis, presumably by direct inhibition of the enzyme. Our results indicate that acrolein may contribute to smoke-induced inflammatory processes in the lung by increasing neutrophil recruitment and reducing neutrophil clearance by apoptosis.

Cigarette smoke impairs neutrophil respiratory burst activation by aldehyde-induced thiol modifications.

Exposure to airborne pollutants such as tobacco smoke is associated with increased activation of inflammatory-immune processes and is thought to contribute to the incidence of respiratory tract disease. We hypothezised that cigarette smoke (CS) could synergize with activated inflammatory/immune cells to cause oxidative injury or result in the formation of unique reactive oxidants. Isolated human neutrophils were exposed to gas-phase CS, and the production of nitrating and chlorinating oxidants following neutrophil stimulation was monitored using the substrate 4-hydroxyphenylacetate (HPA). Stimulation of neutrophils in the presence of CS resulted in a reduced oxidation and chlorination of HPA, suggesting inhibition of NADPH oxidase or myeloperoxidase (MPO), the two major enzymes involved in inflammatory oxidant formation. Peroxidase assays demonstrated that neutrophil MPO activity was not significantly affected after CS-exposure, leaving the NADPH oxidase as a likely target. The inhibition of neutrophil oxidant formation was found to coincide with depletion of cellular GSH, and a similar modification of critical cysteine residues, such as those in NADPH oxidase components, might be involved in reduced respiratory burst activity. As alpha,beta-unsaturated aldehydes such as acrolein have been implicated in thiol modifications by CS, we exposed neutrophils to acrolein prior to stimulation, and observed inhibition of NADPH oxidase activation in relation to GSH depletion. Additionally, translocation of the cytosolic components of NADPH oxidase to the membrane, a necessary requirement for enzyme activation, was inhibited. Protein adducts of acrolein (or related aldehydes) could be detected in several neutrophil proteins, including NADPH oxidase components, following neutrophil exposure to either CS or acrolein. Alterations in neutrophil function by exposure to (environmental) tobacco smoke may affect inflammatory/infectious conditions and thereby contribute to tobacco-related disease.

The role of FGF and VEGF in angioblast induction and migration during vascular development.

The embryonic vasculature forms by the processes of vasculogenesis and angiogenesis. Angioblasts (endothelial cell precursors) appear to be induced by fibroblast growth factor 2 (FGF-2). The angioblasts contributing to the dorsal aortae arise by an epithelial to mesenchymal transformation of cells originating from the splanchnic mesoderm. QH-l and vascular endothelial growth factor receptor 2 (VEGFR-2) both appear to label these cells as they adopt a mesenchymal morphology. Since VEGFR-2 is the earliest known VEGF receptor this suggests that VEGF is not involved in angioblast induction. VEGF does appear to be critical, however, for growth and morphogenesis of angioblasts into the initial vascular pattern. Controlled delivery of FGF-2 from beads and aggregates of cells transfected with quail VEGF have been used in our laboratory to study the role of these growth factors in angioblast induction and migration. We have induced cells from the epithelial quail somite to differentiate into angioblasts with FGF-2 both in the embryo and in culture. This is a useful model system to study the origins of endothelial cells that are normally more diffusely induced during gastrulation by an obscure process probably involving signals from the embryonic endoderm. The origins of arterial versus venous endothelial cells is also poorly understood but recent findings on the distribution of ephrins and Eph receptors suggest that molecular differences exist prior to the onset of circulation. Finally, studies on the role of growth factors in such diverse phenomena as stem cell biology, angiogenesis, and molecular medicine in addition to vascular development suggest multiple roles for FGF-2 and VEGF in vascular development.

Medicare beneficiary satisfaction with durable medical equipment suppliers.

CMS has recently launched a series of initiatives to control Medicare spending on durable medical equipment (DME) and prosthetics, orthotics, and supplies (DMEPOS). An important question is how these initiatives will affect beneficiary satisfaction. Using survey data, we analyze Medicare beneficiary satisfaction with DMEPOS suppliers in two Florida counties. Our results show that beneficiaries are currently highly satisfied with their DMEPOS suppliers. Beneficiary satisfaction is positively related to rapid delivery, training, dependability, and frequency of service. Results of our analysis can be used as baseline estimates in evaluating CMS initiatives to reduce Medicare payments for DMEPOS.

Small malignant melanoma in patients with mycosis fungoides.

An increased risk for a second malignancy has been reported in patients with mycosis fungoides. We describe two subjects with mycosis fungoides who developed small malignant melanoma after topical application of nitrogen mustard.

Reflex sympathetic dystrophy in a 12-year-old twin with comorbid conversion disorder in both twins.

A case of reflex sympathetic dystrophy is presented in a 12-year-old girl with comorbid conversion disorder. Her identical twin also had a conversion disorder. This is the first reported case of coexistence of reflex sympathetic dystrophy and conversion disorder. It is important for clinicians to be aware that these conditions may coexist since the presentation of symptoms differ, even though there are shared features of treatment.

Keratosis lichenoides chronica: a variant of lichen planus.

In order to establish a possible relationship between keratosis lichenoides chronica (KLC) and lichen planus (LP), we performed a comparative study which included routine histologic examination, electron microscopy, and direct immunohistochemical studies from one case of KLC and several patients with LP. Our findings demonstrate that KLC and LP share many similarities; their differences are mostly quantitative. In KLC, the findings are more prominent; we therefore conclude that KLC is at one end of the spectrum of LP.