Gut microbiome and symptoms in females with irritable bowel syndrome: a cross-sectional analysis.

Irritable bowel syndrome (IBS), a disorder of gut-brain interaction, is associated with abdominal pain and stool frequency/character alterations that are linked to changes in microbiome composition. We tested whether taxa differentially abundant between females with IBS vs healthy control females (HC) are associated with daily gastrointestinal and psychological symptom severity. Participants (age 18-50 year) completed a 3-day food record and collected a stool sample during the follicular phase. They also completed a 28-day diary rating symptom intensity; analysis focused on the three days after the stool sample collection. 16S rRNA gene sequencing was used for bacterial identification. Taxon abundance was compared between IBS and HC using zero-inflated quantile analysis (ZINQ). We found that females with IBS (n = 67) had greater Bacteroides abundance (q = 0.003) and lower odds of Bifidobacterium presence (q = 0.036) compared to HC (n = 46) after adjusting for age, race, body mass index, fibre intake, and hormonal contraception use. Intestimonas, Oscillibacter, and Phascolarctobacterium were more often present and Christensenellaceae R-7 group, Collinsella, Coprococcus 2, Moryella, Prevotella 9, Ruminococcaceae UCG-002, Ruminococcaceae UCG-005, and Ruminococcaceae UCG-014 were less commonly present in IBS compared to HC. Despite multiple taxon differences in IBS vs HC, we found no significant associations between taxon presence or abundance and average daily symptom severity within the IBS group. This may indicate the need to account for interactions between microbiome, dietary intake, metabolites, and host factors.

Genetic Variations in TrkB.T1 Isoform and Their Association with Somatic and Psychological Symptoms in Individuals with IBS.

Irritable bowel syndrome (IBS), a disorder of gut-brain interaction, is often comorbid with somatic pain and psychological disorders. Dysregulated signaling of brain-derived neurotrophic factor (BDNF) and its receptor, tropomyosin-related kinase B (TrkB), has been implicated in somatic-psychological symptoms in individuals with IBS. Thus, we investigated the association of 10 single nucleotide polymorphisms (SNPs) in the regulatory 3' untranslated region (UTR) of NTRK2 (TrkB) kinase domain-deficient truncated isoform (TrkB.T1) and the BDNF Val66Met SNP with somatic and psychological symptoms and quality of life in a U.S. cohort (IBS n=464; healthy controls n=156). We found that the homozygous recessive genotype (G/G) of rs2013566 in individuals with IBS is associated with worsened somatic symptoms, including headache, back pain, joint pain, muscle pain, and somatization as well as diminished sleep quality, energy level and overall quality of life. Validation using U.K. BioBank (UKBB) data confirmed the association of rs2013566 with increased likelihood of headache. Several SNPs (rs1627784, rs1624327, rs1147198) showed significant associations with muscle pain in our U.S. cohort. Notably, these SNPs are predominantly located in H3K4Me1-enriched regions, suggesting their enhancer and/or transcription regulation potential. Together, our findings suggest that genetic variation within the 3'UTR region of the TrkB.T1 isoform may contribute to comorbid conditions in individuals with IBS, resulting in a spectrum of somatic and psychological symptoms that may influence their quality of life. These findings advance our understanding of the genetic interaction between BDNF/TrkB pathways and somatic-psychological symptoms in IBS, highlighting the importance of further exploring this interaction for potential clinical applications.

The effects of an aviation-style computerised pre-induction anaesthesia checklist on pre-anaesthetic set-up and non-routine events.

This prospective, observational study compared the proportion of cases with missing critical pre-induction items before and after the implementation of an aviation-style computerised pre-induction anaesthesia checklist. Trained observers recorded the availability of critical pre-induction items and evaluated the characteristics of the pre-induction anaesthesia checklist performance including provider participation and distraction level, resistance to the use of the checklist and the time required for completion. Surgical cases that met the criteria for inclusion in the National Surgical Quality Improvement Program at a single academic hospital were selected for observation. A total of 853 cases were observed before and 717 after implementation of the checklist. The proportion of cases with failure to perform all pre-induction steps decreased from 10.0% to 6.4% (p = 0.012). There was also a significant decrease in the proportion of cases with non-routine events from 1.2% cases before to none after checklist implementation (p = 0.003). In 17 cases, the checklist alerted the anaesthesia provider to correct a mistake in pre-induction preparation.

Management of rocuronium neuromuscular block using a protocol for qualitative monitoring and reversal with neostigmine.

BACKGROUND: Neuromuscular block using subjective monitoring and neostigmine reversal is commonly associated with postoperative residual neuromuscular block. We tested whether a protocol for the management of neuromuscular block that specified appropriate dosing and optimal neostigmine reversal was associated with a reduction in postoperative residual neuromuscular block. METHODS: Rocuronium administration was guided by surgical requirements and based on the ideal body weight, with dose reductions for female sex and age >55 yr. Neostigmine was administered in adjusted doses after a train-of-four count of four was confirmed at the thumb. The protocol ensured a minimum of 10 min between neostigmine administration and tracheal extubation. We measured the postoperative residual neuromuscular block in patients undergoing abdominal surgery before and after introduction of the protocol. Pre-specified primary and secondary endpoints were incidence of postoperative residual neuromuscular block and severe postoperative residual neuromuscular block at the time of tracheal extubation, defined as normalised train-of-four ratios <0.9 and <0.7, respectively. RESULTS: The incidence of postoperative residual neuromuscular block at tracheal extubation was 14/40 (35%) for patients managed according to the protocol compared with 22/38 (58%) for patients in the control group, odds ratio of 0.39, and 95% confidence interval of 0.14-1.07; P=0.068. The incidence of severe postoperative residual neuromuscular block at tracheal extubation showed a highly significant difference, odds ratio=0.06, and confidence interval of 0.00-0.43; P=0.001. CONCLUSIONS: The incidence of severe postoperative residual neuromuscular block was significantly reduced after the protocol was introduced. Given the limitations inherent in this before-and-after study, further research is needed to confirm these results. CLINICAL TRIAL REGISTRATION: NCT02660398.

Stool and urine trefoil factor 3 levels: associations with symptoms, intestinal permeability, and microbial diversity in irritable bowel syndrome.

Previously we showed that urine trefoil factor 3 (TFF3) levels were higher in females with irritable bowel syndrome (IBS) compared to non-IBS females. To assess if TFF3 is associated with symptoms and/or reflect alterations in gastrointestinal permeability and gut microbiota in an IBS population, we correlated stool and urine TFF3 levels with IBS symptoms, intestinal permeability, stool microbial diversity and relative abundance of predominant bacterial families and genera. We also tested the relationship of stool TFF3 to urine TFF3, and compared results based on hormone contraception use. Samples were obtained from 93 females meeting Rome III IBS criteria and completing 4-week symptom diaries. TFF3 levels were measured by ELISA. Permeability was assessed with the urine lactulose/mannitol (L/M) ratio. Stool microbiota was assessed using 16S rRNA. Stool TFF3, but not urine TFF3, was associated positively with diarrhoea and loose stool consistency. Higher stool TFF3 was also associated with lower L/M ratio and microbial diversity. Of the 20 most abundant bacterial families Mogibacteriaceae and Christensenellaceae were inversely related to stool TFF3, with only Christensenellaceae remaining significant after multiple comparison adjustment. There were no significant relationships between stool or urine TFF3 levels and other symptoms, nor between stool and urine levels. In premenopausal females, urine TFF3 levels were higher in those reporting hormone contraception. Collectively these results suggest that higher stool TFF3 levels are associated with IBS symptoms (loose/diarrhoeal stools), lower gut permeability, and altered stool bacteria composition (decreased diversity and decreased Christensenellaceae), which further suggests that TFF3 may be an important marker of host-bacteria interaction.

Relationships of abdominal pain, reports to visceral and temperature pain sensitivity, conditioned pain modulation, and heart rate variability in irritable bowel syndrome.

BACKGROUND: Irritable bowel syndrome (IBS) is a heterogeneous condition with a number of pathophysiological mechanisms that appear to contribute to symptom chronicity. One of these is altered pain sensitivity. METHODS: Women between ages 18-45 were recruited the community. Of those enrolled, 56 had IBS and 36 were healthy control (HC) women. Participants completed questionnaires, kept a 4-week symptom diary and had a 12-h Holter placed to assess nighttime heart rate variability including high frequency power (HF), low frequency power (LF), and total power (TP). At mid-follicular phase approximately 80% of women completed a thermal pain sensitivity test with conditioned pain modulation and visceral pain sensitivity using a water load symptom provocation (WLSP) test. KEY RESULTS: As expected, daily abdominal pain was significantly higher in the IBS compared to HC group. There were no differences between the bowel pattern subgroups (IBS-diarrhea [IBS-D], IBS-constipation plus mixed [IBS-CM]). Thermal pain sensitivity did not differ between the IBS and the HC groups, but was significantly higher in the IBS-CM group than the IBS-D group. In the WLSP test, the IBS group experienced significantly more symptom distress than HCs and the IBS-CM group was higher than the IBS-D group. Heart rate variability indicators did not differ between the groups or IBS subgroups. Daily abdominal pain was positively correlated with LF and TP in the IBS group. CONCLUSIONS & INFERENCES: Despite similar levels of abdominal pain in IBS, the IBS-CM group demonstrated greater sensitivity to both thermal and visceral testing procedures.

Anticipation of public speaking and sleep and the hypothalamic-pituitary-adrenal axis in women with irritable bowel syndrome.

BACKGROUND: Evidence suggests that subgroups of patients with irritable bowel syndrome (IBS) are hyper-responsive to a variety of laboratory stress conditions. METHODS: This study compared sleep quality and night time plasma adrenocorticotropic hormone (ACTH) and serum cortisol levels in response to anticipation of public speaking between 43 women with IBS and 24 healthy control women. In addition, comparisons were made between subgroups within the IBS sample based on predominant stool patterns, 22 IBS-constipation and 21 IBS-diarrhea. Subjects slept three nights in a sleep laboratory, and on the third night serial blood samples were drawn every 20 min from 08:00 PM until awakening. As the subjects had different sleep onsets, each subject's results were synchronized to the first onset of stage 2 sleep. KEY RESULTS: Compared the healthy control group, women with IBS had significantly worse sleep efficiency, and higher cortisol but not ACTH levels over the night. However, there were no IBS bowel pattern subgroup differences. Among IBS subjects, cortisol levels early in the night were higher than found in our previous study with a similar protocol but without the threat of public speaking. These results suggest that a social stressor, such as public speaking prior to bedtime, increases cortisol but not ACTH levels suggesting HPA dysregulation in women with IBS. CONCLUSIONS & INFERENCES: This response to a social stressor contributes to our understanding of the relationship of stress to symptom expression in IBS.

Associations of tryptophan hydroxylase gene polymorphisms with irritable bowel syndrome.

BACKGROUND: Alterations in serotonin (5-HT) are suspected in the pathophysiology of irritable bowel syndrome (IBS). Tryptophan hydroxylase (TPH) is the rate-limiting enzyme in the biosynthesis of serotonin and has two isoforms: TPH1 and TPH2. Genetic variants in both genes have been studied in various disorders related to serotonin dysregulation. The aim of this study was to examine whether TPH gene variants were associated with IBS and IBS-related gastrointestinal (GI) symptoms. METHODS: Five single nucleotide polymorphisms (SNPs) from the TPH1 and one SNP from the TPH2 were genotyped in 199 IBS patients and 79 healthy controls. All subjects were Caucasian women of European origin. Irritable bowel syndrome patients filled in a daily diary with five GI symptoms and stool characteristics for 28 days. KEY RESULTS: The TPH1 SNPs showed no association with the diagnosis of IBS. However, among IBS patients, all five TPH1 SNPs showed some association with diarrhea and loose type of stool consistency, with P-values rating from 0.01 to 0.20. The TPH2 SNP showed a trend towards a reduced risk of IBS and possible associations with stool characteristics, both hard and loose stools. However, no P-values were less than the conservative multiple-comparison-adjusted threshold of 0.001 and hence these results must be interpreted cautiously. CONCLUSIONS & INFERENCES: This study is the first to assess associations of TPH gene variants with IBS-related GI symptoms and stool characteristics. The possible association of TPH gene variants with diarrhea needs to be verified in an independent sample.

Catecholamine and cortisol levels during sleep in women with irritable bowel syndrome.

Evidence suggests that patients with irritable bowel syndrome (IBS) are hyper-responsive to environmental, physical and visceral stimuli. IBS patients also frequently report poor sleep quality. This study compared serum cortisol and plasma catecholamine levels during sleep between women with IBS (n = 30) and healthy controls (n = 31), and among subgroups within the IBS sample based on predominant stool patterns, IBS-diarrhoea (n = 14), IBS-constipation (n = 7) and IBS-alternators (n = 9). Cortisol was measured from serial blood samples drawn every 20 min, and catecholamines every hour, in a sleep laboratory from 8 pm until awakening. Because of the varied sleep schedules of the individual participants, each subject's hormone series time base was referenced with respect to their onset of Stage 2 sleep. Overall, there were no significant differences in cortisol or catecholamine patterns between women with IBS and controls, nor were there any group by time interactions. However, women with constipation-predominant IBS demonstrated significantly increased noradrenaline, adrenaline and cortisol levels throughout the sleep interval, and women with diarrhoea-predominant IBS were significantly lower on noradrenaline and cortisol. These results suggest that differences in neuroendocrine levels during sleep among IBS predominant bowel pattern subgroups may be greater than differences between IBS women and controls. Neuroendocrine profiles during sleep may contribute to our understanding of symptom expression in IBS.

Heart rate variability is related to pain severity and predominant bowel pattern in women with irritable bowel syndrome.

This study examined heart rate variability (HRV) in women with irritable bowel syndrome (IBS) to determine its association with gut pain and predominant bowel pattern. Women with IBS (constipation predominant n = 45, diarrhoea predominant n = 64, alternating n = 56) and healthy controls (n = 50) were recruited from the community. Severity of gut pain was measured retrospectively. The HRV (24 h) was summarized as high-frequency (HF) power and the ratio of low-frequency (LF) power to HF power. Among those women with IBS who have severe gut pain, the 15 constipation-predominant women had lower (P = 0.01) HF power and higher (P = 0.003) LF/HF ratio (geometric means 70 and 7.5, respectively) than the 21 women with diarrhoea-predominant IBS (286 and 3.1) and controls (224 and 3.9). In contrast, among women without severe pain, there is a smaller and not quite significant difference in the opposite direction. Using a broader definition of pain severity based on several questions nearly doubles the number of subjects in the severe pain group and shows even more significant results. The relationship of predominant bowel pattern to HRV is qualitatively different in the subgroup of patients with more severe pain than in the subgroup with less severe pain.

Subjective and objective sleep indices in women with irritable bowel syndrome.

Patients with irritable bowel syndrome (IBS) commonly report sleep disturbances. This study examined self-report (Pittsburgh Sleep Quality Inventory) sleep quality and polysomnography (PSG) sleep variables in 18 women with mild-to-moderate IBS, 18 with severe IBS and 38 with age- and gender-matched controls. All women were studied on two consecutive nights in a sleep research laboratory where PSG data were collected. Retrospective and daily measures were obtained of self-reported sleep quality, psychological distress and gastrointestinal symptoms across one menstrual cycle. Self-report measures of psychological distress and sleep quality were significantly worse in the IBS-severe (IBS-S) group compared with controls. Rapid eye movement (REM) latency was higher in the two IBS groups on Night 1 than the control group (P = 0.06). Percentage time in REM was highest in the IBS-S on Night 2. All groups demonstrated greater sleep disruption on Night 1 (adaptation) when compared with Night 2. These results highlight the importance of considering the 'first-night effect' in those with IBS and the lack of concordance between self-report and objective indices of sleep in women with IBS.

Relationship of cerebral perfusion pressure levels to outcome in traumatic brain injury.

This study examined the relationship of cumulative percent time that cerebral perfusion pressure (CPP) fell below set thresholds to outcome in individuals with traumatic brain injury (TBI). The sample included 157 patients (16 to 89 years of age, 79%, male) admitted to an intensive care unit at an academic medical center who underwent invasive arterial blood pressure and intracranial pressure monitoring. CPP levels were recorded continuously during the first 96 hours of monitoring. Initial neurologic status was assessed using the post-resuscitation Glasgow Coma Scale. Outcome was evaluated at hospital discharge and at six months post-injury using the Extended Glasgow Outcome Scale (GOSE). The relationship of cumulative periods of low CPP to outcome was evaluated using hierarchical and binary logistic regression analysis, controlling for age, gender, and injury severity. Patients experiencing less cumulative percent time below specific CPP thresholds were more likely to have better outcome at discharge (55 mm Hg, p = .004; 60 mm Hg, p = .008; 65 mm Hg, p = .024; 70 mm Hg, p = .016). Although differences in GOSE scores at six months were not significant, those with less time below CPP thresholds were more likely to survive. Accumulated episodes of low CPP had a stronger negative relationship with outcome in patients with more severe primary brain injury.

Nociceptive and neuropathic pain in patients with lung cancer: a comparison of pain quality descriptors.

Predictive validity of each word from the McGill Pain Questionnaire (MPQ) has not been investigated in relation to pain etiology. The purpose of this study was to explore differences in the words used to describe nociceptive and neuropathic pain. Patients with lung cancer (N = 123) selected words from the 78 MPQ pain quality descriptors and indicated the corresponding pain site for each word. Using only the MPQ pain location, and the cancer and treatment data abstracted from medical records, each pain site was classified as nociceptive or neuropathic (etiology). Pain etiology and quality descriptors were tested for proportional differences with sensitivity, specificity, and predictive value calculated for statistically significant descriptors. Of the 457 pain sites, 343 were classified as nociceptive (75%), 114 as neuropathic (25%). Lacerating, stinging, heavy, and suffocating were selected for a significantly larger proportion of nociceptive sites whereas throbbing, aching, numb, tender, punishing, pulling, tugging, pricking, penetrating, punishing, miserable, and nagging were selected for a larger proportion of neuropathic sites. Ten words correctly predicted 78% of the sites with 81% sensitivity to nociceptive pain and 59% sensitivity to neuropathic pain. Interestingly, several pain quality descriptors (burning, shooting, flashing, tingling, itching, and cold) previously associated with neuropathic pain did not distinguish between neuropathic and nociceptive pain. Infrequent selection of many MPQ words and lack of neurological exam data in the medical records are possible explanations for inconsistency with previous literature. Prospective studies are needed to validate pain quality descriptors for nociceptive and neuropathic types of lung cancer pain.

Autonomic nervous system function in women with irritable bowel syndrome.

Autonomic nervous system (ANS) balance was assessed in women with and without irritable bowel syndrome (IBS) using laboratory tests of function (ie, expiratory/inspiratory ratio, Valsalva, posture changes, and cold pressor) and spectral and nonspectral measures of heart rate variability (HRV). Women with (N = 103) and without IBS (N = 49) were recruited, interviewed, then completed a laboratory assessment and wore a 24-hr Holter monitor Analysis using the entire sample showed little difference between IBS and control women and between subgroups with IBS on either laboratory measures or 24-hr HRV measures. However, analysis restricted to those women with severe IBS symptoms showed quite pronounced differences between two IBS subgroups on 24-hr HRV measures. Parasympathetic tone was significantly lower and ANS balance was significantly higher in the constipation-predominant compared to the diarrhea-predominant group. Subgroups of women with IBS do differ in ANS function as measured by 24-hr HRV; however, these differences are only apparent among women with severe symptoms. These findings point out the importance of considering symptom severity when interpreting studies of IBS.

Sleep disturbance influences gastrointestinal symptoms in women with irritable bowel syndrome.

This analysis evaluated the association between sleep disturbance and gastrointestinal symptoms in women with and without irritable bowel syndrome (IBS), and examined the role of psychological distress in this relationship. Women with IBS (N = 82) reported considerably higher levels of sleep disturbance compared to controls (N = 35), using both retrospective seven-day recall and daily diary recall for two menstrual cycles (P < 0.05 on 8 of 10 measures). We used daily diary data to estimate the association between sleep disturbance and gastrointestinal symptoms, both across women (ie, whether women with high average sleep disturbance have higher average gastrointestinal symptoms) and within woman (ie, whether poorer than average sleep on one night is associated with higher than average gastrointestinal symptoms the following day). The regression coefficients for the across-women effect are large and highly significant in both groups (IBS, beta +/- SE = 0.46 +/- 0.08, P < 0.001; controls, 0.57 +/- 0.13, P < 0.001). The regression coefficients for the within-woman effect are considerably smaller and statistically significant only in the IBS group (IBS, 0.06 +/- 0.02, P = 0.006; control, 0.01 +/- 0.03, P = 0.691). These regression coefficients showed little change when daily psychological distress or stress was controlled for, the one exception being the coefficient for the across-women effect in the IBS group, which decreased substantially but still remained highly significant. Because it is possible that gastrointestinal symptoms could, in fact, cause poor sleep, we also fitted the temporally reversed model to evaluate the association between gastrointestinal symptoms on one day and sleep disturbance that night. The within-woman regression coefficients were nonsignificant in both the IBS and control groups. In conclusion, these results are consistent with the hypothesis that poor sleep leads to higher gastrointestinal symptoms on the following day among women with IBS.

Bone resorption levels by age and menopausal status in 5,157 women.

OBJECTIVE: The purpose of this study was to describe bone resorption activity using a biochemical marker according to the categories of age, menopausal status, and selected drug/supplement use in middle-aged and elderly community-based women. DESIGN: This was a cross-sectional study that assessed urinary cross-linked N-telopeptide of type I collagen (NTx) and used self-report data to group women as premenopausal (Pre), perimenopausal (Peri), postmenopausal without hormone replacement therapy (Post), and postmenopausal with hormone replacement therapy (HRT). RESULTS: Mean NTx values were found to be significantly different by group and controlling for age (p = 0.001), with post hoc tests showing all pairwise group comparisons as significantly different (p = 0.001), except that the Pre and HRT groups were not significantly different. Both the Peri and the Post NTx levels were significantly higher than the Pre and the HRT groups'. NTx values in the Peri group varied with age-the youngest Peri women were similar to Pre women, and the oldest Peri women were similar to Post women. Significantly lower NTx levels were found only in the Post (p = 0.009) and HRT (p < 0.001) groups using diuretics compared with nonuse and only in the HRT group using calcium supplements compared with nonuse (p = 0.006). No differences by thyroid use were found. With a biochemical marker, the results showed that bone resorption activity differences could be demarcated in women according to age, estimated menopausal stage, and selected drug/supplement use. CONCLUSIONS: These results support the usefulness of NTx assessment for indicating bone resorption activity and therefore the potential for osteoporosis or for monitoring the efficacy of antiresorptive therapies.

Comparison of autonomic nervous system indices based on abdominal pain reports in women with irritable bowel syndrome.

Abdominal pain is an important symptom in irritable bowel syndrome (IBS), but patients report typical pain intensities ranging from mild to very severe. In a sample of women, the authors sought to determine whether measures of systemic autonomic activity are related to self-reported pain intensity and the occurrence of pain in the postprandial period. One hundred and six women with IBS and 41 controls completed bowel symptom and psychological distress questionnaires and wore 24-h Holter electrocardiogram monitors to estimate global heart rate variability measures of parasympathetic activity and sympathetic nervous system/parasympathetic nervous system balance. About one-third of the IBS sample reported severe or very severe abdominal pain (n = 34/106), and about one-half of the IBS sample reported postprandial pain (n = 52/106). Even after statistically controlling for age, body mass index, and psychological distress, vagal heart rate variability measures were markedly lower in women reporting high pain (P < 0.01) and markedly higher in women reporting postprandial pain (P < 0.02). The vagal component of heart rate variability appears to be reduced in women with severe abdominal pain, especially in those whose pain is not postprandial.

Preferences for life-sustaining treatments in advance care planning and surrogate decision making.

BACKGROUND: Surrogates and clinicians often make treatment decisions for decisionally incapacitated patients with limited knowledge of their preferences. This study examined patients' life-sustaining treatment preferences to facilitate advance care planning discussions and surrogate decision making. METHODS: We interviewed 342 participants from 7 groups: younger and older well adults; persons with chronic illness, terminal cancer, and acquired immunodeficiency syndrome (AIDS); stroke survivors; and nursing home residents. Preferences for antibiotics, short- and long-term mechanical ventilation, hemodialysis, tube feeding, and cardiopulmonary resuscitation (CPR) were elicited for each participant's current health state and three hypothetical health states representing severe dementia, coma, and severe stroke. RESULTS: Participants chose to forego more invasive or long-term treatments at a higher rate than less invasive, short-term treatments in all health states. Participants were much more willing to forego treatments in coma than in their current health state, with stroke and dementia somewhere in between. Participants who were older, female, had worse functional status, had more depressive symptoms, or lived in a nursing home were more inclined to forego treatment in their current health state. In contrast, treatment preferences in hypothetical health states showed either no associations or much weaker associations with these factors. Participants who were willing to accept more invasive treatments were highly likely to accept less invasive treatments and participants who preferred to forego a less invasive treatment were highly likely to forego more invasive treatments. Participants who preferred to receive a treatment in a health state with severe impairments were highly likely to want the same treatment in a less impaired health state. Similarly, participants who preferred to forego a treatment in a less impaired health state were highly likely to forego the same treatment in a more impaired state. CONCLUSIONS: In advance care planning discussions, clinicians might explore with patients their preferences about short- and long-term treatments with variability in their invasiveness (including CPR) in both their current health state and hypothetical situations representing different levels of functional impairment. When surrogates have no knowledge about the wishes of formerly competent patients, clinicians may help them with medical decisions by discussing what other people commonly want in similar circumstances.

PTSD among bereaved parents following the violent deaths of their 12- to 28-year-old children: a longitudinal prospective analysis.

This study examined the prevalence of posttraumatic stress disorder (PTSD) among parents bereaved by the violent deaths of their 12- to 28-year-old children. A community-based sample of 171 bereaved mothers and 90 fathers was recruited by a review of Medical Examiner records and followed for 2 years. Four important findings emerged: Both parents' gender and children's causes of death significantly affected the prevalence of PTSD symptoms. Twice as many mothers and fathers whose children were murdered met PTSD caseness (full diagnostic) criteria compared with accident and suicide bereavement. Symptoms in the reexperiencing domain were the most commonly reported. PTSD symptoms persisted over time, with 21% of the mothers and 14% of the fathers who provided longitudinal data still meeting caseness criteria 2 years after the deaths. Parents who met caseness criteria for PTSD, compared with those who did not, were significantly different on multiple study variables. Both theoretical and clinical implications for the findings are discussed.

Parents' health, health care utilization, and health behaviors following the violent deaths of their 12- to 28-year-old children: a prospective longitudinal analysis.

Health status, health care utilization, and health behaviors of parents bereaved by the violent deaths of their adolescent and young adult children were examined 4, 12, and 24 months later. Participants were 261 bereaved parents (171 mothers, 90 fathers). About 20% of the parents reported "poor" physical health during the early bereavement period compared with 16% of Americans the same age. Over time, mothers' health improved whereas fathers' health deteriorated. Fathers in poor health compared with fathers in good health are 15 times more likely to report emotional distress and 4.6 times more likely to report trauma symptoms. Mothers in poor health compared with mothers in good health are 11 times more likely to report emotional distress and 3 times more likely to report trauma symptoms. Mothers' reports of physician visits and medication use were higher than fathers', however, mothers' rates for both decreased significantly over time whereas fathers' rates remained constant. Over 70% of the mothers and nearly 60% of the fathers practiced 2 or more health protective behaviors over time--a finding significantly associated with fewer stress-related illnesses, days absent from work, and non-productivity at work. Implications for the findings are discussed.