Are we waiting for the sky to fall? Predictors of withdrawal of life-sustaining support in older trauma patients: A retrospective analysis.

BACKGROUND: Limited data exist regarding the impact of advanced care planning for injured geriatric patients. We hypothesized that patients with advance directives limiting care (ADLC) compared with those without ADLC are more likely to undergo withdrawal of life-sustaining support (WLSS). METHODS: This is a propensity-matched analysis utilizing American College of Surgeons Trauma Quality Improvement Program patients 65 years or older who presented between 2017 and 2018. Patients with and without ADLC on admission were compared. The primary outcome was WLSS and days prior to WLSS. Additional factors examined included hospital length of stay (LOS), unplanned operations, unplanned intensive care unit admissions, and in-hospital cardiac arrests. Prior to matching, logistic regression model assessed factors associated with WLSS. Patients with and without ADLC were matched 1:1 via a propensity score using patient and injury factors as covariates, and matched pair analysis compared differences in WLSS between patients with and without ADLC. RESULTS: There were 597,840 patients included: 44,001 patients with an ADLC (7.36%) compared with 553,839 with no ADLC (92.64%). Patients with an ADLC underwent WLSS more often than those with no ADLC (7.68% vs. 2.48%, p < 0.001). In a 1:1 propensity-matched analysis, patients with ADLC were more likely to undergo WLSS (odds ratio [OR], 2.38' 95% confidence interval [CI], 2.22-2.55), although stronger predictors of WLSS included severity of injury (Injury Severity Score, 25+; OR, 23.84; 95% CI, 21.55-26.36), unplanned intensive care unit admissions (OR, 3.30; 95% CI, 2.89-3.75), and in-hospital cardiac arrests (OR, 4.97; 95% CI, 4.02-6.15). CONCLUSION: A small proportion of the geriatric trauma population had ADLC on admission. While ADLC was predictive of WLSS, adverse events were more strongly associated with WLSS. To ensure patient-centered care and reduce futile interventions, surgeons should delineate goals of care early regardless of ADLC. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Disclosure of Misattributed Paternity.

One of the most common dilemmas faced by physicians and genetic counselors is the discovery of misattributed paternity. In this article, we present a case in which misattributed paternity was discovered as an incidental finding. Experts analyze the competing moral obligations that might dictate disclosure or nondisclosure.

Delivering perinatal psychiatric services in the neonatal intensive care unit.

AIM: To describe characteristics of mothers who would likely benefit from on-site short-term psychiatric services while their infant is in the neonatal intensive care unit (NICU). METHODS: For 150 consecutive mothers who were referred for psychiatric evaluation and psychotherapeutic intervention in an innovative NICU mental health programme, baseline information was collected. Data regarding their referrals, diagnosis, treatments and infants were analysed. RESULTS: Most mothers were referred because of depression (43%), anxiety (44%) and/or difficulty coping with their infant's medical problems and hospitalization (60%). Mothers of VLBW infants were disproportionately more likely to be referred. A majority of mothers accepted the referral and were treated; most only required short-term psychotherapy. A minority resisted or refused psychiatric assessment; a quarter of these had more difficult interactions with staff or inappropriate behaviours. In these cases, the role of the psychiatrist was to work with staff to promote healthy interactions and to foster maternal-infant bonding. CONCLUSION: Overall, on-site psychiatric services have been accepted by a majority of referred NICU mothers, and most did not require long-term treatment. A considerable need exists for psychiatric services in the NICU to promote optimal parenting and interactions.

Characterization and steroidal regulation of gonadotropin beta subunits in the male leopard frog, Rana pipiens.

In ranid frogs, the secretion of gonadotropins (GtHs), luteinizing hormone (LH), and follicle-stimulating hormone (FSH), is potently regulated by gonadal steroids. To better understand the gonadal regulation of GtHs at the molecular level, we elucidated the full-length cDNA sequences of LH and FSH beta subunits from the leopard frog, Rana pipiens. The cDNAs for LHbeta and FSHbeta were 1084 and 667 bp in size excluding the poly (A) tail, and encoded proteins of 138 and 127 amino acids, respectively. Using reverse-transcription polymerase chain reaction (RT-PCR), the messages for LHbeta and FSHbeta were found in the pituitary, but not in the brain, heart, kidney, or the liver. Semi-quantitative RT-PCR revealed a significant elevation of FSHbeta, but not LHbeta, in mature male R. pipiens 21 days after gonadectomy (GDX). 17beta-estradiol implant for 21 days in GDX male frogs significantly suppressed the levels of both LHbeta and FSHbeta transcripts, whereas 5alpha-dihydrotestosterone implant suppressed only the latter. Together, these results laid the groundwork for investigating gonadal regulation of GtHbeta subunits in a ranid frog. Importantly, these data also revealed differential feedback effects of an androgen and an estrogen upon GtHbeta expression.

Alteration of the hypothalamic-pituitary-gonadal axis in estrogen- and androgen-treated adult male leopard frog, Rana pipiens.

BACKGROUND: Gonadal steroids, in particular 5 alpha-dihydrotestosterone (DHT) and 17 beta-estradiol (E2), have been shown to feed back on the hypothalamic-pituitary-gonadal (HPG) axis of the ranid frog. However, questions still remain on how DHT and E2 impact two of the less-studied components of the ranid HPG axis, the hypothalamus and the gonad, and if the feedback effects are consistently negative. Thus, the goal of the study was to examine the effects of DHT and E2 upon the HPG axis of the gonadally-intact, sexually mature male leopard frogs, Rana pipiens. METHODS: R. pipiens were implanted with silastic capsules containing either cholesterol (Ch, a control), DHT, or E2 for 10 or 30 days. At each time point, steroid-induced changes in hypothalamic GnRH and pituitary LH concentrations, circulating luteinizing hormone (LH), and testicular histology were examined. RESULTS: Frogs implanted with DHT or E2 for 10 days did not show significant alterations in the HPG axis. In contrast, frogs implanted with hormones for 30 days had significantly lower circulating LH (for both DHT and E2), decreased pituitary LH concentration (for E2 only), and disrupted spermatogenesis (for both DHT and E2). The disruption of spermatogenesis was qualitatively similar between DHT and E2, although the effects of E2 were consistently more potent. In both DHT and E2-treated animals, a marked loss of all pre-meiotic germ cells was observed, although the loss of secondary spermatogonia appeared to be the primary cause of disrupted spermatogenesis. Unexpectedly, the presence of post-meiotic germ cells was either unaffected or enhanced by DHT or E2 treatment. CONCLUSIONS: Overall, these results showed that both DHT and E2 inhibited circulating LH and disrupted spermatogenesis progressively in a time-dependent manner, with the longer duration of treatment producing the more pronounced effects. Further, the feedback effects exerted by both steroid hormones upon the HPG axis were largely negative, although the possibility exists for a stimulatory effect upon the post-meiotic germ cells.