Can We Make More Accurate Prognoses During Last Days of Life?

Background: Life expectancy prediction is important for end-of-life planning. Established methods (Palliative Performance Scale [PPS], Palliative Prognostic Index [PPI]) have been validated for intermediate- to long-term prognoses, but last-weeks-of-life prognosis has not been well studied. Patients admitted to a palliative care facility often have a life expectancy of less than three weeks. Reliable last-weeks-of-life prognostic tools are needed. Objective: To improve short-term survival prediction in terminally ill patients. Method: This prospective study included all patients admitted to a palliative care facility in Montreal, Canada, over one year. PPS and PPI were assessed until patients' death. Seven prognostic clinical signs of impending death (Short-Term Prognosis Signs [SPS]) were documented daily. Results: The analyses included 273 patients (76% cancer). The median survival time for a PPS ≤20% was 2.5 days, while for a PPS ≥50% it was 44.5 days, for a PPI >8 the median survival was 3.5 days and for a PPI ≤4 it was 38.5 days. Receiver operating characteristic curves showed a high accuracy in predicting survival. Median survival after the first occurrence of any SPS was below one week. Conclusions: This study demonstrated that the PPS and PPI perform well between one week and three months extending their usefulness to shorter term survival prediction. SPS items provided survival information during the last week of life. Using SPS along with PPS and PPI during the last weeks of life could enable a more precise short-term survival prediction across various end-of-life diagnoses. The translation of this research into clinical practice could lead to a better adapted treatment, the identification of a most appropriate care setting for patients, and improved communication of prognosis with patients and families.

Disinfection of Pseudomonas aeruginosa from N95 respirators with ozone: a pilot study.

INTRODUCTION: Personal protective equipment shortages require the reuse of N95 respirators. We sought the necessary conditions for ozone to disinfect N95 respirators for reuse and the effects of multiple cycles of exposure. METHODS: Portions of 3M 1870 N95 respirators were exposed to ozone at 400 ppm with 80% humidity for 2 hours to determine effectiveness of ozone on killing Pseudomonas aeruginosa. Entire 3M 1870 N95 respirators were exposed to five cycles of 400 ppm with 80% or higher humidity for 2 hours then evaluated for ozone's effects on airflow resistance, filtration efficiency, strap strength and quantitative fit. RESULTS: Ozone exposure disinfected 3M 1870 N95 respirators heavily inoculated with P. aeruginosa. Ozone exposure did not negatively affect the airflow resistance, filtration efficiency, strap strength or fit of the 3M 1870 N95 respirator. DISCUSSION: These results suggest that ozone is a feasible strategy to disinfect N95 respirators for reuse during this and future pandemics.

Impaired aerobic exercise adaptation in children and adolescents with craniopharyngioma is associated with hypothalamic involvement.

OBJECTIVE: Many patients treated for craniopharyngioma (CP) complain of a relative incapacity for physical activity. Whether this is due to an objective decrease in adaptation to exercise is unclear. We assessed exercise tolerance in children with surgically treated CP and appropriate pituitary hormone replacement therapy compared with healthy controls and we examined the potential relationships with hypothalamic involvement, GH replacement, and the catecholamine deficiency frequently observed in these subjects. DESIGN AND METHODS: Seventeen subjects (12 males and five females) with CP and 22 healthy controls (14 males and eight females) aged 15.3±2.5 years (7.3-18 years) underwent a standardized cycle ergometer test. Maximum aerobic capacity was expressed as the ratio of VO(2max) to fat-free mass (VO(2max)/FFM), a measure independent of age and fat mass in children. RESULTS: VO(2max)/FFM was 20% lower in children with CP compared with controls (P<0.05), even after adjustment for gender. Children with hypothalamic involvement (n=10) had a higher percentage of fat mass (P<0.05) than those without hypothalamic involvement (n=7) and lower VO(2max)/FFM (P<0.05), whereas children without hypothalamic involvement had VO(2max)/FFM close to that of controls (P>0.05). GH treatment was associated with a significant positive effect on aerobic capacity (P<0.05) only in the absence of hypothalamic involvement. No relationship was found between exercise capacity parameters and daily urine epinephrine excretion or epinephrine peak response to insulin-induced hypoglycemia. CONCLUSIONS: Children with CP have a decrease in aerobic capacity mainly related to hypothalamic involvement. The hypothalamic factors altering aerobic capacity remain to be determined.

Baseline inhibin B and anti-Mullerian hormone measurements for diagnosis of hypogonadotropic hypogonadism (HH) in boys with delayed puberty.

CONTEXT: The diagnosis of isolated hypogonadotropic hypogonadism (IHH) in boys with delayed puberty is challenging, as may be the diagnosis of hypogonadotropic hypogonadism (HH) in boys with combined pituitary hormone deficiency (CPHD). Yet, the therapeutic choices for puberty induction depend on accurate diagnosis and may influence future fertility. OBJECTIVE: The aim was to assess the utility of baseline inhibin B (INHB) and anti-Mullerian hormone (AMH) measurements to discriminate HH from constitutional delay of puberty (CDP). Both hormones are produced by Sertoli cells upon FSH stimulation. Moreover, prepubertal AMH levels are high as a reflection of Sertoli cell integrity. PATIENTS: We studied 82 boys aged 14 to 18 yr with pubertal delay: 16 had IHH, 15 congenital HH within CPHD, and 51 CDP, as confirmed by follow-up. Subjects were genital stage 1 (testis volume<3 ml; 9 IHH, 7 CPHD, and 23 CDP) or early stage 2 (testis volume, 3-6 ml; 7 IHH, 8 CPHD, and 28 CDP). RESULTS: Age and testis volume were similar in the three groups. Compared with CDP subjects, IHH and CPHD subjects had lower INHB, testosterone, FSH, and LH concentrations (P<0.05), whereas AMH concentration was lower only in IHH and CPHD subjects with genital stage 1, likely reflecting a smaller pool of Sertoli cells in profound HH. In IHH and CPHD boys with genital stage 1, sensitivity and specificity were 100% for INHB concentration of 35 pg/ml or less. In IHH and CPHD boys with genital stage 2, sensitivities were 86 and 80%, whereas specificities were 92% and 88%, respectively, for an INHB concentration of 65 pg/ml or less. The performance of testosterone, AMH, FSH, and LH measurements was lower. No combination or ratio of hormones performed better than INHB alone. CONCLUSION: Discrimination of HH from CDP with baseline INHB measurement was excellent in subjects with genital stage 1 and fair in subjects with genital stage 2.

Relationship between lumen diameter and length sterilized in the 125L ozone sterilizer.

BACKGROUND: A safe alternative to ethylene oxide for reprocessing heat-sensitive lumen medical devices, such as endoscopes, is needed. The effectiveness of a new, safe, low-cost, and environmentally friendly low-temperature sterilization process using ozone was assessed. METHOD: Rigid lumen devices were used to assess the maximum length of lumens of different internal diameters that can be sterilized in the TSO(3) model 125L ozone sterilizer. Two inoculation techniques were used. An inoculated wire was placed inside lumens with internal diameters of 0.8 mm and larger, whereas lumens with an internal diameter of 0.5 mm were inoculated directly. RESULTS: Lumens with internal diameters of 0.5 mm, 1 mm, 2 mm, 3 mm, and 4 mm with lengths varying between 45 and 70 cm can be sterilized with ozone. Calculation of the log reduction value for each size demonstrated the achievement of a sterility assurance level of 10(-6). Experimental results demonstrated a linear relationship (with r(2) = 0.990) between the length of lumen that can be sterilized in the 125L ozone sterilizer and its internal diameter. Effective sterilization of an ACMI ureteroscope that is more challenging in terms of sterilant penetration in a small lumen (0.8 mm) compared with the stated lumen claims confirms that the relationship can conservatively be used to predict the length of a lumen device that can be sterilized in the 125L ozone sterilizer for a given diameter. CONCLUSION: Intermediate sizes of lumen devices that can be sterilized in the 125L ozone sterilizer can be interpolated from the linear relationship between diameter and length found in the present study.

High birth weight and early postnatal weight gain protect obese children and adolescents from truncal adiposity and insulin resistance: metabolically healthy but obese subjects?

OBJECTIVE: Low birth weight (LBW), no early catch-up weight, and subsequent fat accumulation have been associated with increased risks of insulin resistance from childhood onward and later cardiovascular disease. We sought to clarify the effects of high birth weight (HBW) and postnatal weight gain on insulin resistance. RESEARCH DESIGN AND METHODS: A total of 117 obese children aged 10.4 +/- 2.4 years were divided into three groups according to fetal growth after exclusion of maternal diabetes. They were comparable for age, sex, puberty, and percent body fat. Customized French birth weight standards, adjusted for maternal characteristics and gestation number, identified subjects with true altered fetal growth: 32 had increased fetal growth according to customized standards (HBWcust), 52 were eutrophic, and 33 had restricted fetal growth according to customized standards (LBWcust). Fat distribution by dual-energy X-ray absorptiometry, insulin sensitivity indexes from an oral glucose tolerance test (OGTT), and leptin, adiponectin, and visfatin levels were compared between groups. RESULTS: The HBWcust subjects had a higher adiponectin level, higher whole-body insulin sensitivity index (WBISI), and lower hepatic insulin resistance index, lower insulin and free fatty acid concentrations during OGTT, and lower trunk fat percent than eutrophic (P < 0.05) and LBWcust subjects (P < 0.05). Besides birth weight, weight gain between 0 and 2 years was a positive predictor (P < 0.05) of WBISI, whereas weight gain after 4 years was a negative predictor (P < 0.05). CONCLUSIONS: HBW and early weight gain may program insulin sensitivity and adipose tissue metabolism and contribute to so-called metabolically healthy obesity.