Factors influencing medical decisions for a cognitively impaired family member

Main Category: Public Health
Also Included In: Alzheimer's / Dementia
Article Date: 19 Aug 2013 - 1:00 PDT Current ratings for:
Factors influencing medical decisions for a cognitively impaired family member

Decision-making by a surrogate for a family member who is unable to make medical decisions is more complicated than decision-making by patients themselves, according to a study from the Regenstrief Institute, Indiana University Center for Aging Research and the Charles Warren Fairbanks Center for Medical Ethics of Indiana University Health.

The researchers found that family decision-makers considered the cognitively impaired patient's wishes and interests. But they also took into account their own needs and preferences.

Factors influencing surrogate decision-makers included:

Respect for the patient's input. The patient's prior wishes. Consideration of the patient's best interests. The surrogate's own wishes as a guide. The surrogate's religious and spiritual beliefs. The surrogate's own interests. Family consensus.

"Family members often say that they wish they knew more about their loved one's views on medical care," said Regenstrief Institute investigator Alexia Torke, M.D., associate professor of medicine at the IU School of Medicine and an IU Center for Aging Research scientist. "And whether or not surrogates know what the patient would have wanted had they been able to make the decision for themselves, we learned that family members may feel compelled to substitute what they themselves want, or to paraphrase the Golden Rule: do to others as you would have them do to you.

"Surrogates also consider the feelings and beliefs of other family members," said Dr. Torke, senior author of the study. "The individuals who are making decisions for those who cannot are the survivors - they take into account the fact that they have to live with other family members as and after they make surrogate decisions."

"Making Decisions for Hospitalized Older Adults: Ethical Factors Considered by Family Surrogates" is published in the Summer 2013 issue of the Journal of Clinical Ethics.

An estimated four out of 10 hospitalized adults lack decision-making capacity due to cognitive impairment. When patients are unable to make their own decisions, surrogates often are called upon. Dr. Torke notes that the need for surrogate decision-making is growing as life-sustaining medical technology becomes more available, the population ages, and the prevalence of diseases such as Alzheimer's and other forms of dementia increases.

In the study, the investigators interviewed 35 surrogates with a recent decision-making experience for a hospital patient age 65 or older. The group was almost evenly split between white and African-American surrogates. Eighty percent of the respondents were female; 60 percent were the daughters of the cognitively impaired patient.

"Because surrogates also imagine what they would want under the circumstances and consider their own needs and preferences as well as those of the patient for whom they are acting, standard ethical models of surrogate decision-making [in the academic literature] must account for these additional considerations," the paper noted. "Surrogates' desire for more information about patient preferences suggests a need for greater advance care planning."

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IU School of Medicine student Jenna Fritsch, B.S., is first author of the paper. Co-authors, in addition to Dr. Torke, are Sandra Petronio, Ph.D., of the Department of Communication Studies in the IU School of Liberal Arts at Indiana University-Purdue University Indianapolis; and Paul R. Helft, M.D., of the Department of Medicine at the IU School of Medicine and the IU Melvin and Bren Simon Cancer Center. Drs. Torke, Petronio and Helft are members of the Charles Warren Fairbanks Center for Medical Ethics at IU Health, of which Dr. Helft serves as the director.

Dr. Torke was supported by an award [K23AG031323] from the National Institute on Aging at the National Institutes of Health. Fritch was supported by the Medical Student Training in Aging Research program, administered by the American Federation for Aging Research and the National Institute on Aging. The content of the study is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Indiana University

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International research team identifies top risk factors for children during influenza pandemic

Main Category: Pediatrics / Children's Health
Also Included In: Flu / Cold / SARS
Article Date: 15 Aug 2013 - 2:00 PDT Current ratings for:
International research team identifies top risk factors for children during influenza pandemic

An international team of pediatric specialists, representing the world's five major pediatric emergency medicine research networks, has identified several crucial risk factors for alerting clinicians to children most susceptible to life-threatening infections from the H1N1 influenza (flu). It is the first study to detail which clinical factors at hospital arrival in children with influenza-like illness and H1N1 infection are associated with the progressive risk to either severe infection or death.

In a study now on online in the prestigious British Medical Journal, researchers examined pediatric cases from dozens of emergency departments in hospitals around the world during the global influenza pandemic of 2009. The results enabled the team to pinpoint several clinical risk factors for severe infections in youngsters who arrive at a hospital with influenza-like illnesses due to H1N1 infections. The information would be invaluable during a pandemic, when emergency departments and primary-care facilities experience large surges of young patients who arrive with flu-like symptoms.

The study, which assessed each patient's clinical history and physical examination, identified the following predictors of severe H1N1 infection and potentially fatal outcomes in children:

History of chronic lung diseaseHistory of cerebral palsy/developmental delaySigns of chest retractions (difficulty breathing)Signs of dehydrationRequires oxygen to keep blood levels normalHeart rate that exceeds normal range (tachycardia) relative to age

"The basic question clinicians face when they are in the middle of an influenza epidemic like H1N1 is whether their patient is at risk of severe complications," said Stuart Dalziel, lead author of the study and a pediatrician at New Zealand's Starship Children's Hospital and The University of Auckland, and vice-chair of the Paediatric Research in Emergency Departments International Collaborative (PREDICT) network. "One of the key strengths of this study is that it provides clinicians with meaningful and more precise information that can enable them to identify those children with fever and flu-like symptoms who are at greater risk of severe complications."

The findings stem from 265 pediatric cases culled from 79 emergency departments of hospitals associated with the Pediatric Emergency Research Networks (PERN) in 12 countries.

"Having a more accurate idea of what to look for in pediatric cases, especially during a pandemic, would be especially important to clinicians because it provides crucial guidance for those who would be trying to direct the appropriate levels of treatment for many patients in a short time," said Nathan Kuppermann, professor and chair of emergency medicine at the University of California, Davis, one of the study's senior authors and a principal investigator in the Pediatric Emergency Care Applied Research Network (PECARN).

Because of its unparalleled global network of hospitals and patient data, the PERN study also added weight to the efficacy and use of the anti-viral drug oseltamivir (trade name Tamiflu) to treat the children with H1N1 influenza virus infections to reduce the severity of infection. Researchers noted there was good evidence of an association between oseltamivir treatment and a reduced frequency of death in children admitted to an intensive care unit for assisted ventilation.

"This study shows the incredible power of PERN, bringing together five pediatric emergency research networks and many emergency departments from around the world, to produce this very significant study which has the power to identify the most at-risk children in a future influenza pandemic," said Terry P. Klassen, the study's senior author, CEO and scientific director at the Manitoba Institute of Child Health in Canada and a site investigator with Pediatric Emergency Research Canada (PERC).

The global research collaborative is comprised of the five major pediatric networks, which are located in Europe and the Middle East (Research in European Paediatric Emergency Medicine, or REPEM), North America (PECARN, PERC and the Pediatric Emergency Medicine Collaborative Research Committee), and in Australia and New Zealand (PREDICT). Together, the five networks have access to data from more than three million pediatric emergency department cases annually from more than 100 hospitals, which are located in four of the six World Health Organization (WHO) regions.

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our pediatrics / children's health section for the latest news on this subject.

Funding: PECARN is supported by HRSA/MCHB/EMSC through the following cooperative agreements: U03MC00001, U03MC00003, U03MC00006, U03MC00007, U03MC00008, U03MC22684, and U03MC22685. Stuart Dalziel is supported by the Health Research Council of New Zealand. John M.D. Thompson received funding from the Logan Campbell Trust, Auckland, New Zealand, to attend an investigator meeting, with time funded by CureKids, New Zealand. Investigators’ time was funded by their host institutions and/or research networks. No funding bodies had any role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Predictors of severe H1N1 infection in children presenting within Pediatric Emergency Research Networks (PERN): retrospective case-control study

BMJ 2013; 347 doi: 10.1136/bmj.f4836

Stuart R Dalziel, John MD Thompson, Charles G Macias, Ricardo M Fernandes, David W Johnson, Yehezkel Waisman, Nicholas Cheng, Jason Acworth, James M Chamberlain, Martin H Osmond, Amy Plint, Paolo Valerio, Karen JL Black, Eleanor Fitzpatrick, Amanda S Newton, Nathan Kuppermann, Terry P Klassen

UC Davis Health System

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Saliva from heavy cell phone users shows increased risk factors for cancer

Main Category: Cancer / Oncology
Also Included In: Public Health
Article Date: 31 Jul 2013 - 1:00 PDT Current ratings for:
Saliva from heavy cell phone users shows increased risk factors for cancer

Scientists have long been worried about the possible harmful effects of regular cellular phone use, but so far no study has managed to produce clear results. Currently, cell phones are classified as carcinogenic category 2b - potentially carcinogenic to humans - by the International Agency for Research on Cancer (IARC). A new Tel Aviv University study, though, may bring bad news.

To further explore the relationship between cancer rates and cell phone use, Dr. Yaniv Hamzany of Tel Aviv University's Sackler Faculty of Medicine and the Otolaryngology Head and Neck Surgery Department at the Rabin Medical Center, looked for clues in the saliva of cell phone users. Since the cell phone is placed close to the salivary gland when in use, he and his fellow researchers, including departmental colleagues Profs. Raphael Feinmesser, Thomas Shpitzer and Dr. Gideon Bahar and Prof. Rafi Nagler and Dr. Moshe Gavish of the Technion in Haifa, hypothesized that salivary content could reveal whether there was a connection to developing cancer.

Comparing heavy mobile phone users to non-users, they found that the saliva of heavy users showed indications of higher oxidative stress - a process that damages all aspects of a human cell, including DNA - through the development of toxic peroxide and free radicals. More importantly, it is considered a major risk factor for cancer.

The findings have been reported in the journal Antioxidants and Redox Signaling.

Putting stress on tissues and glands

For the study, the researchers examined the saliva content of 20 heavy-user patients, defined as speaking on their phones for a minimum of eight hours a month. Most participants speak much more, Dr. Hamzany says, as much as 30 to 40 hours a month. Their salivary content was compared to that of a control group, which consisted of deaf patients who either do not use a cell phone, or use the device exclusively for sending text messages and other non-verbal functions.

Compared to the control group, the heavy cell phone users had a significant increase in all salivary oxidative stress measurements studied.

"This suggests that there is considerable oxidative stress on the tissue and glands which are close to the cell phone when in use," he says. The damage caused by oxidative stress is linked to cellular and genetic mutations which cause the development of tumors.

Making the connection

This field of research reflects longstanding concerns about the impact of cell phone use, specifically the effects of radiofrequency non-ionizing electromagnetic radiation on human tissue located close to the ear, say the researchers. And although these results don't uncover a conclusive "cause and effect" relationship between cellular phone use and cancer, they add to the building evidence that cell phone use may be harmful in the long term, and point to a new direction for further research.

One potential avenue of future research would be to analyze a person's saliva prior to exposure to a cell phone, and then again after several intense minutes of exposure. This will allow researchers to see if there is an immediate response, such as a rise in molecules that indicate oxidative stress, Dr. Hamzany says.

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
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Yaniv Hamzany, Raphael Feinmesser, Thomas Shpitzer, Aviram Mizrachi, Ohad Hilly, Roy Hod, Gideon Bahar, Irina Otradnov, Moshe Gavish, and Rafael M. Nagler. Is Human Saliva an Indicator of the Adverse Health Effects of Using Mobile Phones? Antioxidants & Redox Signaling. February 20, 2013, 18(6): 622-627. doi:10.1089/ars.2012.4751

American Friends of Tel Aviv University

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Protein moulds RNA to ensure that activating factors can hold on to it

Main Category: Genetics
Article Date: 30 Jul 2013 - 0:00 PDT Current ratings for:
Protein moulds RNA to ensure that activating factors can hold on to it

X chromosomes are very special genetic material. They differ in number between men and women. To achieve equality between sexes, one out of two X chromosomes in women is silenced. In flies, the opposite happens: in male flies, the only available X chromosome is highly activated, to compensate for the absence of the second X-chromosome. Researchers from the Max Planck Institute of Immunobiology and Epigenetics (MPI-IE) in Freiburg have now shown how the RNA molecules and proteins involved in the activation find and stick to each other. Similar to a monkey that grabs a liana with hands and feet, one of the proteins holds on to the RNA. Then it moulds the molecular liana with its hands and thus generates a dynamic RNA - protein meeting place.

Just a few years ago, they were assumed to be genetic trash: DNA sequences that are not translated into proteins. But this has rapidly changed during the last years. Nowadays, it is widely known among scientists that much of the DNA is transcribed into RNA that, in turn, can act as gene regulator and structural element. Also in the regulation of sex chromosomes, RNA plays a central role. In both female humans and male flies one X chromosome is covered by a protein-RNA complex. In humans, this leads to chromosome silencing, while in flies it results in a double activation of the chromosome. Misregulation is lethal. Although known for many years, the interaction between the central proteins and the distinct role of the RNA strand was unclear.

Asifa Akhtar of the MPI-IE and her team now unravelled the function of the RNA and the interaction of the proteins. The protein MLE that is known to be a central player in X chromosome activation binds to the RNA in a very special manner. Like a monkey that grabs a liana with hands and feet, the protein grabs the RNA in two different ways. While one site is a simple anchor (the feet), the other (the hands) changes the form of the RNA. "The protein MLE moulds the RNA strand. This allows MLE to bind the RNA in a dynamic manner", says Asifa Akhtar, head of the study. Like one monkey helping the other to catch the liana MLE could thus help other proteins to grab the RNA strand. Thus, the whole X chromosome can be covered by the RNA-protein complex.

During his PhD work, first author Ibrahim Ilik investigated why MLE was found at the same places on the X chromosome but did not directly interact with other proteins. "The biochemical and the biological results seemed to point in different directions in the beginning", says Ilik. "But when we realised that the proteins bind highly specifically to certain regions of the very long RNA, this was a very exciting moment."

The researchers also found that individual mutations in the RNA hardly harm the protein-RNA binding. Only multiple mutations lead to a non-functional RNA and thus to lethality of male flies. "The system is very robust for evolutionary influences. This shows how important it is for the survival of the animals. In this, RNA could provide the necessary plasticity", says Akhtar. The scientists now want to explore the evolutionary conservation of the RNA-protein system and its equivalent in mammals.

Scientists at the Max Planck Institute of Immunobiology and Epigenetics (MPI-IE) in Freiburg investigate the development of the immune system over the course of evolution and during lifetime. They analyse genes and molecules that are important for immune cells maturation and activation. Researchers in the field of epigenetics investigate the inheritance of traits that are not caused by changes in the DNA sequence. Epigenetic research is expected to lead to a better understanding of many complex diseases, such as cancer and metabolic disorders.

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