Policy statement on inappropriate ICU requests
FIVE professional medical societies in the US have issued a joint policy statement on how clinicians should respond to requests for potentially inappropriate treatments in intensive care units (ICUs). The statement, published in the American Journal of Respiratory and Critical Care Medicine, provides guidelines to prevent and manage disputes with patients with advanced critical illness and their families. The four recommendations were developed using an iterative consensus process, including expert committee development and peer review by designated committees of the American Thoracic Society, American Association for Critical Care Nurses, American College of Chest Physicians, European Society for Intensive Care Medicine and Society of Critical Care. The statement said that how to respond to requests from surrogates to administer life-prolonging interventions when clinicians believe those interventions should not be administered was one of the most ethically controversial issues in ICUs. The recommendations are: 1) Institutions implement strategies to prevent intractable treatment conflicts, including proactive communication and early involvement of expert consultants; 2) The term “potentially inappropriate” be used rather than “futile” to describe treatments that have at least some chance of accomplishing the effect sought by the patient, but where clinicians believe competing ethical considerations do not justify providing them; 3) Use of the term “futile” be restricted to rare situations where surrogates request interventions that simply cannot accomplish their intended physiologic goal, and that clinicians not provide futile interventions; 4) The medical profession lead public engagement efforts and advocate for policies and legislation about when life-prolonging technologies should not be used. “This multisociety statement recommends strategies to prevent treatment disputes in ICUs, provides a framework to characterize disputes, and outlines processes to manage intractable treatment disputes with an emphasis on procedural fairness”, the authors wrote.
Childhood cancer treatment, genetics and obesity risk
US researchers have found that 47% of adult survivors of childhood cancer who received cranial radiotherapy (CRT) and 29.4% of those who did not receive CRT were obese. The research, published in Cancer, included 1996 survivors who were treated for cancer at a children’s research hospital and who survived for a median 24.6 years or more from diagnosis (media age at diagnosis 7.2 years and median age at follow-up 32.4 years). Among males, the highest prevalence of obesity was in survivors of leukaemia (42.5%) and other tumours (38.8%). Among female survivors, the prevalence of obesity was highest in survivors of neuroblastoma (43.6%) and leukaemia (43.1%). The prevalence of obesity was highest among survivors who were diagnosed before age 5 years and among those more than 30 years from diagnosis. In survivors who received CRT, older age at follow-up (30 or more years v <30 years), younger age at diagnosis (0–4 years v 15 or more years) and treatment with glucocorticoids were associated with obesity. Among survivors who were not exposed to CRT, older age at follow-up was associated with obesity, but abdominal or pelvic radiation was inversely associated with obesity. The researchers also identified genetic polymorphisms in regions near or within the FAM155A, SOX11, CDH18 and GLRA3 genes that were associated with obesity among survivors who received CRT. The researchers wrote that their findings confirmed that the high prevalence of obesity among childhood cancer survivors persisted decades after cancer treatment and appeared to be influenced by therapies received during childhood and obesity status at diagnosis. “The high prevalence of obesity among survivors underscores the need for immediate focus on research directed at developing effective interventions for weight management to optimize health outcomes among survivors of childhood cancer as they age”, they wrote.
Non-disclosure clauses “hard to justify”
A RETROSPECTIVE review of medical malpractice claim files which resulted in settlement agreements has found that nearly 90% of the settlements include non-disclosure clauses. The research, published in JAMA Internal Medicine, was based on 715 medical malpractice files, including 150 settlement agreements, from the University of Texas System, which self-insures malpractice claims that involve 6000 physicians at six academic medical centres in five cities. Of the 124 settlement agreements studied, the researchers found all the non-disclosure clauses prohibited disclosure of the settlement terms and amount, 61 (55.5%) prohibited disclosure that the settlement had been reached, 51 (46.4%) prohibited disclosure of the facts of the claim, 29 (26.4%) prohibited reporting to regulatory agencies, and 10 (9.1%) prohibited disclosure by the settling physicians and hospitals as well as the claimant. Three agreements (2.7%) included specific language that prohibited the claimant from disparaging the physicians or hospitals. The study authors wrote that if adverse events could not be identified and investigated, unsafe medical practices would continue. They wrote that although their data indicated few settlement agreements preclude health care professionals from sharing information from malpractice claims with one another, “other hospitals and physicians may be denied knowledge that allowing patients to discuss their experiences and complain to regulators might convey”. They said the academic health system had a “declared commitment to patient safety and transparency” yet it used non-disclosure clauses in most malpractice settlement agreements with little standardisation or consistency, and the scope of this non-disclosure was often broader than seemed needed to protect physicians and hospitals from “disparagement” or to avoid publicising settlement amounts that might attract other claimants. “Some agreements prohibited reporting to regulatory agencies, a practice that the health care system changed in response to our findings”, they wrote. An accompanying commentary said restrictions on public disclosure of the facts of the event, without identifying the health care professionals or institutions involved, was hard to justify.
Rewards help smokers quit
SMOKERS are more likely to accept a rewards-based program to help them quit, but those who agree to participate in deposit-based programs are more likely to sustain quit attempts, according to research published in the New England Journal of Medicine. In a randomised controlled trial which enrolled 2538 adult smokers, the researchers reported that 90.0% assigned to the reward-based programs accepted the assignment compared with just 13.7% assigned to a program based on refundable deposits. Participants were assigned to one of five groups — usual care, individual reward, group collaborative reward, individual deposit or competitive deposit. Participants in all four intervention groups who stopped smoking stood to gain up to $800, whether by reward or returned deposit plus reward. Each of the four programs resulted in greater rates of sustained abstinence from smoking for 6 months (9.4% to 16.0%) than usual care (6%). At 12 months, 6 months after the cessation of incentives, about half the participants who were abstinent at 6 months had submitted negative cotinine assays. “Perhaps the most important finding is that incentive programs that required people to deposit $150 of their own money were less effective overall than reward-based programs of similar value because few people accepted such deposit programs”, the authors wrote, even when they were offered a $650 reward in addition to the return of the deposit. “However, analyses that account for the different acceptance rates of the interventions showed that deposit-based incentives were substantially more efficacious than reward-based incentives among people who would have accepted either.” An accompanying editorial said the challenge was to find a way to “nudge” people to enrol in such programs.
Concussion affects academic performance
CONCUSSION impacts on a child’s academic learning and performance, with more adverse effects reported by students who have not yet recovered from injury, research has found. The study, published in Pediatrics, included 349 students aged 5–18 years who underwent an initial evaluation in an outpatient concussion clinic in the US, and their parents. Both students and parents reported academic concerns and problems, including interfering symptoms and diminished academic skills, through a structured school questionnaire within 4 weeks of injury. Post-concussion symptoms were measured as a marker of injury severity, and results were examined based on recovery status (recovered or actively symptomatic) and level of schooling (elementary, middle and high school). Actively symptomatic students and their parents reported higher levels of concern for the impact of concussion on school performance and more school-related problems than recovered peers and their parents, the authors said. They found that high school students who had not yet recovered reported significantly more adverse academic effects than their younger counterparts. Greater severity of post-concussion symptoms was also associated with more school-related problems and worse academic effects, regardless of time since injury. The authors said their study provided initial evidence of a concussion’s effects on academic learning and performance across all grades, including student and parent report of the nature and extent of school concerns and post-injury problems. “Medical-school partnerships can facilitate a targeted approach to school-based management for students with active concussion symptoms, minimizing the potential for adverse academic effects and postinjury morbidities”, the authors wrote.
Neuropathy risk with coeliac disease
COELIAC disease (CD) is associated with a 2.5-fold increased risk of neuropathy, according to a population-based study published in JAMA Neurology. The researchers collected data on small-intestine biopsies performed at 28 Swedish pathology departments between 1969 and 2008. The risk of neuropathy in 28 232 patients with CD was compared with 139 473 people in an age and gender matched control group. A total of 41.7% of patients with CD were diagnosed in childhood, with a median age at diagnosis of 29 years. Patients were followed up for a median of 10 years. The authors found that 0.7% of patients with CD received a later diagnosis of neuropathy, compared with 0.3% of control participants. There was also an increased risk of chronic inflammatory demyelinating neuropathy, autonomic neuropathy and mononeuritis multiplex among people with CD. However, there was no association between CD and acute inflammatory demyelinating polyneuropathy, the authors wrote. Risk estimates for neuropathy were highest in the first year after diagnosis of CD, but there was also a significantly increased risk of neuropathy after the first year of follow-up. The absolute risks of neuropathy were 64 per 100 000 person-years in patients with CD and 15 per 100 000 person-years in the control group, the authors said. Overall, there were no differences between men and women in the risk of neuropathy in patients with CD, and age at diagnosis also did not influence the risk estimate for any neuropathy in patients with CD. “Although absolute risks for neuropathy are low, CD is a potentially treatable condition with a young age of onset”, the authors wrote. They suggested that screening for CD could be beneficial in patients with neuropathy.
Olive oil and nuts key in improved cognition
MEDITERRANEAN diet supplemented with either olive oil or nuts is associated with improved cognitive function among older adults, according to Spanish research published in JAMA Internal Medicine. The study, conducted between 2003 and 2009, included 447 cognitively healthy volunteers from Barcelona with a mean age of 66.9 years and at high cardiovascular risk. Participants were randomly assigned to a Mediterranean diet supplemented with one litre of extra virgin olive oil per week or with 30 g per day of mixed nuts, or a low fat control diet. The authors measured cognitive change with a neuropsychological test battery and constructed three cognitive composites: memory, frontal (attention and executive function) and global. After a median 4 years of the intervention, follow-up results were available for 334 participants. The authors wrote that their results revealed cognitive improvement in those on both versions of the Mediterranean diet and cognitive decline in those on the control diet. The benefit of the Mediterranean diet was independent of sex, age, energy intake and cognition-related variables. No dementia cases were documented in participants who completed follow up. Changes above baseline of the memory composite were 0.04 for the Mediterranean diet plus olive oil, 0.09 for the Mediterranean diet plus nuts and ‒0.17 for the control diet. “The beneficial effect of Mediterranean diets on cognition probably stems from the abundance of antioxidants and anti-inflammatory agents that they provide”, the authors wrote. “The supplemental foods, extra virgin olive oil and nuts, are particularly rich in phenolic compounds that might counteract oxidative processes in the brain, leading to neurodegeneration.” While acknowledging the limitations of the research, the authors said the results suggested that in an older population a Mediterranean diet supplemented with olive oil or nuts may counteract age-related cognitive decline. “The lack of effective treatments for cognitive decline and dementia points to the need of preventive strategies to delay the onset and/or minimise the effects of these devastating conditions”, they wrote.