Medical Decision-Making Incapacity among Newly Diagnosed Older Patients with Hematological Malignancy Receiving First Line Chemotherapy: A Cross-Sectional Study of Patients and Physicians

Background

Decision-making capacity to provide informed consent regarding treatment is essential among cancer patients. The purpose of this study was to identify the frequency of decision-making incapacity among newly diagnosed older patients with hematological malignancy receiving first-line chemotherapy, to examine factors associated with incapacity and assess physicians’ perceptions of patients’ decision-making incapacity.

Methods

Consecutive patients aged 65 years or over with a primary diagnosis of malignant lymphoma or multiple myeloma were recruited. Decision-making capacity was assessed using the Structured Interview for Competency and Incompetency Assessment Testing and Ranking Inventory-Revised (SICIATRI-R). Cognitive impairment, depressive condition and other possible associated factors were also evaluated.

Results

Among 139 eligible patients registered for this study, 114 completed the survey. Of these, 28 (25%, 95% confidence interval [CI]: 17%-32%) were judged as having some extent of decision-making incompetency according to SICIATRI-R. Higher levels of cognitive impairment and increasing age were significantly associated with decision-making incapacity. Physicians experienced difficulty performing competency assessment (Cohen’s kappa -0.54).

Conclusions

Decision-making incapacity was found to be a common and under-recognized problem in older patients with cancer. Age and assessment of cognitive impairment may provide the opportunity to find patients that are at a high risk of showing decision-making incapacity.     

Glucose Homeostatic Law: Insulin Clearance Predicts the Progression of Glucose Intolerance in Humans

Homeostatic control of blood glucose is regulated by a complex feedback loop between glucose and insulin, of which failure leads to diabetes mellitus. However, physiological and pathological nature of the feedback loop is not fully understood. We made a mathematical model of the feedback loop between glucose and insulin using time course of blood glucose and insulin during consecutive hyperglycemic and hyperinsulinemic-euglycemic clamps in 113 subjects with variety of glucose tolerance including normal glucose tolerance (NGT), impaired glucose tolerance (IGT) and type 2 diabetes mellitus (T2DM). We analyzed the correlation of the parameters in the model with the progression of glucose intolerance and the conserved relationship between parameters. The model parameters of insulin sensitivity and insulin secretion significantly declined from NGT to IGT, and from IGT to T2DM, respectively, consistent with previous clinical observations. Importantly, insulin clearance, an insulin degradation rate, significantly declined from NGT, IGT to T2DM along the progression of glucose intolerance in the mathematical model. Insulin clearance was positively correlated with a product of insulin sensitivity and secretion assessed by the clamp analysis or determined with the mathematical model. Insulin clearance was correlated negatively with postprandial glucose at 2h after oral glucose tolerance test. We also inferred a square-law between the rate constant of insulin clearance and a product of rate constants of insulin sensitivity and secretion in the model, which is also conserved among NGT, IGT and T2DM subjects. Insulin clearance shows a conserved relationship with the capacity of glucose disposal among the NGT, IGT and T2DM subjects. The decrease of insulin clearance predicts the progression of glucose intolerance.     

Extreme rapid warming yields high functional survivals of vitrified 8-cell mouse embryos even when suspended in a half-strength vitrification solution and cooled at moderate rates to −196 °C

To cryopreserve cells, it is essential to avoid intracellular ice formation during cooling and warming. One way to do so is to subject them to procedures that convert cell water into a non-crystalline glass. Current belief is that to achieve this vitrification, cells must be suspended in very high concentrations of glass-inducing solutes (i.e., ?6 molal) and cooled at very high rates (i.e., ?1000 °C/min). We report here that both these beliefs are incorrect with respect to the vitrification of 8-cell mouse embryos. In this study, precompaction 8-cell embryos were vitrified in several dilutions of EAFS10/10 using various cooling rates and warming rates. Survival was based on morphology, osmotic functionality, and on the ability to develop to expanded blastocysts. With a warming rate of 117,500 °C/min, the percentages of embryos vitrified in 1×, 0.75×, and 0.5× EAFS that developed to blastocysts were 93%, 92%, and 83%, respectively. And the percentages of morphological survivors that developed to expanded blastocysts were 100%, 92%, and 97%, respectively. Even when the solute concentration of the EAFS was reduced to 33% of normal, we obtained 40% functional survival of these 8-cell embryos.     

Effects of TGF-β1 on the proliferation and differentiation of human periodontal ligament cells and a human periodontal ligament stem/progenitor cell line

Periodontal ligament (PDL) is a specialized connective tissue that influences the lifespan of the tooth. Transforming growth factor-β1 (TGF-β1) is a multifunctional cytokine, but little is known about the effects of TGF-β1 on PDL cells. Our aim has been to demonstrate the expression of TGF-β1 in rat PDL tissues and to evaluate its effects on the proliferation and gene expression in human PDL cells (HPLCs) and a human PDL stem/progenitor cell line, line 1-11, that we have recently developed. The expression of TGF-β1 in the entire PDL tissue was confirmed immunohistochemically, and both HPLCs and cell line 1-11 expressed mRNA from the TGF-β1, TGF-β type I receptor, and TGF-β type II receptor genes. Although exogenous TGF-β1 stimulated the proliferation of HPLCs, it did not upregulate the expression of alpha-smooth muscle actin (α-SMA), type I collagen (Col I), or fibrillin-1 (FBN1) mRNA or of α-SMA protein in HPLCs, whereas expression for these genes was attenuated by an anti-TGF-β1 neutralizing antibody. In contrast, exogenous TGF-β1 reduced the proliferation of cell line 1-11, although it upregulated the expression of α-SMA, Col I, and FBN1 mRNA and of α-SMA protein in this cell line. In addition, interleukin-1 beta stimulation significantly reduced the expression of TGF-β1 mRNA and protein in HPLCs. Thus, TGF-β1 seems to play an important role in inducing fibroblastic differentiation of PDL stem/progenitor cells and in maintaining the PDL apparatus under physiological conditions.     

Comparison of brain–computer interface decoding algorithms in open-loop and closed-loop control

Neuroprosthetic devices such as a computer cursor can be controlled by the activity of cortical neurons when an appropriate algorithm is used to decode motor intention. Algorithms which have been proposed for this purpose range from the simple population vector algorithm (PVA) and optimal linear estimator (OLE) to various versions of Bayesian decoders. Although Bayesian decoders typically provide the most accurate off-line reconstructions, it is not known which model assumptions in these algorithms are critical for improving decoding performance. Furthermore, it is not necessarily true that improvements (or deficits) in off-line reconstruction will translate into improvements (or deficits) in on-line control, as the subject might compensate for the specifics of the decoder in use at the time. Here we show that by comparing the performance of nine decoders, assumptions about uniformly distributed preferred directions and the way the cursor trajectories are smoothed have the most impact on decoder performance in off-line reconstruction, while assumptions about tuning curve linearity and spike count variance play relatively minor roles. In on-line control, subjects compensate for directional biases caused by non-uniformly distributed preferred directions, leaving cursor smoothing differences as the largest single algorithmic difference driving decoder performance.     

Long-term trends in food habits of Asiatic black bears in the Misaka Mountains on the Pacific coast of central Japan

I did the food habits of the Asiatic black bear Ursus thibetanus from 1013 fecal samples collected between 1999 and 2005 in the Misaka Mountains on the Pacific coast of central Japan. The food habits of the bears showed clear seasonal changes, and I classified the food resources of the bears into three types. Staple foods were green vegetation in spring, soft mast (Prunus spp.) and insects in summer, and hard mast (Quercus spp.) in autumn. Alternative foods were green vegetation and other soft mast (Rubus spp.) in summer and Japanese chestnuts Castanea crenata and vine fruits in autumn. Foods of opportunity were hard mast (Quercus spp.) that had been shed in the previous autumn and were found in spring and other fruits in autumn. Seasonal food habits showed yearly variations: bears used alternative foods and foods of opportunity in response to the yearly variation in staple food amount, but the magnitude of variability of food habits differed among seasons, with large variability in autumn and small variability in summer and spring. The primary influence on the yearly variation in food habit is presumably the fluctuation in fruit production among years. Summer is probably the most difficult season in terms of the bear's food supply, because the number of fruiting species is limited and staple foods such as new green vegetation and fruits are less available. Long-term studies of the availability of the main food items and food habits of bears will be critical for further understanding these animals’ feeding ecology and for determining the factors that influence their behavior.     

Evolution of indirect reciprocity in groups of various sizes and comparison with direct reciprocity

Recently many studies have investigated the evolution of indirect reciprocity through which cooperative action is returned by a third individual, e.g. individual A helped B and then receives help from C. Most studies on indirect reciprocity have presumed that only two individuals take part in a single interaction (group), e.g. A helps B and C helps A. In this paper, we investigate the evolution of indirect reciprocity when more than two individuals take part in a single group, and compare the result with direct reciprocity through which cooperative action is directly returned by the recipient. Our analyses show the following. In the population with discriminating cooperators and unconditional defectors, whether implementation error is included or not, (i) both strategies are evolutionarily stable and the evolution of indirect reciprocity becomes more difficult as group size increases, and (ii) the condition for the evolution of indirect reciprocity under standing reputation criterion where the third individuals distinguish between justified and unjustified defections is more relaxed than that under image scoring reputation criterion in which the third individuals do not distinguish with. Furthermore, in the population that also includes unconditional cooperators, (iii) in the presence of errors in implementation, the discriminating strategy is evolutionarily stable not only under standing but also under image scoring if group size is larger than two. Finally, (iv) in the absence of errors in implementation, the condition for the evolution of direct reciprocity is equivalent to that for the evolution of indirect reciprocity under standing, and, in the presence of errors, the condition for the evolution of direct reciprocity is very close to that for the evolution of indirect reciprocity under image scoring.