Effects of ruminal degradability of ensiled whole crop maize varieties on feed intake and milk production of dairy cows.

The feed value of whole crop maize silage (WCMS) depends on nutrient composition, ruminal degradability and whole tract digestibility. However, as the ruminal degradation rate is involved in physical regulation of feed intake, ruminal degradability of WCMS may also affect feed intake and milk production of dairy cows. Thus, the aim of this study was to examine relationships between nutrient composition, ruminal degradability, and whole tract digestibility of WCMS and feed intake and milk production of dairy cows. Nine varieties were tested in 3 consecutive years. Nutrient composition analyses included proximate analysis and determination of cell wall constituents. Whole tract digestibility was determined in vivo using wethers and ruminal degradability was examined in situ using four rumen-fistulated steers. Feed intake and milk production were measured using nine cows per variety. Cows were fed a ration consisting of 75.0% WCMS, 8.5% hay and 16.5% soya bean meal (dry matter basis) ad libitum. Variety did not influence nutrient composition, except for the concentration of ADF (ADFom), ADL and utilisable CP (uCP). In contrast, variety had a significant effect (P < 0.05) on ruminal degradability of NDF (aNDFom) and on whole tract digestibility of organic matter (OM) and non-fibre carbohydrates. Dry matter intake (DMI) of WCMS tended to be affected by variety (0.05

An approach to including protein quality when assessing the net contribution of livestock to human food supply.

The production of protein from animal sources is often criticized because of the low efficiency of converting plant protein from feeds into protein in the animal products. However, this critique does not consider the fact that large portions of the plant-based proteins fed to animals may be human-inedible and that the quality of animal proteins is usually superior as compared with plant proteins. The aim of the present study was therefore to assess changes in protein quality in the course of the transformation of potentially human-edible plant proteins into animal products via livestock production; data from 30 Austrian dairy farms were used as a case study. A second aim was to develop an approach for combining these changes with quantitative aspects (e.g. with the human-edible feed conversion efficiency (heFCE), defined as kilogram protein in the animal product divided by kilogram potentially human-edible protein in the feeds). Protein quality of potentially human-edible inputs and outputs was assessed using the protein digestibility-corrected amino acid score and the digestible indispensable amino acid score, two methods proposed by the Food and Agriculture Organization of the United Nations to describe the nutritional value of proteins for humans. Depending on the method used, protein scores were between 1.40 and 1.87 times higher for the animal products than for the potentially human-edible plant protein input on a barn-gate level (=protein quality ratio (PQR)). Combining the PQR of 1.87 with the heFCE for the same farms resulted in heFCE×PQR of 2.15. Thus, considering both quantity and quality, the value of the proteins in the animal products for human consumption (in this case in milk and beef) is 2.15 times higher than that of proteins in the potentially human-edible plant protein inputs. The results of this study emphasize the necessity of including protein quality changes resulting from the transformation of plant proteins to animal proteins when evaluating the net contribution of livestock to the human food supply. Furthermore, these differences in protein quality might also need to be considered when choosing a functional unit for the assessment of environmental impacts of the production of different proteins.

Feeding of wheat bran and sugar beet pulp as sole supplements in high-forage diets emphasizes the potential of dairy cattle for human food supply.

Besides the widely discussed negative environmental effects of dairy production, such as greenhouse gas emissions, the feeding of large amounts of potentially human-edible feedstuffs to dairy cows is another important sustainability concern. The aim of this study was therefore to investigate the effects of a complete substitution of common cereal grains and pulses with a mixture of wheat bran and sugar beet pulp in a high-forage diet on cow performance, production efficiency, feed intake, and ruminating behavior, as well as on net food production potential. Thirteen multiparous and 7 primiparous mid-lactation Holstein dairy cows were randomly assigned to 1 of 2 treatments in a change-over design with 7-wk periods. Cows were fed a high-forage diet (grass silage and hay accounted for 75% of the dry matter intake), supplemented with either a cereal grain-based concentrate mixture (CON), or a mixture of wheat bran and dried sugar beet pulp (WBBP). Human-edible inputs were calculated for 2 different scenarios based on minimum and maximum potential recovery rates of human-edible energy and protein from the respective feedstuffs. Dietary starch and neutral detergent fiber contents were 3.0 and 44.1% for WBBP, compared with 10.8 and 38.2% in CON, respectively. Dietary treatment did not affect milk production, milk composition, feed intake, or total chewing activity. However, chewing index expressed in minutes per kilogram of neutral detergent fiber ingested was 12% lower in WBBP compared with CON. In comparison to CON, the human-edible feed conversion efficiencies for energy and protein, defined as human-edible output per human-edible input, were 6.8 and 5.3 times higher, respectively, in WBBP under the maximum scenario. For the maximum scenario, the daily net food production (human-edible output minus human-edible input) increased from 5.4 MJ and 250 g of crude protein per cow in CON to 61.5 MJ and 630 g of crude protein in the WBBP diet. In conclusion, our data suggest that in forage-based dairy production systems, wheat bran and sugar beet pulp could replace common cereal grains in mid-lactation dairy cows without impairing performance, while strongly increasing human-edible feed conversion efficiency and net food production index.

Substitution of common concentrates with by-products modulated ruminal fermentation, nutrient degradation, and microbial community composition in vitro.

A rumen simulation technique was used to evaluate the effects of the complete substitution of a common concentrate mixture (CON) with a mixture consisting solely of by-products from the food industry (BP) at 2 different forage-to-concentrate ratios on ruminal fermentation profile, nutrient degradation, and abundance of rumen microbiota. The experiment was a 2×2 factorial arrangement with 2 concentrate types (CON and BP) and 2 concentrate levels (25 and 50% of diet dry matter). The experiment consisted of 2 experimental runs with 12 fermentation vessels each (n=6 per treatment). Each run lasted for 10d, with data collection on the last 5d. The BP diets had lower starch, but higher neutral detergent fiber (NDF) and fat contents compared with CON. Degradation of crude protein was decreased, but NDF and nonfiber carbohydrate degradation were higher for the BP diets. At the 50% concentrate level, organic matter degradation tended to be lower for BP and CH4 formation per unit of NDF degraded was also lower for BP. The BP mixture led to a higher concentration of propionate and a lower acetate-to-propionate ratio, whereas concentrations of butyrate and caproate decreased. Concentrate type did not affect microbial community composition, except that the abundance of bacteria of the genus Prevotella was higher for BP. Increasing the concentrate level resulted in higher degradation of organic matter and crude protein. At the higher concentrate level, total short-chain fatty acid formation increased and concentrations of isobutyrate and valerate decreased. In addition, at the 50% concentrate level, numbers of protozoa increased, whereas numbers of methanogens, anaerobic fungi, and fibrolytic bacteria decreased. No interaction was noted between the 2 dietary factors on most variables, except that at the higher concentrate level the effects of BP on CH4 and CO2 formation per unit of NDF degraded, crude protein degradation, and the abundance of Prevotella were more prominent. In conclusion, the results of this study suggest that BP in the diet can adequately substitute CON with regard to ruminal fermentation profile and microbiota, showing even favorable fermentation patterns when fed at 50% inclusion rate.

Feeding of by-products completely replaced cereals and pulses in dairy cows and enhanced edible feed conversion ratio.

When fed human-edible feeds, such as grains and pulses, dairy cows are very inefficient in transforming them into animal products. Therefore, strategies to reduce human-edible inputs in dairy cow feeding are needed to improve food efficiency. The aim of this feeding trial was to analyze the effect of the full substitution of a common concentrate mixture with a by-product concentrate mixture on milk production, feed intake, blood values, and the edible feed conversion ratio (eFCR), defined as human-edible output per human edible input. The experiment was conducted as a change-over design, with each experimental period lasting for 7wk. Thirteen multiparous and 5 primiparous Holstein cows were randomly assigned to 1 of 2 treatments. Treatments consisted of a grass silage-based forage diet supplemented with either conventional ingredients or solely by-products from the food processing industry (BP). The BP mixture had higher contents of fiber and ether extract, whereas starch content was reduced compared with the conventional mixture. Milk yield and milk solids were not affected by treatment. The eFCR in the BP group were about 4 and 2.7 times higher for energy and protein, respectively. Blood values did not indicate negative effects on cows' metabolic health status. Results of this feeding trial suggest that by-products could replace common concentrate supplements in dairy cow feeding, resulting in an increased eFCR for energy and protein which emphasizes the unique role of dairy cows as net food producers.

[Influence of package inserts on adherence to medication in primary care patients]. / Der Einfluss des Beipackzettels auf die medikamentöse Adhärenz bei hausärztlichen Patienten.

BACKGROUND: German legislation requires a package insert (PI) to be attached to any drug that informs patients about the use, indications, dosage and possible side effects. This PI is often blamed for deliberate deviations from the patient's prescribed medication regimen. It is unknown to what extent patients use the opportunity to inform themselves by the PI and potential consequences for medication adherence. METHODS: In semi-structured interviews patients were asked about their use of package inserts, their opinion about PI and potential consequences of PI. Patients with newly prescribed drugs were included in the study. Data analysis was carried according to the qualitative content analysis by Mayring. RESULTS: 71 interviews were analyzed. PIs are used in very different ways and intensity. PIs are predominantly associated with negative connotations. Reading of PI seems to have hardly any immediate impact on medication adherence. Patients expressed that they feel confidence in the pharmaceutical industry and especially rely on the expertise of theirs general practitioner. CONCLUSION: These results point out that the use of PIs may have less impact than often assumed. Reading the package insert in these patients did hardly affect medication adherence.

Dietary supplementation with nonconventional feeds from the Middle East: assessing the effects on physicochemical and organoleptic properties of Awassi sheep milk and yogurt.

Increased feed costs affect the livelihoods of dairy sheep farmers in the Middle East. Farmers endure high risks with large fluctuations in the price of grain used as animal feed, which is further affected by drought and declining range productivity. Using agricultural by-products and treated straw or vetch grazing for supplementing sheep diets would provide resource-poor dairy farmers with increased options to reduce feed costs, but the effects of such feeds on the quality of yogurt (the main product) need to be better understood. Two experiments were conducted to evaluate these effects. The first trial evaluated alternative diets using locally available feedstuffs, including agricultural by-products, compared with traditional diets used by dairy sheep farmers, and was conducted on-station at the International Center for Agricultural Research in Dry Areas (ICARDA, Tel Hadya, Aleppo, Syria). Milking Awassi ewes (n=56) were used to test 6 alternative diets against a traditional control diet containing barley, wheat bran, and barley straw. The 6 alternative diets contained 4 or more of the following ingredients: barley, sugar beet pulp, molasses, cotton seed cake, wheat bran, urea-treated wheat straw, and barley straw. Ewes on one of the alternative diets grazed vetch pasture, whereas ewes on the control diet and the 5 alternative diets grazed native range pasture. The milk fat content was higher in diets containing urea-treated straw. Yogurt firmness and adhesiveness were significantly lower in energy-rich diets (e.g., the control diet) and in the diets rich in soluble sugar (molasses). The effects of diet on yogurt color and on citric and succinic acid contents were significant. A yogurt produced from the milk of the group grazing on vetch was the most yellowish in color, which is appealing to Syrian consumers. The content of citric acid tended to be higher in yogurts produced from diets containing molasses. The second trial was conducted on 3 farms in northern Syria to assess an alternative diet (1 of the 6 tested in the first trial) on 15 milking ewes compared with the farmer's traditional diet (control). The alternative diet increased yogurt firmness and adhesiveness by 7 to 9% and 10 to 16%, respectively. The use of nonconventional feeds available in the region enhances yogurt quality, may reduce requirements for expensive grains, and thus, increase farmers' livelihoods by targeting expanding markets with better quality products.

Prospects for using nonconventional feeds in diets for Awassi dairy sheep in Syria.

High feed costs are major obstacles for resource-poor dairy sheep farmers in West Asia, along with large fluctuation in grain and straw prices. Farmers need low-cost diets using locally available feeds that can provide sufficient milk of good quality. Two experimental trials were conducted on Awassi milking ewes to evaluate nonconventional and balanced low-cost diets against the traditional unbalanced diet used by farmers (control) on the total yields (milk, fat, protein, and total solids) and milk composition (fat, protein, total solids, and lactose), an important indicator of milk quality. The first trial was conducted at the research station of the International Center for Agricultural Research in the Dry Areas (ICARDA, Aleppo, Syria) to test 6 low-cost balanced diets using locally available feeds and agro byproducts against the control diet. Each diet was tested on 8 ewes that were kept on pasture as a basal diet, but received different supplements, including barley, wheat bran and nonconventional feeds (urea-treated wheat straw, molasses, sugar beet pulp, and cotton seed cake). Five balanced diets enhanced the total yields of milk, fat, protein, and total solids, in 2 cases, significantly. These diets increased total milk yield by 17.7 to 50.2% and decreased supplement feeding costs by 43% compared with the control. However, milk composition remained unaffected. The second trial was conducted on 3 different farms in northern Syria to assess in each farm a low-cost balanced diet on milking ewes (n=15) in comparison to the farmer's control (n=15). The balanced diet was a modification requested by farmers of the best performing diet in the on-station trial. Confirming the first trial's research results, the balanced diet outperformed the control in total yields; for instance, it increased total milk yield by 28 to 40% and raised net income by 30%, without affecting milk composition. Both trials showed that using locally available nonconventional feedstuffs, such as molasses, integrated into balanced dairy sheep diets can decrease feed costs of resource-poor farmers, while enhancing total yields of milk and milk constituents without compromising milk quality components. This will greatly improve the profitability of dairy sheep production in dry areas.

Characterization of Awassi lamb fattening systems: a Syrian case study.

Intensive lamb fattening systems are evolving in developing Middle Eastern countries due to high demand for lambs at favorable prices; however, little is known about their characteristics and constraints. A survey was conducted in Syria involving 241 farmers to characterize the fattening production systems and main constraints, with emphasis on feeding, management, labor, and marketing. Most farmers (90%) considered the income from fattening to be from medium to high, and 57% expressed that lamb fattening along with alternative income sources compose the family's livelihood strategies. Fattening systems offer employment to family members. Market price was the main decision factor to buy and sell lambs, but this was only part of various marketing aspects. Male lambs usually bought at markets at the mean age of 4 months (mean weight of 31 kg) are sold after fattening at a 50-60 kg weight range. The average yearly fattening cycle was 2.7 batches, and the average number of lambs per batch was 232. For 65% (n = 241) of the farmers the major constraint to fattening was feeding cost, and for about a half of farmers (51%, n = 241), disease outbreaks and prices for veterinarian services constituted the second important constraint. Research on least-cost fattening diets and curbing disease problems to increase farmer's income margins is needed. It is expected that due to existing commonalities, the information emerging from this study regarding major constraints to Awassi lamb fattening systems could be useful for an across-synthesis on Awassi fattening production in the region.

Health Heritage© a web-based tool for the collection and assessment of family health history: initial user experience and analytic validity.

A detailed family health history is currently the most potentially useful tool for diagnosis and risk assessment in clinical genetics. We developed and evaluated the usability and analytic validity of a patient-driven web-based family health history collection and analysis tool. Health Heritage(©) guides users through the collection of their family health history by relative, generates a pedigree, completes risk assessment, stratification, and recommendations for 89 conditions. We compared the performance of Health Heritage to that of Usual Care using a nonrandomized cohort trial of 109 volunteers. We contrasted the completeness and sensitivity of family health history collection and risk assessments derived from Health Heritage and Usual Care to those obtained by genetic counselors and genetic assessment teams. Nearly half (42%) of the Health Heritage participants reported discovery of health risks; 63% found the information easy to understand and 56% indicated it would change their health behavior. Health Heritage consistently outperformed Usual Care in the completeness and accuracy of family health history collection, identifying 60% of the elevated risk conditions specified by the genetic team versus 24% identified by Usual Care. Health Heritage also had greater sensitivity than Usual Care when comparing the identification of risks. These results suggest a strong role for automated family health history collection and risk assessment and underscore the potential of these data to serve as the foundation for comprehensive, cost-effective personalized genomic medicine.

[Severity assessment by APACHE III system in Spain]. / Objetivación de la gravedad mediante el sistema APACHE-III aplicado en España.

BACKGROUND: To assess the performance of the prediction equation of the APACHE(Acute Physiology Age and Chronic Health Evaluation) III prognostic scoring system when applied in Spain. PATIENTS AND METHOD: Prospective multicenter cohort study that included 10786 adult patients from 86 Spanish intensive care units (ICU). Data collection during first 24 hours of admission: acute physiology score, age and comorbilties,for calculating APACHE III score; treatment location prior to ICU admission and main diagnosis admission category for applying the mortality prediction equation of APACHE III system. Main outcome was observed hospital mortality. RESULTS: Age was 57.74 (0.16); 68% males. Non-operative patients represented 76% of sample. APACHE III score was 53.75(0.26); observed and predicted hospital mortality were 21.2% and 19.8% respectively, with a standardized mortality ration of 1.07. The Chi2 Hosmer-Lemershow statistic was (H) 135.6, (C) 133.91: p < 0.001. The area under the Receiver Operating Curve (ROC) was 0.808, and correct classification at mortality risk of 50% was 82%. Uniformity of fit was better for non-operative diagnoses and for patients admitted from the emergency area. Calibration was excellent for risk lower than 60% but slightly underestimated observed risks above this level. CONCLUSIONS: The American APACHE III equation fit well when applied to Spanish critical patients but with limitations. Discrepancies could be attributed to differences in case-mix and variations in practice style.

Optimization of rate and efficiency of dietary nitrogen utilization through the use of animal by-products and(or) urea and their effects on nutrient digestion in Holstein steers.

The objective of this N balance study was to determine the potential for improving the efficiency and rate of dietary N utilization in Holstein steers by feeding an amino acid-balanced mixture of animal by-product protein sources in combination with urea. The Beef NRC 1996 Model Level 2 was used to formulate a corn-based (86:14 concentrate-hay) control diet with soybean meal as the primary N supplement that would provide ME and metabolizable protein (MP) allowable ADG of 1.4 kg in 250-kg steers with an estrogenic implant and fed an ionophore. A combination of porcine meat and bone meal, fish meal, hydrolyzed feather meal, and blood meal was also formulated as an undegradable intake protein (UIP) blend to complement those amino acids (AA) derived from microbial protein synthesis. Four steers with an average initial BW of 259 kg were assigned in a 4 x 4 Latin square design to treatments consisting of control, two levels of UIP inclusion (2.6 and 5.2%; DM basis) in combination with urea, and a negative control "urea diet" containing no UIP and no SBM. The steers were fed at hourly intervals 95% of ad libitum intake and were injected with 500 microg of estradiol-17beta twice daily. Nitrogen intakes were 155, 160, 162, and 145 g/d, and N balances were 47, 51, 42, and 47 g/d when the 0, 2.6, 5.2% UIP and the urea diets were fed, respectively. Nitrogen balance was reduced with the 5.2% UIP diet (P < 0.05), and was less than the capacity estimate derived from abosmasal casein infusion studies. Apparent N digestibilities averaged 69%, but DM, OM, and nonstructural carbohydrate digestibilities were significantly reduced for the urea diet. Feeding 5.2% UIP in the diet reduced (P < 0.05) the biological value from 46 to 38%, which was accompanied by a significant elevation of plasma urea N. Results indicate that genetic capacity for N retention was approximately 51 g/d. Results demonstrate that use of an AA-balanced blend of animal by-product protein sources did not improve the efficiency of dietary N usage when added to corn-based diets formulated with the Beef NRC 1996 Model Level 2 to meet nutrient requirements of rapidly growing steers. Using urea as the only N supplement achieved equal rate and efficiency of N use.

Intensive care unit length of stay: recent changes and future challenges.

OBJECTIVE: To compare case-mix adjusted intensive care unit (ICU) length of stay for critically ill patients with a variety of medical and surgical diagnoses during a 5-yr interval. DESIGN: Nonrandomized cohort study. SETTING: A total of 42 ICUs at 40 US hospitals during 1988-1990 and 285 ICUs at 161 US hospitals during 1993-1996. PATIENTS: A total of 17,105 consecutive ICU admissions during 1988-1990 and 38,888 consecutive ICU admissions during 1993-1996. MEASUREMENTS AND MAIN RESULTS: We used patient demographic and clinical characteristics to compare observed and predicted ICU length of stay and hospital mortality. Outcomes for patients studied during 1993-1996 were predicted using multivariable models that were developed and cross-validated using the 1988-1990 database. The mean observed hospital length of stay decreased by 3 days (from 14.8 days during 1988-1990 to 11.8 days during 1993-1996), but the mean observed ICU length of stay remained similar (4.70 vs. 4.53 days). After adjusting for patient and institutional differences, the mean predicted 1993-1996 ICU stay was 4.64 days. Thus, the mean-adjusted ICU stay decreased by 0.11 days during this 5-yr interval (T-statistic, 4.35; p < .001). The adjusted mean ICU length of stay was not changed for patients with 49 (75%) of the 65 ICU admission diagnoses. In contrast, the mean observed hospital length of stay was significantly shorter for 47 (72%) of the 65 admission diagnoses, and no ICU admission diagnosis was associated with a longer hospital stay. Aggregate risk-adjusted hospital mortality during 1993-1996 (12.35%) was not significantly different during 1988-1990 (12.27%, p = .54). CONCLUSIONS: For patients admitted to ICUs, the pressures associated with a decrease in hospital length of stay do not seem to have influenced the duration of ICU stay. Because of the high cost of intensive care, reduction in ICU stay may become a target for future cost-cutting efforts.

Initial development of a system-wide maternal-fetal outcomes assessment program.

OBJECTIVE: This study was undertaken to develop a comprehensive risk-assessment approach capable of evaluating maternal and fetal outcomes. STUDY DESIGN: Data from 10,984 women and 11,066 infants delivered at 79 military treatment facilities in the United States from 1995 to 1997 were used to develop two individual but complementary risk-adjustment models for maternal and, separately, fetal outcomes. A range of maternal and delivery-related risk variables and clinically important outcomes were identified by expert opinion and selected and weighted with ordinal logistic regression analysis. Receiver operating characteristic curves for the maternal and fetal models were determined. Variation across the facilities in risk-adjusted performance was also evaluated. RESULTS: Risk factors and poor outcomes were rare for both mothers and infants, with 96.9% of infants and 97.7% of mothers having good or excellent outcomes (0.7% mortality and 0.01% mortality, respectively). Despite the low frequency of poor outcomes both models performed well, with receiver operating characteristic curves of 0.75 for maternal outcomes and 0.78 for infant outcomes. When the models were applied to the military treatment facilities, there were significant differences among facilities in risk-adjusted outcomes. Twenty-four of the facilities in the study (30%) had outcomes odds ratios that were significantly >1 or significantly <1 (P <.05). There did not appear to be any relationship between the performance of a military treatment facility for maternal outcome and that for infant outcome. CONCLUSION: Complementary risk models for maternal and infant outcomes were developed that had satisfactory discriminatory power across a variety of facilities within a large health system. With further development and refinement this approach holds promise of being able to detect variations in risk-adjusted performance that could be used to identify best practices. The results might also be used to help coordinate and improve the quality of care for the entire conception-to-delivery process.

Prediction of survival for older hospitalized patients: the HELP survival model. Hospitalized Elderly Longitudinal Project.

OBJECTIVE: To develop and validate a model estimating the survival time of hospitalized persons aged 80 years and older. DESIGN: A prospective cohort study with mortality follow-up using the National Death Index. SETTING: Four teaching hospitals in the US. PARTICIPANTS: Hospitalized patients enrolled between January 1993 and November 1994 in the Hospitalized Elderly Longitudinal Project (HELP). Patients were excluded if their length of hospital stay was 48 hours or less or if admitted electively for planned surgery. MEASUREMENTS: A log-normal model of survival time up to 711 days was developed with the following variables: patient demographics, disease category, nursing home residence, severity of physiologic imbalance, chart documentation of weight loss, current quality of life, exercise capacity, and functional status. We assessed whether model accuracy could be improved by including symptoms of depression or history of recent fall, serum albumin, physician's subjective estimate of prognosis, and physician and patient preferences for general approach to care. RESULTS: A total of 1266 patients were enrolled over a 10-month period, (median age 84.9, 61% female, 68% with one or more dependency), and 505 (40%) died during an average follow-up of more than 2 years. Important prognostic factors included the Acute Physiology Score of APACHE III collected on the third hospital day, modified Glasgow coma score, major diagnosis (ICU categories together, congestive heart failure, cancer, orthopedic, and all other), age, activities of daily living, exercise capacity, chart documentation of weight loss, and global quality of life. The Somers' Dxy for a model including these factors was 0.48 (equivalent to a receiver-operator curve (ROC) area of 0.74, suggesting good discrimination). Bootstrap estimation indicated good model validation (corrected Dxy of 0.46, ROC of 0.73). A nomogram based on this log-normal model is presented to facilitate calculation of median survival time and 10th and 90th percentile of survival time. A count of geriatric syndromes or comorbidities did not add explanatory power to the model, nor did the hospital of patient recruitment, depression, or the patient preferences for general approach to care. The physician's perception of the patient's preferences and the physician's subjective estimate of the patient's prognosis improved the estimate of survival time significantly. CONCLUSIONS: Accurate estimation of length of life for older hospitalized persons may be calculated using a limited amount of clinical information available from the medical chart plus a brief interview with the patient or surrogate. The accuracy of this model can be improved by including measures of the physician's perception of the patient's preferences for care and the physician's subjective estimate of prognosis.

Family satisfaction with end-of-life care in seriously ill hospitalized adults.

OBJECTIVE: To examine factors associated with family satisfaction with end-of-life care in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). DESIGN: A prospective cohort study with patients randomized to either usual care or an intervention that included clinical nurse specialists to assist in symptom control and facilitation of communication and decision-making. SETTING: Five teaching hospitals in the United States. PARTICIPANTS: Family members and other surrogate respondents for 767 seriously ill hospitalized adults who died. MEASUREMENTS: Eight questionnaire items regarding satisfaction with the patient's medical care expressed as two scores, one measuring satisfaction with patient comfort and the other measuring satisfaction with communication and decision-making. RESULTS: Sixteen percent of respondents reported dissatisfaction with patient comfort and 30% reported dissatisfaction with communication and decision-making. Factors found to be significantly associated with satisfaction with communication and decision-making were hospital site, whether death occurred during the index hospitalization (adjusted odds ratio (AOR) 2.2, 95% CI, 1.3-3.9), and for patients who died following discharge, whether the patient received the SUPPORT intervention (AOR 2.0, 1.2-3.2). For satisfaction with comfort, male surrogates reported less satisfaction (0.6, 0.4-1.0), surrogates who reported patients' preferences were followed moderately to not at all had less satisfaction (0.2, 0.1-0.4), and surrogates who reported the patient's illness had greater effect on family finances had less satisfaction (0.4, 0.2-0.8). CONCLUSIONS: Satisfaction scores suggest the need for improvement in end-of-life care, especially in communication and decision making. Further research is needed to understand how factors affect satisfaction with end-of-life care. An intervention like that used in SUPPORT may help family members.

Withholding versus withdrawing life-sustaining treatment: patient factors and documentation associated with dialysis decisions.

OBJECTIVE: We evaluated prospectively the use of acute hemodialysis among hospitalized patients to identify demographic and clinical predictors of and chart documentation concerning dialysis withheld and withdrawn. DESIGN: Prospective cohort study. SETTING: Five teaching hospitals. PATIENTS: Five hundred sixty-five seriously ill hospitalized patients who had not previously undergone dialysis who developed renal failure. MAIN OUTCOME MEASURES: Patient demographics, clinical characteristics, preferences, and prognostic estimates associated with having dialysis withheld rather than initiated and withdrawn rather than continued. Differences in chart documentation concerning decision-making for dialysis withheld, withdrawn, and continued. RESULTS: Older patient age, cancer diagnosis, and male gender were associated with dialysis withheld rather than withdrawn. Age and gender differences persisted after adjustment for patients' aggressiveness of care preference. Worse 2-month prognosis was associated with both withholding and withdrawing dialysis. Chart documentation of decision-making was lacking more often for patients with dialysis withheld than for dialysis withdrawn. CONCLUSIONS: Measuring the equity of life-sustaining treatment use will require evaluation of care withheld, not just care withdrawn. Older patients and men, after accounting for prognosis and function, are more likely to have dialysis withheld than withdrawn after a trial. Further exploration is needed into this disparity and the inadequate chart documentation for patients with dialysis withheld.

A predictive risk model for outcomes of ischemic stroke.

BACKGROUND AND PURPOSE: The great variability of outcome seen in stroke patients has led to an interest in identifying predictors of outcome. The combination of clinical and imaging variables as predictors of stroke outcome in a multivariable risk adjustment model may be more powerful than either alone. The purpose of this study was to determine the multivariable relationship between infarct volume, 6 clinical variables, and 3-month outcomes in ischemic stroke patients. METHODS: Included in the study were 256 eligible patients from the Randomized Trial of Tirilazad Mesylate in Acute Stroke (RANTTAS). Six clinical variables and 1-week infarct volume were the prespecified predictor variables. The National Institutes of Health Stroke Scale, Barthel Index, and Glasgow Outcome Scale were the outcomes. Multivariable logistic regression techniques were used to develop the model equations, and bootstrap techniques were used for internal validation. Predictive performance of the models was assessed for discrimination with receiver operator characteristic (ROC) curves and for calibration with calibration curves. RESULTS: The predictive models had areas under the ROC curve of 0.79 to 0.88 and demonstrated nearly ideal calibration curves. The areas under the ROC curves were statistically greater (P<0.001) with both clinical and imaging information combined than with either alone for predicting excellent recovery and death or severe disability. CONCLUSIONS: Combined clinical and imaging variables are predictive of 3-month outcome in ischemic stroke patients. Demonstration of this relationship with acute clinical variables and 1-week infarct information supports future attempts to predict 3-month outcome with all acute variables.

Older age, aggressiveness of care, and survival for seriously ill, hospitalized adults. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

BACKGROUND: Older age is associated with less aggressive treatment and higher short-term mortality due to serious illness. It is not known whether less aggressive care contributes to this survival disadvantage in elderly persons. OBJECTIVE: To determine the effect of age on short-term survival, independent of baseline patient characteristics and aggressiveness of care. DESIGN: Secondary analysis of data from a prospective cohort study. SETTING: Five academic medical centers participating in SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments). PATIENTS: 9105 adults hospitalized with one of nine serious illnesses associated with an average 6-month mortality rate of 50%. MEASUREMENTS: Survival through 180 days of follow-up. In Cox proportional hazards modeling, adjustment was made for patient sex; ethnicity; income; baseline physical function; severity of illness; intensity of hospital resource use; presence of do-not-resuscitate orders on study day 1; and presence and timing of decisions to withhold transfer to the intensive care unit, major surgery, dialysis, blood transfusion, vasopressors, and tube feeding. RESULTS: The mean (+/- SD) patient age was 63 +/- 16 years, 44% of patients were female, and 16% were black. Overall survival to 6 months was 53%. In analyses that adjusted for sex, ethnicity, income, baseline functional status, severity of illness, and aggressiveness of care, each additional year of age increased the hazard of death by 1.0% (hazard ratio, 1.010 [95% CI, 1.007 to 1.013]) for patients 18 to 70 years of age and by 2.0% (hazard ratio, 1.020 [CI, 1.013 to 1.026]) for patients older than 70 years of age. Adjusted estimates of age-specific 6-month mortality rates were 44% for 55-year-old patients, 48% for 65-year-old patients, 53% for 75-year-old patients, and 60% for 85-year-old patients. Similar results were obtained in analyses that did not adjust for aggressiveness of care. Acute physiology and diagnosis had much larger relative contributions to prognosis than age. CONCLUSIONS: We found a modest independent association between patient age and short-term survival of serious illness. This age effect was not explained by the current practice of providing less aggressive care to elderly patients.