Longitudinal analysis of changes in energy intake and macronutrient composition during pregnancy and 6 weeks post-partum.

PURPOSE: This prospective study was carried out in order to investigate changes in nutritional intake during pregnancy with regard to caloric intake and macronutrient composition in normal-weight pregnant women. METHODS: Using food scales, 32 healthy pregnant women estimated their food intake over a period of 2 days at gestational week 16, 22, 30, 36 and, in addition, 6 weeks after delivery. The recorded food logs were analyzed with respect to caloric intake and macronutrient composition. RESULTS: The women's age was averaged 29.6 ± 4.5 years, and the mean pre-pregnancy BMI was 22.4 ± 2.5 kg/m². Mean weight gain was 16.5 ± 4.5 kg. On average, birth took place during the 40th week of gestation, with the babies having a mean birth weight of 3,515 ± 406 g. Caloric intake during the gestation period and post-partum showed no statistically significant changes and added up 9,237 ± 1,876 kJ/day during the 16th week of gestation, 9,496 ± 2,437 kJ/day during the 22nd, 9,073 ± 1,863 kJ/day during the 30th, 9,525 ± 2,135 kJ/day during the 36th week and 8,445 ± 2,160 kJ/day 6 weeks after delivery. No significant changes were observed in the composition of macronutrients during the pregnancy. The daily composition of macronutrients was as follows: carbohydrates 281 ± 57 g/day (51.7%), fat 86 ± 16 g/day (35.8%) and protein 75 ± 13 g/day (13.9%). However, we observed a decrease in carbohydrate intake of 239 ± 72 g/day (48%) after birth. CONCLUSIONS: Healthy pregnant women showed no significant changes in their caloric intake or nutritional profiles. Performed with an accurate measurement, this prospective study shows that healthy pregnant require neither increased caloric intake nor a change in macronutrient composition.

Adiponectin during pregnancy: correlation with fat metabolism, but not with carbohydrate metabolism.

BACKGROUND: Several studies show an association of adiponectin deficiency with obesity, insulin resistance and dysfunctional fat metabolism. This study investigates to what extent the correlations described occurs in pregnant women. METHOD: Metabolism parameters and adiponectin serum levels were measured in 32 pregnant women at various times during their pregnancies and during the first six postpartum weeks. RESULTS: In this random group of pregnant subjects no correlation was found between adiponectin and insulin, C-peptides, blood sugar levels or BMI. No correlation was found between adiponectin and carbohydrate metabolism. The adiponectin levels of the pregnant women correlated negatively with triglyceride levels during the various stages of pregnancy; in the 36th week of gestation and at 6 weeks after the birth a positive correlation with HDL cholesterol was observed. The decrease in adiponectin concentration in pregnancy must therefore be more closely connected with changes in fat metabolism than with an increase in insulin resistance or weight gain during the pregnancy. The decrease in adiponectin does not correlate with an increase in body fat, BMI or weight; however, it does correlate with metabolism. The mechanisms of the regulation, which causes adiponectin levels to fall, is still unknown.

Longitudinal changes in the continuous glucose profile measured by the CGMS in healthy pregnant women and determination of cut-off values.

OBJECTIVE: This longitudinal study performed continuous evaluation of daily blood glucose level profiles in healthy normal-weight pregnant patients during various gestational age and determined normal levels. STUDY DESIGN: Thirty-two healthy normal-weight pregnant women received a continuous glucose monitoring system (CGMS) device for periods of 72h in the 16th, 22nd, 30th and 36th weeks of gestational age and at 6 weeks after delivery. All observations took place in the outpatient clinic of the Charité hospital. The daily blood glucose level profiles obtained with the CGMS provided pre- and postprandial blood glucose levels and a mean glucose value for a 24-h period. Caloric intake was determined using detailed food logs. Additionally, a fetal biometry and an measurement of maternal weight were performed at each visit. The correlation was tested using Spearman's test. RESULTS: The average age of the study subjects was 29.6+/-4.5. Average pre-pregnancy BMI was 22.4+/-2.5kg/m(2). The births occurred on average in the 40th week of pregnancy. Average caloric intake was 2223+/-356kcal. No significant changes in caloric intake were observed during the course of the study. The blood glucose levels showed a significant rise throughout the course of the pregnancy, going from 4.84+/-0.4mmol/l (87.2+/-7.2mg/dl) during the 30th week of pregnancy to 5.22+/-0.5mmol/l (94.0+/-9.0mg/dl) during the 36th week (p=0.002). Postpartum levels were 5.20+/-0.5mmol/l (93.7+/-9.0mg/dl) (p=0.51). Fasting blood glucose levels did not change during the course of the pregnancy. A noticeable aspect were the significantly increased fasting postpartum levels with 5.02+/-0.6mmol/l (90.4+/-10.8mg/dl) (p=0.00). Analysis of the postprandial glucose levels confirmed a rise from 5.30+/-0.6mmol/l (95.5+/-10.8mg/dl) in the 16th week to 6.14+/-0.7mmol/l (110.6+/-12.6mg/dl) in the fourth study phase (36th week), and a decrease after the birth to 5.59+/-0.6mmol/l (100.7+/-10.8mg/dl). These measurements were adapted to the gestational age. CONCLUSION: Continuous measured glucose levels rose during the pregnancy in healthy pregnant women in spite of normal pre-pregnancy metabolism and unchanged carbohydrate intake during gestation. These results suggest the necessity of gestational-age-dependent cut-off values.

Molecular epidemiology of oral treponemes in patients with periodontitis and in periodontitis-resistant subjects.

The etiologic role of oral treponemes in human periodontitis is still under debate. Although seen by dark-field microscopy in large numbers, their possible role is still unclear since they comprise some 60 different phylotypes, most of which are still uncultured. To determine their status as mere commensals or opportunistic pathogens, molecular epidemiological studies are required that include both cultured and as-yet-uncultured organisms. Here we present such data, comparing treponemal populations from chronic periodontitis (CP) or generalized aggressive periodontitis (GAP) patients. As a periodontitis-resistant (PR) control group, we included elderly volunteers with more than 20 natural teeth and no history of periodontal treatment and no or minimal clinical signs of periodontitis. Almost every treponemal phylotype was present in all three groups. For most treponemes, the proportion of subjects positive for a certain species or phylotype was higher in both periodontitis groups than in the PR group. This difference was pronounced for treponemes of the phylogenetic groups II and IV and for Treponema socranskii and Treponema lecithinolyticum. Between the periodontitis groups the only significant differences were seen for T. socranskii and T. lecithinolyticum, which were found more often in periodontal pockets of GAP patients than of CP patients. In contrast, no difference was found for Treponema denticola. Our findings, however, strengthen the hypothesis of treponemes being opportunistic pathogens. It appears that T. socranskii, T. lecithinolyticum and group II and IV treponemes may represent good indicators for periodontitis and suggest the value of the respective probes for microbiological diagnosis in periodontitis subjects.

Rate of dyspareunia after delivery in primiparae according to mode of delivery.

OBJECTIVES: The purpose of this study was to evaluate the influence of mode of delivery on sexual function. DESIGN: One thousand six hundred and thirteen questionnaires containing 16 questions about sexual behavior and dyspareunia before, during and after pregnancy were sent out to primiparous, ethnically homogeneous (fluent in German) patients who delivered in a large tertiary referral center between 6 months and 2(1/2) year before. The returned questionnaires were merged to clinical data from our obstetric database in an anonymous fashion. The patients were subdivided into four groups (A) "spontaneous without injuries (except minor labial laceration)", (B) "c-section", (C)"episiotomy or perineal laceration", and (D) "operative vaginal delivery". RESULTS: The response rate of primiparae was 41% (655/1613). Forty-seven percent of women resumed sexual intercourse (SI) within 8 weeks after delivery. Altogether 31% of the women did not experience any pain during the first SI post-partum whereas 49% of all patients noted significant pain (medium, considerable or severe), depending on the mode of delivery (p = 0.007). Persistence of dyspareunia longer than 6 months was 3.5% (4/115; group A), 3.4% (2/58; group B), 11% (34/316; group C), and 14% (20/114; group D). CONCLUSIONS: Recently, female sexuality may not have been prominent in any discussion concerning possible advantages and disadvantages of different modes of childbirth. Our results should be taken into consideration when counseling patients antenatally regarding mode of delivery.

Gender differences in the performance of a computerized version of the alcohol use disorders identification test in subcritically injured patients who are admitted to the emergency department.

OBJECTIVE: The Alcohol Use Disorder Identification Test (AUDIT) has been recommended as a screening tool to detect patients who are appropriate candidates for brief, preventive alcohol interventions. Lower AUDIT cutoff scores have been proposed for women; however, the appropriate value remains unknown. The primary purpose of this study was to determine the optimal AUDIT cutpoint for detecting alcohol problems in subcritically injured male and female patients who are treated in the emergency department (ED). An additional purpose of the study was to determine whether computerized screening for alcohol problems is feasible in this setting. METHODS: The study was performed in the ED of a large, urban university teaching hospital. During an 8-month period, 1205 male and 722 female injured patients were screened using an interactive computerized lifestyle assessment that included the AUDIT as an embedded component. World Health Organization criteria were used to define alcohol dependence and harmful drinking. World Health Organization criteria for excessive consumption were used to define high-risk drinking. The ability of the AUDIT to classify appropriately male and female patients as having one of these three conditions was the primary outcome measure. RESULTS: Criteria for any alcohol use disorder were present in 17.5% of men and 6.8% of women. The overall accuracy of the AUDIT was good to excellent. At a specificity >0.80, sensitivity was 0.75 for men using a cutoff of 8 points and 0.84 for women using a cutoff of 5 points. Eighty-five percent of patients completed computerized screening without the need for additional help. CONCLUSIONS: Different AUDIT scoring thresholds for men and women are required to achieve comparable sensitivity and specificity when using the AUDIT to screen injured patients in the ED. Computerized AUDIT administration is feasible and may help to overcome time limitations that may compromise screening in this busy clinical environment.

Intermittent hirudin versus continuous heparin for anticoagulation in continuous renal replacement therapy.

BACKGROUND: Besides possible bleeding complications a further problem in anticoagulation during continuous renal replacement therapy (CRRT) is the development of heparin-induced thrombocytopenia type II (HIT II) where further anticoagulation with heparin is contraindicated. The application of continuous hirudin as alternative for heparin caused bleeding complications by comparable filter efficacy. Aim of this prospective-controlled pilot study was to compare the efficacy and safety of intermittent hirudin and continuous heparin for anticoagulation during CRRT in critically ill patients. METHODS: 26 patients receiving CRRT were randomly allocated to two groups: Heparin group (14 patients): continuous administration of 250 IU/h heparin, dose was adjusted in 125 IU/h steps with a targeted activated clotting time (ACT) of 180-210 s. Hirudin group (12 patients): initial bolus application of 2-2-5 microg/kg hirudin, dose was adjusted in 2 microg/kg bolus steps with a targeted ecarin clotting time (ECT) >80 s. Observation time was 96 hours. RESULTS: Measured filter run time was virtually longer for heparin. No bleeding complications were observed in the hirudin group, two bleeding complications in the heparin group. CONCLUSIONS: Intermittent hirudin can be used safely for anticoagulation in CRRT. However, the in tendency better filter survival for heparin elucidates the need for further investigations to find the right dosage equilibrium between filter clotting and bleeding complications.

The usefulness of glycosuria and the influence of maternal blood pressure in screening for gestational diabetes.

OBJECTIVE: Although gestational diabetes is among the most common diseases arising during pregnancy, glucose stix is the only screening test to date in Germany. Our goal was to evaluate the sensitivity of the glucose-stix for diabetes screening and the possible influence of other parameters. METHODS: 1001 patients who underwent the 50 g glucose screening test between June 1, 1997 and January 5, 2000 as part of prenatal care were asked to participate. In accordance with the guidelines of the American Diabetes Association, patients with a screening test result >/= 140 mg/dl underwent a oral glucose tolerance test (Carpenter/Coustan criteria). A urine sample was collected prior to the test. The glucose content of the urine was semiquantitatively analyzed using a test strip (Multistix 10 SG Bayer), Munich, Germany). Blood pressure was measured in 349 consecutive cases according to the criteria of the National Institute of Health. RESULTS: The overall frequency of gestational diabetes was 4.1% (37/912). 8.2% of the women presented with glycosuria (82/1001, 36 before screening, 46 based on the pregnancy medical records booklet). 30/82 (37%) of these patients had a pathological screening test (P = 0.029). 7.1% (52/729) of the healthy patients and 10.8% (4/37) of the gestational diabetics had glycosuria at least once. Therefore, the sensitivity of glycosuria is 10.8%, the positive predictive value is 6.6%. The systolic blood pressure was 116+/- 12 mmHg and the diastolic blood pressure 72 +/- 9 mmHg. Three of 349 (0.9%) patients were documented with preexisting hypertension, 14/349 (4.0%) patients with "pregnancy induced hypertension". Patients with glycosuria were both significantly more advanced in gestational age (34.4 +/- 2.8 versus 33.7 +/- 2.9, P = 0.673) and had higher diastolic blood pressure (79 +/- 9 versus 71 +/- 9, P = 0.005). The 50 g glucose screening test results showed only a tendency to differ (131 +/- 23 versus 127 +/- 24, P = 0.073). A multivariate analysis of these factors showed a significant influence of the diastolic blood pressure (P = 0.016) and the 50 g glucose screening test (P = 0.032), whereas the gestational week had no influence (P = 0.673). CONCLUSIONS: Urine glucose dip stick analysis is not useful in the detection of gestational diabetes because of its low sensitivity and negative predictive value. Our study suggests that glycosuria is not only dependent on the blood glucose level, but highly influenced by diastolic blood pressure. The results clearly underscore the need for standardized, routine testing of every pregnant woman.

No influence of high- and low-carbohydrate diet on the oral glucose tolerance test in pregnancy.

OBJECTIVE: Our objective was to determine the influence of the carbohydrate content of the diet preceding the oral glucose tolerance test (OGTT) in pregnancy on the test results and to evaluate the necessity of the recommended preparatory high-carbohydrate diet. STUDY DESIGN: Thirty-four women from our outpatient clinic were enrolled in this prospective study. After giving informed consent, each women underwent a 90-min lesson (supervised by a dietary assistant) covering the carbohydrate, protein and fat content of different foods. Women were then randomized and in a crossover design started a diet with either a low or a high carbohydrate content. We were aiming at a carbohydrate intake of 40% in the low-carbohydrate week (LCH) and 50% in the high-carbohydrate week (HCH). Compliance was monitored by a detailed food diary which the women kept and which included the weight of the foods they consumed. RESULTS: The actual dietary intakes as calculated from the food diaries showed that the mean caloric intake was 1801 +/- 314 kcal in the LCH and 2118 +/- 312 kcal in the HCH week (<0.001). During the LCH diet, CH intake was 39 +/- 6.1% and 49 +/- 6.6% in the HCH week (P < 0.001). The carbohydrate intake per kilogram bodyweight was 30 +/- 5.3 kcal vs. 35 +/- 5.2 kcal (P < 0.001). The number of patients diagnosed with gestational diabetes was two in the LCH and three in the HCH week (not significant). The sum of the OGTT values (fasting, 1 h and 2 h) after the LCH was 18.9 +/- 2.1 mmol/l vs. 18.8 +/- 2.1 mmol/l after the HCH (P = 0.51). No differences could be found in both groups regarding the fasting, 1-h, or 2-h glucose values. Including patients with a CH difference of at least 5%, 10%, and 15% carbohydrate between the weeks, we still did not observe any differences in the OGTT sum. We also looked at a possible influence of the CH content of the diet on the day before the test and of the last meal before the OGTT results and observed there was none. CONCLUSION: This is the first study which has observed the influence of the previous day's meal on the test results. We conclude from our results that the carbohydrate percentage of the preparatory diet did not influence the results of an OGTT, even when we increased the difference in carbohydrate intake stepwise up to 15%. This might indicate that a preparatory diet before the OGTT is not necessary for women with normal nutritional behavior.

A randomized trial evaluating a predominantly fetal growth-based strategy to guide management of gestational diabetes in Caucasian women.

OBJECTIVE: To compare the management of Caucasian women with gestational diabetes (GDM) based predominantly on monthly fetal growth ultrasound examinations with an approach based solely on maternal glycemia. RESEARCH DESIGN AND METHODS: Women with GDM who attained fasting capillary glucose (FCG) <120 mg/dl and 2-h postprandial capillary glucose (2h-CG) <200 mg/dl after 1 week of diet were randomized to management based on maternal glycemia alone (standard) or glycemia plus ultrasound. In the standard group, insulin was initiated if FCG was repeatedly >90 mg/dl or 2h-CG was >120 mg/dl. In the ultrasound group, thresholds were 120 and 200 mg/dl, respectively, or a fetal abdominal circumference >75th percentile (AC>p75). Outcome criteria were rates of C-section, small-for-gestational-age (SGA) or large-for-gestational-age (LGA) infants, neonatal hypoglycemia (<40 mg/dl), and neonatal care admission. RESULTS: Maternal characteristics and fetal AC>p75 (36.0 vs. 38.4%) at entry did not differ between the standard (n = 100) and ultrasound groups (n = 99). Assignment to (30.0 vs. 40.4%) and mean duration of insulin treatment (8.3 vs. 8.1 weeks) did not differ between groups. In the ultrasound group, AC>p75 was the sole indication for insulin. The ultrasound-based strategy, as compared with the maternal glycemia-only strategy, resulted in a different treatment assignment in 34% of women. Rates of C-section (19.0 vs. 18.2%), LGA (10.0 vs. 12.1%), SGA (13.0 vs. 12.1%), hypoglycemia (16.0 vs. 17.0%), and admission (15.0 vs. 14.1%) did not differ significantly. CONCLUSIONS: GDM management based on fetal growth combined with high glycemic criteria provides outcomes equivalent to management based on strict glycemic criteria alone. Inclusion of fetal growth might provide the opportunity to reduce glucose testing in low-risk pregnancies.

Comparison of point-of-care-testing glucose meters with standard laboratory measurement of the 50g-glucose-challenge test (GCT) during pregnancy.

OBJECTIVES: Although glucose meters are well-established instruments for self-monitoring blood glucose levels, diagnostic and screening procedures should be performed using standard laboratory methods. In addition to standard laboratory methods, HemoCue is authorized for screening and diagnostic purposes in Germany. The rapid development of other glucose meters makes it necessary to re-evaluate this recommendation. Our objective was to test the usefulness of glucose meters in screening pregnant patients for gestational diabetes. METHODS: The 50-g glucose challenge test was administered to one hundred and ninety-three pregnant patients whose blood glucose levels were then simultaneously measured with five portable meters and the HemoCue. The results were compared to our standard method (Hexokinase). A cut-off of 7.8 mmol/L was used and sensitivity, specificity, accuracy, the Youden index, and the Kappa index were calculated. The tests were performed by well-trained personnel (C.D. and U.S.). RESULTS: 1212 measurements were performed on 193 patients. All glucose meters showed a very good correlation (r > 0.90). None of the measurements showed an extreme deviation necessitating the error grid analysis. The GlucoTouch (5.93% +/- 7.4) and the HemoCue (-9.04% +/- 5.9) showed a mean deviation greater than 5%. None of the meters had a mean deviation greater than 10%. The accuracy fluctuated between 0.85 and 0.94. The Kappa index was between 66 to 85. In our clinical trial, the Accu-Chek, Glucotouch, OneTouch, and Precision demonstrated greater accuracy and a higher Kappa index than the HemoCue. CONCLUSIONS: Our data showed good concordance in statistical and clinical parameters for most of the six glucose meters. The HemoCue, recommended as a standard method in several countries, did not show better concordance than most of the tested glucose meters. When used by well-trained personnel, the accuracy of the Accu-Chek, Glucotouch, One-Touch, and Precision was acceptable for use in gestational diabetes screening.

Risk for gestational diabetes and hypertension for women with twin pregnancy compared to singleton pregnancy.

OBJECTIVES: This study was undertaken to determine the incidence of pregnancy induced hypertension (PIH) and gestational diabetes (GDM) in twin pregnancies (TP) in comparison with singleton pregnancies (SP), and to test whether TP with GDM have a higher risk than TP without GDM, as is known to be the case in SP. MATERIALS AND METHODS: Eighty-nine patients with TP who sought prenatal care between 1 September 1994 and 30 October 1997, were asked to participate. One hundred and seventy-eight of the 1,416 patients were matched in a 1:2 ratio by age, body-mass-index, parity, gestational age at screening, and ethnicity with a singleton pregnancy from our database dating from the same period. The diagnosis "hypertension" or "preeclampsia" was made using clinical criteria including a repeated blood pressure above 140/90 mm Hg. Maternal and fetal outcome were compared between SP and TP, between TP with and without pathological screening, between TP with and without GDM. RESULTS: Patients with TP did not have a higher rate of GDM but of PIH (GDM 3.4% vs. 3.4%, p=0.63; PIH 2.8% vs. 9.0%, p=0.036). Expectant mothers of twins whose glucose screening test was pathological have a higher incidence of hypertension than those whose screening test was normal (17.9% vs. 4.9%, p=0.048). Twins of gestational diabetics have a higher rate of admission to the neonatal intensive care unit than twins of healthy pregnant patients (100% vs. 31%, p=0.028). CONCLUSIONS: TP are associated with a higher risk of hypertension than SP but not for GDM. Patients expecting twins who show a carbohydrate intolerance are at a higher risk for hypertension and fetal diabetes-associated complications.

Rate and risk factors of hypoglycemia in large-for-gestational-age newborn infants of nondiabetic mothers.

OBJECTIVE: The purpose of this study was to investigate the rate of hypoglycemia in large-for-gestational-age infants of nondiabetic mothers in relation to maternal or neonatal risk factors. STUDY DESIGN: Hospital charts of all term large-for-gestational-age infants born between 1994 and 1998 (n = 1136) were analyzed for the rate of neonatal hypoglycemia (capillary glucose level, < or =30 mg/dL) during the first 24 hours of life. Infants of women with preexisting or gestational diabetes mellitus were excluded (n = 180). Neonatal glucose testing was performed at 1 or 2 hours of life, with subsequent measurements every 4 to 6 hours. Maternal and neonatal parameters were compared between neonates with and without hypoglycemia, including recent oral glucose tolerance test values in those women who were tested (n = 358). RESULTS: Of 956 infants, 69 infants (7.2%) were not tested for hypoglycemia. In the remaining 887 infants, hypoglycemia occurred in 142 infants (16%) within the first 24 hours of life. The incidence of hypoglycemia decreased sharply during the first few hours of life, from 9.2% within the first hour of life, to 3.5% between 2 to 5 hours (cumulative) of life, and 2.4% between 6 and 24 hours of life. Gestational age at delivery was the only neonatal parameter that differed significantly between infants with and without hypoglycemia (39.5 vs 39.3 weeks, P =.01). The antenatal 1-hour oral glucose tolerance test value was the only predictive maternal parameter (141.5 vs 163.0 mg/dL, P <.006). There was an incremental risk of hypoglycemia with increasing 1-hour oral glucose tolerance test values, with hypoglycemia rates of 2.5%, 9.3%, 22.0%, and 50.0% that were associated with maternal 1-hour glucose values of <120, 120-179, 180-239, and > or =240 mg/dL, respectively (P <.05, for all comparisons). CONCLUSION: Routine glucose testing is indicated in large-for-gestational-age newborn infants of nondiabetic mothers. The 1-hour glucose value of the maternal oral glucose tolerance test is a fairly good predictor of subsequent neonatal hypoglycemia. A single elevated 1-hour value of > or =180 mg/dL markedly increases the risk of neonatal hypoglycemia.

Long-term outcomes in acute renal failure patients treated with continuous renal replacement therapies.

BACKGROUND: Limited health care budgets have raised the issue of how much therapy should be dedicated to critically ill patients with multiorgan and acute renal failure (ARF). No data are available on patients with ARF after hospital discharge. METHODS: We assessed long-term survival and quality of life after discharge. Nine hundred seventy-nine patients with ARF who needed continuous renal replacement therapies were analyzed retrospectively. Contact was achieved by questionnaires assessing health status and mental and physical well-being. RESULTS: The in-hospital mortality rate was 69% (n = 678). Postdischarge information was obtained from 89% (n = 267). Kaplan-Meier analyses showed surprisingly good postdischarge survival. Discharged patients had a 77% probability to survive the first 6 months. Those who did so had a probability of 89% to survive the following 6 months. After 5 years, the survival probability was 50%. Age and more than one comorbidity before hospitalization were associated with significantly lower postdischarge survival. Seventy-seven percent of questionnaire responders assessed their current health status as good to excellent, 57% were self-sustaining, and 49% stated that their quality of life had improved. Renal insufficiency remained in 41%, whereas 10% required chronic dialysis therapy. CONCLUSION: ARF is associated with a high in-hospital mortality rate. Nevertheless, patients leaving the hospital had a reasonable survival rate and good quality of life. We conclude that aggressive intensive care unit treatment is justified in these patients.