Risk factors for 30-day mortality in elderly patients with lower respiratory tract infection. Community-based study.

BACKGROUND: Pneumonia is a major cause of death in the elderly, but there are few studies of risk factors for death that include both ambulatory and nursing home patients. OBJECTIVE: To assess factors associated with 30-day mortality in a population-based study of older adults with lower respiratory tract infection. METHODS: Identification of (1) a previously identified retrospective cohort of all residents of Rochester, Minn, aged 65 years or older who experienced a first episode of pneumonia or bronchitis during a calendar year and (2) the risk factors associated with 30-day mortality through review of complete inpatient and ambulatory medical records. Logistic regression was used to identify significant independent risk factors for 30-day mortality. RESULTS: A total of 413 adults aged 65 years or older were identified. The independent factors for 30-day mortality were atypical symptoms (odds ratio [OR], 4.98; 95% confidence interval [CI], 2.14-11.60), neurologic illness (OR, 3.92; 95% CI, 1.47-6.59), current diagnosis of cancer (OR, 6.2; 95% CI, 2.40-15.99), and recent or current use of antibiotics (OR, 3.13; 95% CI, 1.45-6.77). CONCLUSIONS: Malignancy and neurologic disease are well-recognized conditions that identify patients with lower respiratory tract infections who have a high risk of death within 30 days. An atypical presentation with confusion, lethargy, poor eating, or recent or current antibiotic use also identifies patients, with a high risk of 30-day mortality.

Prophylactic agents for venous thrombosis in elective hip surgery. Meta-analysis of studies using venographic assessment.

BACKGROUND: We determined the relative efficacy of various agents or combinations of agents in the prophylaxis of deep venous thrombosis after elective hip arthroplasty. METHODS: Peer-reviewed, English-language, human studies articles from 1975 through 1991 were obtained through a MEDLINE database search. Additional references were obtained from bibliographies. Articles that compared the effect of two or more prophylactic agents or placebo in preventing deep venous thrombosis as assessed by venography were selected for further review. Only studies of elective hip surgery in which all patients had venographic screening for thrombosis were included. Twenty-three of 101 studies met these criteria. Data were abstracted by one of us. Methodologic criteria and outcome data from each study were recorded and analyzed. RESULTS: There was significant heterogeneity in the deep venous thrombosis rate among studies. Although the rates were lowest for low-molecular-weight heparin with or without the use of stockings, adjusted-dose heparin, and warfarin, many agents had similar low rates. There was less heterogeneity when the relative risk was used as a summary statistic for studies in which two agents were compared. With pairwise comparisons, low-molecular-weight heparin performed better than every agent with which it was compared. Other agents performed well but were not consistently better. CONCLUSIONS: Multiple agents or combinations are effective prophylaxis for deep venous thrombosis, but none decreases the rate to zero. There was overlap in the 95% confidence intervals for the probability of deep venous thrombosis for various agents and especially for the probabilities for proximal thrombi. Many agents have not been compared directly with each other, but low-molecular-weight heparin consistently performed well.

The clinical utility of the Ca19-9 radioimmunoassay for the diagnosis of pancreatic cancer presenting as pain or weight loss. A cost-effectiveness analysis.

CA 19-9 is a promising radioimmunoassay for the detection of pancreatic cancer, but its clinical role and cost-effectiveness are not yet known. To investigate these factors, we used clinical decision analysis to study diagnostic strategies for patients with suspected pancreatic cancer presenting as pain or weight loss. Comprehensive diagnostic strategies were developed to reflect current and future patterns of practice utilizing CA19-9 radioimmunoassay (RIA) to yield biopsy-proved cancer or confidently exclude its presence. The performance of the strategies beginning with CA19-9 RIA and ultrasonography were equivalent in positive and negative predictive values over a range of prevalence of pancreatic cancer from 0.02 to 0.15. At higher prevalence, the negative predictive value of the ultrasonography strategy became significantly better. The CA19-9 RIA strategy used fewer noninvasive tests, endoscopic retrograde cholangiopancreatographic procedures, and invasive radiologic studies than did the ultrasonography strategy at each prevalence. The health care costs ranged between $848 and $1413 per patient for the CA19-9 RIA strategy and $1186 and $1848 per patient for the ultrasonography strategy. We conclude that the CA19-9 RIA is a useful, cost-effective initial test for the examination of patients with suspected pancreatic cancer.

Life-sustaining treatment. A prospective study of patients with DNR orders in a teaching hospital.

We conducted a prospective survey of attending, resident, and intern physicians who had written a "do not resuscitate" (DNR) order for 93 patients in their care. After writing a DNR order, 11% of respondents would still use chest compression if their patient experienced a cardiopulmonary arrest. Many physicians did not plan to withdraw therapy except intensive care, but most physicians planned to withhold a spectrum of life-sustaining therapies, from hemodialysis (86%) to intravenous fluids (21%). Attending and house-staff physicians generally agreed on whether to withdraw a given therapy or not but frequently disagreed on whether to withhold a therapy or not. After patient discharge or death, 88 charts were reviewed. None of the 88 patients was coded. Physicians initiated 68 life sustaining therapies in 43 patients and discontinued 64 therapies in 34 patients; there was no change in management in 31 patients. We conclude that individual physicians interpret the DNR order differently. These orders often are associated with the discontinuation or noninitiation of life-sustaining therapies other than emergency CPR.

The probability of malignancy in solitary pulmonary nodules. Application to small radiologically indeterminate nodules.

BACKGROUND: A clinical prediction model to identify malignant nodules based on clinical data and radiological characteristics of lung nodules was derived using logistic regression from a random sample of patients (n = 419) and tested on data from a separate group of patients (n = 210). OBJECTIVE: To use multivariate logistic regression to estimate the probability of malignancy in radiologically indeterminate solitary pulmonary nodules (SPNs) in a clinically relevant subset of patients with SPNs that measured between 4 and 30 mm in diameter. PATIENTS AND METHODS: A retrospective cohort study at a multispecialty group practice included 629 patients (320 men, 309 women) with newly discovered (between January 1, 1984, and May 1, 1986) 4- to 30-mm radiologically indeterminate SPNs on chest radiography. Patients with a diagnosis of cancer within 5 years prior to the discovery of the nodule were excluded. Clinical data included age, sex, cigarette-smoking status, and history of extrathoracic malignant neoplasm, asbestos exposure, and chronic interstitial or obstructive lung disease; chest radiological data included the diameter, location, edge characteristics (eg, lobulation, spiculation, and shagginess), and other characteristics (eg, cavitation) of the SPNs. Predictors were identified in a random sample of two thirds of the patients and tested in the remaining one third. RESULTS: Sixty-five percent of the nodules were benign, 23% were malignant, and 12% were indeterminate. Three clinical characteristics (age, cigarette-smoking status, and history of cancer [diagnosis, > or = 5 years ago]) and 3 radiological characteristics (diameter, spiculation, and upper lobe location of the SPNs) were independent predictors of malignancy. The area (+/-SE) under the evaluated receiver operating characteristic curve was 0.8328 +/- 0.0226. CONCLUSION: Three clinical and 3 radiographic characteristics predicted the malignancy in radiologically indeterminate SPNs.

Organizing pneumonia. Features and prognosis of cryptogenic, secondary, and focal variants.

BACKGROUND: Organizing pneumonia (OP) is a non-specific response to many types of lung injury. Clinicians frequently encounter pathology reports of OP in patients with no underlying condition (cryptogenic OP, also known as BOOP or bronchiolitis obliterans OP) or in association with drugs or nonpulmonary disease. The goals of this study are to describe the clinical course and outcomes in patients with 3 clinical variants of OP. METHODS: A retrospective study of patients with OP seen at the Mayo Clinic, Rochester, Minn, from January 1, 1984, through June 30, 1994, was conducted. Initial features were obtained from medical records. Chest radiographs and pathology specimens were reviewed for this study. Resolution, relapse, and survival were obtained from medical records and a follow-up patient questionnaire. RESULTS: Seventy-four patients had pathologically confirmed OP. Organizing pneumonia was classified into 3 clinical groups: symptomatic cryptogenic OP; symptomatic OP related to underlying hematologic malignant neoplasm, collagen vascular disease, or drugs (secondary OP); and asymptomatic OP presenting as a focal nodule (focal OP). Thirty-seven patients (50%) had cryptogenic OP and 27 patients (36%) had secondary OP. No difference was found between cryptogenic and secondary OP in type or severity of symptoms, signs, laboratory and pulmonary function tests, or radiologic or pathologic findings. Corticosteroids were given at a similar initial dose (prednisone, about 50 mg/d). Resolution of symptoms was more frequent in patients with cryptogenic OP than those with secondary OP. Relapse was infrequent in both of these groups. Five-year survival was higher in patients with cryptogenic OP (73%) than in secondary OP (44%), and respiratory-related deaths were more frequent in patients with secondary OP. Organizing pneumonia was an asymptomatic focal rounded opacity in 10 patients (14%), most often detected on chest radiograph and diagnosed on lung biopsy done for suspicion of lung cancer. Patients with focal OP required no treatment and had no relapse or respiratory-related deaths. CONCLUSIONS: Clinical classification of OP is useful to predict clinical course and outcome. Cryptogenic OP most often was a symptomatic bilateral lung process that had an overall favorable prognosis with prolonged corticosteroid therapy. Patients with secondary OP had a high mortality rate when the disease was associated with predisposing conditions or drugs. Patients with asymptomatic focal OP had an excellent prognosis.

Predictors of recurrence after deep vein thrombosis and pulmonary embolism: a population-based cohort study.

BACKGROUND: The appropriate duration of oral anticoagulation after a first episode of venous thromboembolism (VTE) is uncertain and depends upon VTE recurrence rates. OBJECTIVE: To estimate VTE recurrence rates and determine predictors of recurrence. METHODS: Patients in Olmsted County, Minnesota, with a first lifetime deep vein thrombosis or pulmonary embolism diagnosed during the 25-year period from 1966 through 1990 (N = 1,719) were followed forward in time through their complete medical records in the community for first VTE recurrence. RESULTS: Four hundred four patients developed recurrent VTE during 10,198 person-years of follow-up. The overall (probable/definite) cumulative percentages of VTE recurrence at 7, 30, and 180 days and 1 and 10 years were 1.6% (0.2%), 5.2% (1.4%), 10.1% (4.1%), 12.9% (5.6%), and 30.4% (17.6%), respectively. The risk of recurrence was greatest in the first 6 to 12 months after the initial event but never fell to zero. Independent predictors of first overall VTE recurrence included increasing age and body mass index, neurologic disease with paresis, malignant neoplasm, and neurosurgery during the period from 1966 through 1980. Independent predictors of first probable/definite recurrence included diagnostic certainty of the incident event and neurologic disease in patients with hospital-acquired VTE. Recurrence risk was increased by malignant neoplasm but varied with concomitant chemotherapy, patient age and sex, and study year. CONCLUSIONS: Venous thromboembolism recurs frequently, especially within the first 6 to 12 months, and continues to recur for at least 10 years after the initial VTE. Patients with VTE with neurologic disease and paresis or with malignant neoplasm are at increased risk for recurrence, while VTE patients with transient or reversible risk factors are at less risk.

Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study.

BACKGROUND: Reported risk factors for venous thromboembolism (VTE) vary widely, and the magnitude and independence of each are uncertain. OBJECTIVES: To identify independent risk factors for deep vein thrombosis and pulmonary embolism and to estimate the magnitude of risk for each. PATIENTS AND METHODS: We performed a population-based, nested, case-control study of 625 Olmsted County, Minnesota, patients with a first lifetime VTE diagnosed during the 15-year period from January 1, 1976, through December 31, 1990, and 625 Olmsted County patients without VTE. The 2 groups were matched on age, sex, calendar year, and medical record number. RESULTS: Independent risk factors for VTE included surgery (odds ratio [OR], 21.7; 95% confidence interval [CI], 9.4-49.9), trauma (OR, 12.7; 95% CI, 4.1-39.7), hospital or nursing home confinement (OR, 8.0; 95% CI, 4.5-14.2), malignant neoplasm with (OR, 6.5; 95% CI, 2.1-20.2) or without (OR, 4.1; 95% CI, 1.9-8.5) chemotherapy, central venous catheter or pacemaker (OR, 5.6; 95% CI, 1.6-19.6), superficial vein thrombosis (OR, 4.3; 95% CI, 1.8-10.6), and neurological disease with extremity paresis (OR, 3.0; 95% CI, 1.3-7.4). The risk associated with varicose veins diminished with age (for age 45 years: OR, 4.2; 95% CI, 1.6-11.3; for age 60 years: OR, 1.9; 95% CI, 1.0-3.6; for age 75 years: OR, 0.9; 95% CI, 0.6-1.4), while patients with liver disease had a reduced risk (OR, 0.1; 95% CI, 0.0-0.7). CONCLUSION: Hospital or nursing home confinement, surgery, trauma, malignant neoplasm, chemotherapy, neurologic disease with paresis, central venous catheter or pacemaker, varicose veins, and superficial vein thrombosis are independent and important risk factors for VTE.

Predictors of survival after deep vein thrombosis and pulmonary embolism: a population-based, cohort study.

BACKGROUND: Because reported survival after venous thromboembolism (VTE) varies widely, we performed a population-based retrospective cohort study to estimate survival, compare observed with expected survival, and determine predictors of short-term (< or =7 days) and long-term survival (>7 days) after VTE. METHODS: We followed the 25-year (1966-1990) inception cohort (n = 2218) of Olmsted County, Minnesota, patients with deep vein thrombosis alone (DVT) or pulmonary embolism with or without deep vein thrombosis (PE+/-DVT) forward in time until death or the last clinical contact. RESULTS: During 14 629 person-years of follow-up, 1333 patients died. Seven-day, 30-day, and 1-year VTE survival rates were 74.8% (DVT, 96.2%; PE+/-DVT, 59.1%), 72.0% (DVT, 94.5%; PE+/-DVT, 55.6%), and 63.6% (DVT, 85.4%; PE+/-DVT, 47.7%), respectively. Observed survival after DVT, PE+/-DVT, and overall was significantly worse than expected for Minnesota whites of similar age and sex (P<.001). More than one third of deaths occurred on the date of onset or after VTE that was unrecognized during life. Short-term survival improved during the 25-year study period, while long-term survival was unchanged. After adjusting for comorbid conditions, PE+/-DVT was an independent predictor of reduced survival for up to 3 months after onset compared with DVT alone. Other independent predictors of both short- and long-term survival included age, body mass index, patient location at onset, malignancy, congestive heart failure, neurologic disease, chronic lung disease, recent surgery, and hormone therapy. Additional independent predictors of long-term survival included tobacco smoking, other cardiac disease, and chronic renal disease. CONCLUSIONS: Survival after VTE, and especially after PE+/-DVT, is much worse than reported, and significantly less than expected survival. Compared with DVT alone, symptomatic PE+/-DVT is an independent predictor of reduced survival for up to 3 months after onset, implying that treatment for the 2 disorders should be different.

Long-term use of oral anticoagulants and the risk of fracture.

BACKGROUND: Vitamin K participates in bone metabolism and, since oral anticoagulants antagonize vitamin K, their use may increase the risk of osteoporosis. OBJECTIVE: To evaluate fracture risk at all skeletal sites following exposure to oral anticoagulants. METHODS: In a population-based retrospective cohort study, 572 Olmsted County, Minnesota, women 35 years or older at their first lifetime venous thromboembolism event between 1966 and 1990 were followed up for fractures. Risk was assessed by comparing new fractures with the number expected from sex- and age-specific fracture incidence rates for the general population (standardized incidence ratio [SIR]). RESULTS: Altogether, 480 fractures occurred during 6314 person-years of follow-up. Increasing exposure to oral anticoagulation was associated with an increased SIR for vertebral fractures: at less than 3 months of exposure, 2.4 (95% confidence interval [CI], 1.6-3.4); 3 to less than 12 months, 3.6 (95% CI, 2.5-4.9); and 12 months or more, 5.3 (95% CI, 3.4-8.0); and for rib fractures: at less than 3 months, 1.6 (95% CI, 0.9-2.7); 3 to less than 12 months, 1.6 (95% CI, 0.9-2.6); and 12 months or more, 3.4 (95% CI, 1.8-5.7). The data revealed no increased risk for other types of fractures. Oral anticoagulation for 12 months or more was an independent predictor of vertebral fractures (P = .009) and rib fractures (P = .02), but not other fractures. CONCLUSIONS: Long-term exposure to oral anticoagulation is associated with an increased risk of vertebral and rib fractures. The mechanism by which this occurs is still unclear and needs further investigation.

Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study.

BACKGROUND: The incidence of venous thromboembolism has not been well described, and there are no studies of long-term trends in the incidence of venous thromboembolism. OBJECTIVES: To estimate the incidence of deep vein thrombosis and pulmonary embolism and to describe trends in incidence. METHODS: We performed a retrospective review of the complete medical records from a population-based inception cohort of 2218 patients who resided within Olmsted County, Minnesota, and had an incident deep vein thrombosis or pulmonary embolism during the 25-year period from 1966 through 1990. RESULTS: The overall average age- and sex-adjusted annual incidence of venous thromboembolism was 117 per 100000 (deep vein thrombosis, 48 per 100000; pulmonary embolism, 69 per 100000), with higher age-adjusted rates among males than females (130 vs 110 per 100000, respectively). The incidence of venous thromboembolism rose markedly with increasing age for both sexes, with pulmonary embolism accounting for most of the increase. The incidence of pulmonary embolism was approximately 45% lower during the last 15 years of the study for both sexes and all age strata, while the incidence of deep vein thrombosis remained constant for males across all age strata, decreased for females younger than 55 years, and increased for women older than 60 years. CONCLUSIONS: Venous thromboembolism is a major national health problem, especially among the elderly. While the incidence of pulmonary embolism has decreased over time, the incidence of deep vein thrombosis remains unchanged for men and is increasing for older women. These findings emphasize the need for more accurate identification of patients at risk for venous thromboembolism, as well as a safe and effective prophylaxis.

Yield of laboratory tests for case-finding in the ambulatory general medical examination.

PURPOSE: To examine the diagnostic and therapeutic yield of frequently obtained laboratory tests for case-finding in the comprehensive ambulatory medical examination. PATIENTS AND METHODS: A prospective cohort study was conducted in four Mayo Clinic general internal medicine divisions that provide care to community, regional, and geographically distant patients. The main outcome measurements were the diagnostic yield and therapeutic yield of the complete blood count, chemistry panel, lipid profile, thyroid tests, and urinalysis ordered for case-finding. RESULTS: Overall, 1,508 laboratory tests consisting of 7,008 individual components were obtained for case-finding in the 531 patients (mean age 63 +/- 14 years; 57% female). Thirty-six percent (544 of 1508) of the tests were abnormal, of which 6% (33 of 544) were repeated and 9% (47 of 544) led to further investigations. The 1,508 case-finding tests had a diagnostic yield of 4.8% (73 new diagnoses) and a therapeutic yield of 4.0% (60 new therapies). The therapeutic yield of each test ordered for case-finding was as follows: lipid profile (16.5%), chemistry panel (2.8%), complete blood count (0.9%), urinalysis (0.8%), and thyroid tests (0.7%). Therapeutic yield was not associated with patient's age, gender, or referral distance but was approximately twice as high in new patients compared with established patients. CONCLUSIONS: The majority of treatments for conditions identified by case-finding laboratory tests resulted from the lipid profile. The therapeutic yield of the chemistry panel was low, and the therapeutic yield of the complete blood count, thyroid tests, and urinalysis were all less than 1%. The low therapeutic yield of many routine laboratory tests ordered for case-finding should be provided to patients, physicians, and managed care organizations to set priorities for case-finding and screening.

The epidemiology of venous thromboembolism in the community.

The incidence of venous thromboembolism exceeds 1 per 1000; over 200,000 new cases occur in the United States annually. Of these, 30% die within 30 days; one-fifth suffer sudden death due to pulmonary embolism. Despite improved prophylaxis, the incidence of venous thromboembolism has been constant since 1980. Independent risk factors for venous thromboembolism include increasing age, male gender, surgery, trauma, hospital or nursing home confinement, malignancy, neurologic disease with extremity paresis, central venous catheter/transvenous pacemaker, prior superficial vein thrombosis, and varicose veins; among women, risk factors include pregnancy, oral contraceptives, and hormone replacement therapy. About 30% of surviving cases develop recurrent venous thromboembolism within ten years. Independent predictors for recurrence include increasing age, obesity, malignant neoplasm, and extremity paresis. About 28% of cases develop venous stasis syndrome within 20 years. To reduce venous thromboembolism incidence, improve survival, and prevent recurrence and complications, patients with these characteristics should receive appropriate prophylaxis.

High-grade astrocytomas: resource use, clinical outcomes, and cost of care.

OBJECTIVE: To describe the clinical course, survival, resource use, and direct medical costs of care for patients with high-grade astrocytomas. MATERIAL AND METHODS: All patients with grade 3 or 4 astrocytoma who resided in Olmsted County, Minnesota, or one of the six adjacent counties and had a tissue diagnosis first made between 1987 and 1992 were studied. Clinical characteristics, initial management, use of resources, clinical course, survival, and medical charges were analyzed. RESULTS: Sixty-four patients, with a mean age of 62 years, were identified; 81% had glioblastoma multiforme. Approximately 60% underwent surgical resection, 80% had radiotherapy, and 50% had chemotherapy for initial management. After initial treatment (median duration, 116 days), approximately 75% of patients had a course with stable disease (median duration, 198 days). The overall median duration of survival was 323 days; lower grade and younger age were significantly associated with longer median survival-for example, 1,493 days for patients younger than 65 years with grade 3 astrocytomas and 205 days for patients 65 years old or older with grade 4 astrocytomas. The mean total direct medical charges were $67,887. CONCLUSION: In most patients with high-grade astrocytomas, a substantial period elapsed before disease progressed. Although the overall median duration of survival was less than 1 year, younger patients, especially those with grade 3 astrocytomas, had a longer survival. The management of patients with high-grade astrocytomas uses substantial health-care resources.

Management of urinary retention: rapid versus gradual decompression and risk of complications.

The literature was reviewed to quantify the risk of complications related to the relief of obstruction in urinary retention. We also sought to determine whether the risk of complications is higher with rapid or gradual decompression (or "clamping") of the obstructed urinary bladder. The medical literature was identified by a search of the MEDLINE database and a manual review of the bibliographies of the identified articles. Studies show that, after quick, complete relief of obstruction, hematuria occurs in 2 to 16% of patients; however, clinically significant hematuria is rare. After relief of obstruction, blood pressure often decreases, but it usually normalizes and does not progress to clinically significant hypotension. Postobstructive diuresis occurs after relief of obstruction in 0.5 to 52% of patients; however, it is easily managed and rarely of clinical significance. We were unable to identify any randomized controlled studies that directly compared quick, complete emptying with gradual emptying of the obstructed bladder. Moreover, we identified no studies supporting the practice of gradual emptying of the obstructed bladder. The available published studies support quick, complete emptying for relief of the obstructed urinary bladder. We conclude that hematuria, hypotension, and postobstructive diuresis may occur after decompression of the obstructed urinary bladder, but these complications are rarely clinically significant. Quick, complete emptying of the obstructed bladder is safe, simple, and effective and is recommended as the optimal method for decompressing the obstructed urinary bladder. Prudent, supportive care is needed for all patients, with special attention to elderly patients and those with hypovolemia.

Cigarette smoking and ulcerative colitis: a case-control study.

OBJECTIVE: To determine whether the previously reported decreased risk of ulcerative colitis in current smokers and increased risk in former smokers are explained by age, sex, race, ethnicity, or socioeconomic status. DESIGN: We conducted a case-control study at a university hospital gastroenterology clinic. MATERIAL AND METHODS: One hundred patients with ulcerative colitis and 100 age- and sex-matched community control subjects were randomly selected for a telephone interview to collect information on smoking habits, race, religion, income, education, and occupation. Smoking habits at the onset of symptoms were analyzed with use of conditional logistic regression for matched data to obtain adjusted odds ratios and 95% confidence intervals for current or former smokers. RESULTS: In comparison with those who had never smoked, current smokers were less likely to have ulcerative colitis: odds ratio = 0.13; 95% confidence interval = 0.05 to 0.38. Former smokers had no increased risk for ulcerative colitis: odds ratio = 1.24; 95% confidence interval = 0.52 to 2.95. No dose-response effect was noted on the basis of pack-years of cigarette smoking, and among former smokers, the interval since quitting smoking was not significantly associated with the relative risk of ulcerative colitis. No confounding effect was detected from race, religion, income, education, or occupation. CONCLUSION: An association seems to exist between ulcerative colitis and nonsmoking; perhaps patients with ulcerative colitis who smoke are less likely to experience symptoms than are nonsmokers because of the effects of nicotine.

Amyotrophic lateral sclerosis and life-sustaining therapy: patients' desires for information, participation in decision making, and life-sustaining therapy.

To identify the wishes of patients with amyotrophic lateral sclerosis (ALS) for information, participation in decision making, and life-sustaining therapy and to determine whether these wishes are stable over time, we conducted a prospective survey (baseline and 6-month follow-up interviews) of 38 consecutive patients with an established diagnosis of ALS at the University of Chicago Motor Neuron Disease Clinic. Demographic data, clinical stage of ALS, illness experience, wishes for information, and desires for participating in decisions about life-sustaining therapy were elicited. Patients readily expressed their wishes for specific information on communication aids and ventilator care for respiratory failure. Demographic, socioeconomic, and clinical characteristics did not predict patients' desires for information and decision making. The preferences for information and participation in decisions were stable during the 6-month study period, whereas preferences for cardiopulmonary resuscitation in two hypothetical circumstances were less stable. Changes were unrelated to demographic or clinical characteristics of the patients. Because many patients with ALS change their preferences for life-sustaining therapy, advance directives for end-of-life care must be reevaluated periodically.

Bleeding and thromboembolism during anticoagulant therapy: a population-based study in Rochester, Minnesota.

OBJECTIVE: To estimate the incidence of and identify risk factors for hemorrhage and thromboembolism during long-term anticoagulant therapy. DESIGN: We conducted a population-based retrospective cohort study of all residents of Rochester, Minnesota, in whom a course of warfarin therapy intended to last for more than 4 weeks was initiated between Sept. 1, 1987, and Dec. 31, 1989. METHODS: Medical records were reviewed, and pertinent data were compiled. All bleeding complications were classified as minor or major on the basis of the bleeding severity index, and thromboembolic events were classified as major if they were fatal or life-threatening. Cumulative incidences of adverse events were analyzed statistically. RESULTS: During the study period, 261 patients had incident courses of anticoagulation (52% were male, 61% were 65 years of age or older, and 31% were 75 years of age or older), with 221 patient-years of warfarin exposure. The primary indications for anticoagulation were venous thromboembolism (39%); stroke or transient ischemic attack (21%); atrial fibrillation (11%); and coronary artery disease, procedures for coronary artery disease, or cardiomyopathy (7%). The cumulative incidence of major hemorrhage at 1, 3, 12, and 24 months was 1.6%, 3.3%, 5.3%, and 10.6%, respectively, and of major or minor thromboembolic events was 2.3%, 5.0%, 7.4%, and 13.1%, respectively. In multivariate analysis, (1) a malignant condition was significantly associated with major hemorrhage; (2) malignant disease and history of peptic ulcer were significantly associated with the combined outcome of major or minor hemorrhage; and (3) malignant disease was significantly associated with any thromboembolism. Age, sex, atrial fibrillation, history of gastrointestinal hemorrhage, history of peptic ulcer, alcohol abuse, hypertension, stroke, and the Charlson comorbidity index were not significantly associated with major hemorrhage. CONCLUSION: In this population-based study, including a high proportion of elderly patients, malignant disease at initiation of warfarin anticoagulation was significantly associated with both major hemorrhage and any thromboembolism. Advanced age is not a contraindication to anticoagulant therapy.

Utilization and outcomes of surgical gastrostomies and jejunostomies in an era of percutaneous endoscopic gastrostomy: a population-based study.

OBJECTIVE: To determine the indications for use of surgical gastrostomy (SG) and surgical jejunostomy (SJ) as feeding tubes, the complications, and the trends in the use of SG and SJ after the introduction of percutaneous endoscopic gastrostomy (PEG) at our institution in 1981. DESIGN: We conducted a retrospective, population-based cohort study of residents of Olmsted County, Minnesota, who received surgically placed feeding tubes between 1976 and 1989. MATERIAL AND METHODS: The medical records of all Olmsted County residents with surgical placement of a feeding tube during the designated study period were reviewed, and underlying conditions, complications, and survival were analyzed. RESULTS: Of 77 adult patients (mean age, 66 years; 48% women), 54 underwent SG and 23 had SJ. General anesthesia was used in 42 patients (55%). The indications for SG or SJ were stroke in 23 patients, cancer in 19, other central nervous system-related conditions in 16, and other conditions in 19. Among the numerous comorbid conditions, pulmonary disease (N = 44) and cardiac disease (N = 32) were most frequent. The median duration of follow-up was 181 days. Complications occurred in 31 of 54 patients (57%) with SG and in 13 of 23 (57%) with SJ. Of the 117 complications, 15% were considered major. Twenty patients (26%) resumed eating. Survival at 1, 6, and 12 months was 79%, 49% and 36%, respectively. Most deaths were due to the disease for which the feeding tube had been placed. In a Cox proportional hazards regression analysis, only age and hypoxemia were found to be significantly associated with survival. Hypoxemia, type of tube, central nervous system disease as indication for procedure, and previous aspiration were associated with failure to resume eating (P < 0.05). Survival was similar to that for our patients with PEG during the same period. The overall incidence of feeding tube placement increased throughout the study period. CONCLUSION: Patients who require enteral feeding tubes have multiple comorbid conditions that have a major influence on the outcome. The overall incidence of feeding tube placement increased after the introduction of PEG. In patients who require long-term enteral nutrition and are unable to have a feeding tube placed percutaneously, surgically placed feeding tubes have outcomes similar to those reported for patients with PEG.

Venous thromboembolism associated with hip and knee arthroplasty: current prophylactic practices and outcomes.

Joint registry and hospital data bases for 5,024 total hip and total knee arthroplasties done between 1986 and 1988 at the Mayo Clinic were used to study prophylactic measures and frequency of symptomatic deep venous thrombosis and pulmonary embolism. In virtually all patients, graduated compression stockings were used, with or without another type of prophylaxis. Only 44 of 3,115 patients who underwent hip arthroplasty (1.4%) and 32 of 1,909 patients who underwent knee arthroplasty (1.7%) had definite or probable deep venous thrombosis or pulmonary embolism. Death definitely or possibly attributable to pulmonary embolism occurred in 11 patients who underwent hip arthroplasty (0.35%) and 1 patient who underwent knee arthroplasty (0.05%). Although patients with a history of deep venous thrombosis or pulmonary embolism were more likely to receive warfarin than were patients without such a history, the relative risk of symptomatic deep venous thrombosis or pulmonary embolism in patients who underwent hip arthroplasty and received warfarin postoperatively was approximately half that in patients who received other types of prophylaxis. The risk of death from pulmonary embolism was similarly diminished in the group that received warfarin. The lower rates of these complications in the patients who received warfarin support the prophylactic use of this agent after total hip arthroplasty.