Variation in the use of do-not-resuscitate orders in patients with stroke.

OBJECTIVES: To identify sociodemographic and clinical characteristics associated with the use of do-not-resuscitate (DNR) orders in hospitalized patients with stroke. To examine whether the use of DNR orders varies across hospitals. METHODS: This observational cohort study used data collected for 13337 consecutive eligible patients with a primary diagnosis of stroke. These patients were discharged in 1991 through 1994 from 30 hospitals in a large metropolitan area. Study data were abstracted from patients' hospital records using standard forms. Admission severity of illness was measured using a validated multivariable model. Sociodemographic and clinical factors independently associated with the use of DNR orders were identified using stepwise logistic regression. RESULTS: Do-not-resuscitate orders were written for 2898 patients (22%). Patient characteristics independently (P < .01) associated with increased use of DNR orders included increasing age (odds ratio [OR], 1.06 per year); admission from a skilled nursing facility (OR, 2.44) or through the emergency department (OR, 1.49); cancer (OR, 2.73), intracerebral hemorrhage (OR, 2.12), coma (OR, 7.47), or lethargy or stupor on admission neurological assessment (OR, 3.38); and increasing admission severity (OR; 1.29 per decile). In contrast, African American race was associated with lower use of DNR orders (OR, 0.54). Although substantial variation in the use of DNR orders was observed across hospitals, with rates ranging from 12% to 32%, adjusting for the above patient characteristics eliminated much of this variation, including differences between major teaching and other hospitals and between hospitals with and without religious affiliations. CONCLUSIONS: In our community-based analysis of patients with stroke, the use of DNR orders was common and was strongly related to several patient characteristics. These factors explained much of the variation across hospitals. While our analysis did not account for differences in patient preferences for treatment, the differences we observed in the use of DNR orders across sociodemographic groups are suggestive of variations in care and may have important implications for the cost and quality of hospital care.

The impact of a respiratory therapy consult service on house officers' knowledge of respiratory care ordering.

BACKGROUND: Although available studies show that implementation of respiratory care protocols by respiratory therapists can enhance the allocation of respiratory care services, concern has been expressed that respiratory therapists' involvement in assessing patients and in determining treatment plans may detract from medical trainees' education and experience in ordering respiratory care services. OBJECTIVE: Compare the rates of correct responses to case-based questions about respiratory care ordering in two groups of internal medicine house officers at academic medical centers: one group training at an institution using respiratory care protocols (The Cleveland Clinic Foundation) and the other group training in an institution at which respiratory care protocols have not been used (University of Nebraska). DESIGN: Prospective cohort study. SETTING: Two academic medical centers, one using respiratory protocols and the other not using respiratory care protocols. MEASUREMENTS: Percent of correct responses to questions regarding respiratory care management posed in 5 case studies administered to both groups. RESULTS: Responses were available from 41 and 17 internal medicine house officers at The Cleveland Clinic Foundation and University of Nebraska, respectively. Respondents represented postgraduate years one, two, and three, and constituted a similar percentage of all internal medicine house officers at each institution (33%). The rate of correct responses to the 20 questions posed in the 5 case studies was high overall (76.8%) and similar in the two house staff groups (77.2 +/- 11.6% at The Cleveland Clinic Foundation and 75.8 +/- 12.0% at University of Nebraska, p = 0.69). The 95% confidence interval for the difference straddled zero (-5.4%, 8.1%), making it very unlikely that any important difference exists between the two groups in rate of correct responses. Analysis of covariance also showed no difference between groups, suggesting that postgraduate training level did not affect this conclusion. In one of the 5 case studies, the percent of correct responses was higher among trainees where respiratory care protocols were in use (86.8 +/- 18% at The Cleveland Clinic Foundation vs 69.1 +/- 14% at University of Nebraska, p = 0.0001). CONCLUSIONS: In this comparison of internal medicine house officers' knowledge regarding respiratory care ordering at institutions using versus not using respiratory care protocols, the rates of correct responses by both groups were similar and unlikely to differ significantly. For one of the 5 case studies, respondents from the institution using respiratory care protocols scored significantly higher. Taken together, these results suggest that use of respiratory care protocols implemented by respiratory therapists does not detract from internal medicine trainees' expertise in respiratory care management. Whether these results generalize to other institutions or reflect expertise in actual practice remains uncertain.

First Report of Acidovorax avenae subsp. citrulli as a Pathogen of Cucumber.

In March 1999, a foliar bacterial disease was observed in a commercial crop of cucumber (Cucumis sativus L.) cv. Jetset in Gumlu in northern Queensland, Australia. Initial symptoms consisted of angular, chlorotic, water-soaked lesions that later dried to necrotic areas of light brown, dead tissue. White bacterial ooze was commonly found on the undersides of young water-soaked lesions. Lesions were delimited by veins and distributed uniformly over leaf surfaces, and more than 20% of the crop was affected. No symptoms were observed on plant stems or fruits. Bacterial streaming from the edges of freshly cut young lesions was clearly visible in a droplet of water under ×100 magnification in the laboratory. Isolations were made from young lesions on King's medium B (1). A slow-growing, white, gram-negative, nonfluorescent bacterium was consistently isolated. Three isolates of the bacterium were identified, using the Biolog software program (Biolog, Hayward CA), and in each instance, the bacterium was confirmed as Acidovorax avenae subsp. citrulli, with a similarity of >0.80. Koch's postulates were completed with 8-day-old glasshouse-grown cucumber (cv. Jetset) seedlings. Seedlings were misted until runoff with a bacterial suspension of 3 × 108 CFU/ml and enclosed in plastic bags for ≈30 h at 22°C. Water-soaked lesions were observed on cucumber cotyledons 4 days after inoculation. This is the first report of A. avenae subsp. citrulli as a pathogen of cucumber. Reference: (1) E. O. King et al. J. Lab. Clin. Med. 44:301, 1954.

Mechanical failure begins preferentially near resorption cavities in human vertebral cancellous bone under compression.

The amount of bone turnover in the body has been implicated as a factor that can influence fracture risk and bone strength. Here we test the idea that remodeling cavities promote local tissue failure by determining if microscopic tissue damage (microdamage) caused by controlled loading in vitro is more likely to form near resorption cavities. Specimens of human vertebral cancellous bone (L4, 7 male and 2 female, age 70±10, mean±SD) were loaded in compression to the yield point, stained for microscopic tissue damage and submitted to three-dimensional fluorescent imaging using serial milling (image voxel size 0.7×0.7×5.0 µm). We found the resulting damage volume per bone volume (DV/BV) was correlated with percent eroded surface (p<0.01, r(2)=0.65), demonstrating that whole specimen measures of resorption cavities and microdamage are related. Locations of microdamage were more than two times as likely to have a neighboring resorption cavity than randomly selected sites without microdamage (relative risk 2.39, 95% confidence interval of relative risk: 2.09-2.73), indicating a spatial association between resorption cavities and microdamage at the local level. Individual microdamage sites were 48,700 (40,100; 62,700) µm(3) in size (median, 25th and 75th percentiles). That microdamage was associated with resorption cavities when measured at the whole specimen level as well as at the local level provides strong evidence that resorption cavities play a role in mechanical failure processes of cancellous bone and therefore have the potential to influence resistance to clinical fracture.

Status of patients 5 or more years after correction of coarctation of the aorta over age 1 year.

In this retrospective study, we reviewed the records of patients who had coarctectomies at the University of Virginia Hospital after 1 year of age. Follow-up data for 5 years or more after surgery were available for 52 patients. Data from 23 similar patients from the Medical College of Virginia brought the total postoperative sample size to 75. The blood pressure of this group of patients did not differ significantly from that of the population at large. We conclude that successful repair of coarctation of the aorta in childhood or early adolescence does not lead to a higher-than-expected incidence of resting hypertension in childhood.

Does aminophylline benefit adults admitted to the hospital for an acute exacerbation of asthma?

OBJECTIVE: To determine the effect of adding intravenous theophylline (administered as aminophylline) to nebulizations of albuterol and intravenous methylprednisolone in adults hospitalized for acute asthma. DESIGN: Randomized, placebo-controlled, double-blind study. SETTING: Inpatient service of a tertiary-care, university teaching hospital. PATIENTS: 21 adults (22 to 48 years old)--10 in the aminophylline group and 11 in the placebo group. INTERVENTIONS: Nebulized albuterol, 2.5 or 5.0 mg every 0.5 to 4 hours; intravenous methylprednisolone, 60 mg every 6 hours; and either individualized doses of aminophylline or placebo for 48 hours. MEASUREMENTS: Forced expiratory volume in 1 second (FEV1), the number of "as needed" albuterol nebulizations and total dose, asthma symptom scores, and adverse effects. RESULTS: At admission from the emergency department, the mean +/- SD baseline FEV1 was 49% +/- 19% of the predicted value in the aminophylline group and 43% +/- 13% of the predicted value in the placebo group. The improvement in FEV1 at 3 hours was greater in the aminophylline group (29% +/- 23% compared with 10% +/- 10% in the placebo group; mean difference, 19 percentage points; 95% CI, 3 to 35 percentage points; P = 0.023). At 48 hours, FEV1 was 75% +/- 19% of the predicted value in the aminophylline group and 58% +/- 15% of the predicted value in the placebo group (mean difference, 17 percentage points; CI, 0.2 to 34.8 percentage points; P = 0.048). Aminophylline-treated patients required fewer nebulizations of albuterol (10.3 +/- 3.8 compared with 16.4 +/- 5.3; mean difference, -6.1; CI, -10.3 to -1.8) and less total dosage (34 +/- 16 mg compared with 70 +/- 34 mg; mean difference, -36 mg; CI, -60.6 to -11.3 mg P = 0.02). No statistical differences were observed in asthma symptom scores or frequency of adverse effects. CONCLUSIONS: Individualized doses of intravenous theophylline added to frequent nebulizations of albuterol and intravenous methylprednisolone appear to benefit adults admitted to the hospital with acute asthma and are well tolerated when serum concentrations are maintained in the therapeutic range.