Arch Intern Med
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Because of extremely poor outcomes, the practice of continuing cardiopulmonary resuscitation in hospital emergency departments after unsuccessful out-of-hospital cardiopulmonary resuscitation has been strongly questioned. Before revising our institutional guidelines according to previous pessimistic reports we wished to review our own experience with this practice. ⋯ Institutional guidelines for the decision whether to continue resuscitation after failed out-of-hospital efforts should be based on an analysis of the characteristics and results of the local emergency medical system. Continuing efforts in the hospital may not be inevitably futile.
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Antiendotoxin monoclonal antibodies are under investigation as adjunctive therapy for severe sepsis. One of these antibodies (the human IgM monoclonal antibody HA-1A) was marketed in Europe during 1992 for treatment of patients with severe sepsis, especially those with shock, and probable gram-negative bacilli (GNB) bacteremia, after a placebo-controlled trial showed improved outcome in such patients. This cohort study was designed to assess characteristics and determinants of outcome of patients through a nationwide registry of all adult patients hospitalized in intensive care units of French hospitals and treated with HA-1A. ⋯ This cohort study did not confirm decreased mortality in patients with GNB bacteremia, as reported in the first placebo-controlled HA-1A trial, and it further suggests excess mortality in the subgroup of patients with non-GNB infection. In clinical trials of patients with severe sepsis, controlling for both the severity of acute illness score and the number of organ system failures, as well as for the severity of underlying disease and the source of infection, should be considered, especially when subgroups are analyzed.
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The purpose of this study was to investigate the association of glycemia with cause-specific mortality in a diabetic population. ⋯ These results suggest possible benefit to the control of glycemia with respect to death due to vascular disease and diabetes.
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Counseling patients about the risks and benefits of in-hospital cardiopulmonary resuscitation (CPR) can potentially reduce patient suffering and hospital costs. However, there is currently much disagreement regarding the overall rate of in-hospital CPR survival and characteristics that identify patients more or less likely to survive CPR. ⋯ The use of do-not-resuscitate orders to exclude patients who were inappropriate candidates for CPR may explain why the survival rate reported here is higher than similar reports and why more clinical characteristics were not found to predict CPR survival. Investigators of in-hospital CPR should use explicit criteria to describe the conditions studied and report survival for patients who receive basic CPR. The impact of do-not-resuscitate orders on survival rates must be considered. Functional capacity deserves further investigation as a predictor of CPR survival.
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The attitudes of hospitalized patients and their attending physicians about advance directives have not been well studied. We compared these attitudes and explored relationships between them and the frequency of actual directives and directive discussions during hospitalization. ⋯ Most medical inpatients in a community hospital want to, are able to, and meet their own physicians' indications to discuss advance directives. Hospitalization presents an unrealized opportunity for physicians and patients to initiate these discussions.