Arch Intern Med
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Comparative Study
Evaluation of the do not resuscitate orders at a community hospital.
Demographic, medical, and outcome characteristics for 821 do not resuscitate (DNR) patients were compared with 300 age- and sex-matched control patients, and with 230 patients for whom cardiopulmonary resuscitation had been performed. Do not resuscitate patients were more likely to be female and older than cardiopulmonary resuscitation patients and to have a child as next of kin. Although DNR patients in intensive care units had comparable illness levels before and at the time of the order, treatment levels were reduced when the order was written. ⋯ We identified diagnosis, prior activity, hospital unit, and employment status as predictors of DNR. According to documentation, 20% of patients participated in the DNR decision. Introduction of a DNR progress note form significantly improved documentation of the DNR process, but further efforts to improve DNR practice and patient participation are recommended.
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We report a case of Lyme myocarditis presenting solely as complete heart block in a previously healthy 32-year-old white man. Indium cardiac antimyosin scan showed diffuse uptake (2+, on a scale of 0 to 4+) during the acute phase of the illness. The electrocardiogram and the indium cardiac antimyosin scan were normal 6 weeks after completion of tetracycline and prednisone treatment. Lyme carditis should be considered in the differential diagnosis of complete heart block of unclear origins, even in patients presenting without other signs or symptoms suggestive of Lyme disease.
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Fifty-four elderly patients with thermoregulatory failure were evaluated retrospectively. The most commonly associated cause was underlying sepsis, which occurred in 78% of cases. Underlying conditions that increased the incidence of hypothermia were hypoproteinemia (50%), cachexia (30%), and neuroleptic medications (21%), most commonly thioridazine. ⋯ The mortality rate was not affected by age, sex, or degree of hypothermia. We conclude that thermo-regulatory failure in the elderly can occur in warm as well as cold environments or climates. The development of hypothermia in elderly patients should be promptly treated as sepsis unless proven otherwise, in light of the poor prognosis of this condition.
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We studied five patients with hemophilia A in the age range of 18 to 64 years who were infected with human immunodeficiency virus and who developed immune thrombocytopenia. The clinical course of immune thrombocytopenia in relation to human immunodeficiency virus infection and the patients' responses to splenectomy and immune variables were determined. All five patients developed antibody to human immunodeficiency virus 6 to 60 months (median, 24 months) before the onset of thrombocytopenia, and two patients became human immunodeficiency virus antigenemic (one patient at the onset of immune thrombocytopenia and the other 60 months after the onset of immune thrombocytopenia [24 months after splenectomy]). ⋯ Because of the progression of immune thrombocytopenia, four of the five patients underwent splenectomy with preoperative high-dose intravenous immune globulin. All four had an excellent immediate response to splenectomy, with a rise in platelet count to more than 300 x 10(9)/L and sustained remission during postsplenectomy follow-up of 6 to 45 months. There was no significant drop in CD4 and CD8 counts after splenectomy, and all four patients remained clinically well.
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Clinical and demographic characteristics of 122 patients undergoing cardiopulmonary resuscitation were retrospectively collected to develop a predictive model for immediate success of resuscitation (restoration of pulse and blood pressure). The project focused on objective measurement of parameters available before resuscitation was performed. ⋯ The four predictive before arrest factors were age between 40 and 70 years, scheduled for surgery, location of arrest in an intensive care unit, and before arrest PO2 greater than 8 mm Hg. The model had an accuracy of 69%, sensitivity of 76%, and specificity of 61%.