Amplification of the graft-versus-host reaction by partial body irradiation

An experimental model has been developed for the study of combined effects of partial body irradiation (PBI) and graft-versus-host disease (GVHD) in which irradiation is delivered to the thorax 24 hr prior to induction of GVHD in hybrid mice by the injection of parental lymphoid cells. In mice irradiated to 1000 cGy or exposed to low doses of allogeneic lymphoid cells (20 X 10(6)), survival was 100% at 250 days. In contrast, combination of the two treatments, GVHD and PBI, resulted in a mortality of 83% and a mean survival time of 29 days, indicating synergy between GVHD and PBI. From histological studies of the lung it appeared that about 40% of the deaths occurring after combined GVHD/PBR treatment might be attributable to pneumonia. The cause of death in the remaining mice receiving combined treatment is not known. Mice receiving combined PBI/lymphoid cell treatment develop a characteristic skin lesion that is not seen in nonirradiated mice and is confined to the irradiated area. The effect of preinduction PBR on the timing and severity of GVHD is similar to that which would be produced by an increase in the number of effector cells.     

Do-not-resuscitate orders for critically ill patients in the hospital. How are they used and what is their impact?

We studied compliance with do-not-resuscitate (DNR) orders at a university hospital where a DNR protocol has existed since 1979. Documentation of DNR status in patient progress notes and chart orders increased through 1983. During a 12-month period (March 1983 through April 1984), we studied in detail the medical records of 521 patients who had a cardiopulmonary arrest in the hospital. Seventy-five percent (389 of 521) of these patients were designated DNR. Patients who were designated DNR were significantly more likely to be older, to have malignancy or an abnormal mental status, and to be less likely to have acute myocardial infarction, stroke, or chronic obstructive pulmonary disease than patients in whom resuscitation was attempted. Eighty-six percent of families, but only 22% of patients, were involved in the decision to designate a patient DNR. The decision to designate a patient DNR occurred late in the course of a patient's illness, often when the patient was in coma. For 28% of patients, some form of medical care was withdrawn or withheld after they were designated DNR. These data suggest that use of the DNR protocol requires changes if patients are to participate in the decision not to undergo cardiopulmonary resuscitation.     

An improved transilial crest bone biopsy drill for quantitative histomorphometry

Transilial crest bone biopsy with quantitative histomorphometry is an important technique for the assessment of metabolic and endocrine bone disease. The surface area of the histologic section suitable for histomorphometric analysis is reduced by the build-up of bone dust and by trabecular fracture, produced by the conventional Bordier bone drill. We describe here a modification of this drill that both allows escape of dust from around the cutting edge of the teeth and greatly reduces bone dust volume and trabecular fracture. In paired samples the new drill was shown to improve significantly the quality of the biopsy specimens.