Intrathecal morphine for post-thoracotomy pain

We wished to investigate possible differences in the duration of postoperative analgesia and the incidence of respiratory depression after the intrathecal injection in the lumbar area of 10 micrograms/kg morphine in hypobaric and hyperbaric solution for relief of post-thoracotomy pain. Twenty-nine patients received morphine plus dextrose (hyperbaric) and 21 received morphine in preservative-free normal saline. The duration of analgesia was longer with the morphine in the normal saline group than in the hyperbaric group (P less than 0.04). One patient developed delayed respiratory depression. Our data support the use of morphine in normal saline mixtures for greater duration of analgesia after thoracic operations.     

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 For 28% of patients, some form of medical care was withdrawn or withheld after they were designated DNR.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.     

Socio-medical indicators of health in South Africa

Socio-medical indicators developed by WHO for monitoring progress towards Health-for-All have been adapted to reveal, clearly and objectively, the devastating impact of state planning based on an outmoded immoral and unscientific philosophy of race superiority in South Africa on the health of the disenfranchised majority within the context of social and economic discrimination; Health policy indicators confirm that the government is committed to three options (Bantustans, A New Constitution, and A Health Services Facilities Plan) all of which are inconsistent with the attainment of Health-for-All; Social and economic indicators reveal gross disparities between African, Coloured, Indian, and White living and working conditions; Provision of health care indicators show the overwhelming dominance of high technology curative medical care consuming about 97 percent of the health budget with only minor shifts towards community-based comprehensive care; and Health status indicators illustrate the close nexus between privilege, dispossession and disease with Whites falling prey to health problems related to affluence and lifestyle, while Africans, Coloureds, and Indians suffer from disease due to poverty. All four categories of the indicator system reveal discrepancies which exist between Black and White, rich and poor, urban and rural. To achieve the social goal of Health-for-All requires a greater measure of political commitment from the state. We conclude that it is debatable whether a system which maintains race discrimination and exploitation can in fact be adapted to provide Health-for-All.