DNR directives are established early in mechanically ventilated intensive care unit patients

Purpose

Setting treatment goals in the intensive care unit (ICU) often involves resuscitation decisions. Our objective was to study the rate of establishing do-not-resuscitate (DNR) directives, determinants, and outcomes of those directives for mechanically ventilated patients.

Methods

In a multicentre observational study, we included consecutive adults with no DNR directives within 24 hr of ICU admission who were mechanically ventilated for at least 48 hr. We identified the rate with which DNR directives were established, and factors associated with these directives.

Results

Among 765 patients, DNR directives were established for 231 (30.2%) patients; 143 (62.1%) of these were established within the first week. Factors independently associated with a DNR directive were: patient age [> 75 yr (hazard ratio [HR] 2.3, 95% confidence interval 1.5–3.4], 65 to 74yr(HR 1.8, 1.2–2.7), 50 to 64 yr (HR 1.4, 1.0–2.2) relative to < 50 yr); medical rather than surgical diagnosis (HR 1.8, 1.3–2.5); multiple organ dysfunction score (HR 1.7 for each five-point increment, 1.4–2.0); physician prediction of ICU survival [< 10% (HR 15.0, 6.7–33.6)], 10 to 40% [(HR 5.0, 2.3–11.2), 41 to 60% (HR 4.0, 1.8–9.0) relative to > 90%]; and physician perception of patient preference to limit life support (no advanced life support [(HR 5.8, 3.6–9.4) or partial advanced life support (HR 3.2, 2.2–4.6) compared to full measures].

Conclusion

One third of mechanically ventilated patients had DNR directives established early during their ICU stay after the first 24 hr of admission. The strongest predictors of DNR directives were physician prediction of low probability of survival, physician perception of patient preference to limit life support, organ dysfunction, medical diagnosis and age.     

Cytodiagnosis of submandibular sialadenitis with crystalloids mimicking metastasis

Sialomrgaly of suhmandibultir gland, whether inflammatory or neoplastic can be clinically mistaken for lymphoid metastasis especially when encountered in an elderly patient. Other than the neoptastic lesions and usual inflammatory lesions rarely amylase crystalloids can evoke a granulomatous response and can result in sialomegaly. We report an interesting case which presented as a submandibular swelling and was clinically diagnosed as metastasis where the diagnosis of granulomatous response to crystalloids was made at FNAC. The aim of this report is to bring an awareness of the existence of such lesions and to highlight the role of FNAC in diagnosis of such lesions in order to avoid unnecessary surgeries.     

Mixed mesodermal tumours of the ureter.

This report is of a 78 year-old male with a mixed mesodermal tumour of the left ureter. A comparison of all reported patients with such neoplasms has been made in the discussion, in an attempt at characterization of this neoplasm.     

Injecting drug users in Bangladesh: prevalence of syphilis, hepatitis, HIV and HIV subtypes.

Injecting drug users (IDU) were enrolled from two detoxification clinics and two needle/syringe exchange programmes (NEP) in central and northwest Bangladesh. Syphilis, hepatitis C and HIV rates were highest in IDU from the NEP of central Bangladesh (23, 66.5 and 1.4%, respectively), whereas current hepatitis B infection rates were highest in IDU from the NEP of northwest Bangladesh (12%). Five HIV strains were subtype C and one E/B. The 32 base pair (bp) deletion of the CCR5 gene was not detected.     

Psychological distress as a mediator in the relationships between biopsychosocial factors and disordered eating among Malaysian university students

The mechanism linking biopsychosocial factors to disordered eating among university students is not well understood especially among Malaysians. This study aimed to examine the mediating role of psychological distress in the relationships between biopsychosocial factors and disordered eating among Malaysian university students. A self-administered questionnaire measured self-esteem, body image, social pressures to be thin, weight-related teasing, psychological distress, and disordered eating in 584 university students (59.4% females and 40.6% males). Body weight and height were measured. Structural equation modeling analysis revealed that the partial mediation model provided good fit to the data. Specifically, the relationships between self-esteem and weight-related teasing with disordered eating were mediated by psychological distress. In contrast, only direct relationships between body weight status, body image, and social pressures to be thin with disordered eating were found and were not mediated by psychological distress. Furthermore, multigroup analyses indicated that the model was equivalent for both genders but not for ethnic groups. There was a negative relationship between body weight status and psychological distress for Chinese students, whereas this was not the case among Malay students. Intervention and prevention programs on psychological distress may be beneficial in reducing disordered eating among Malaysian university students.     

Transvaginal cholecystectomy versus single-incision laparoscopic cholecystectomy versus four-port laparoscopic cholecystectomy: a prospective cohort study

Objective

This report describes the first prospective cohort study comparing transvaginal cholecystectomies (TVC) with single incision laparoscopic cholecystectomies (SILC) and four-port laparoscopic cholecystectomies (4PLC).

Methods

Between May 2009 and August 2010, 14 patients underwent a TVC. These patients were compared with patients who underwent SILC (22 patients) or 4PLC (11 patients) in a concurrent, randomized, controlled trial. Demographic data, operative time, numerical pain scales, complications, and return to work were recorded.

Results

Mean age (TVC: 33.5?±?3.0?year; SILC: 38.4?±?3.3?year; 4PLC: 35.5?±?4.1?year; p?=?0.58) and mean BMI (TVC: 28.8?±?1.5?kg/m²; SILC: 31.8?±?1?kg/m²; 4PLC: 31.4?±?2.2?kg/m²; p?=?0.35) were not statistically significant. However, mean operative time (TVC: 67?±?3.9?min; SILC: 48.9?±?2.6?min; 4PLC: 42.3?±?3.9?min; p?p?=?0.02) with equilibration of pain scores by days 14 and 30. Return to work (TVC: 6.4?±?1.5?days; SILC: 13.1?±?1.3?days; 4PLC: 14.1?±?1.4?days; p?Conclusions Transvaginal cholecystectomy is a safe and well-tolerated procedure with statistically significantly less pain at 1 and 3?days after surgery, with a faster return to work but longer operative times compared with single incision and four-port laparoscopic cholecystectomy.     

Interrater and Intrarater Reliability of the Active Knee Extension (AKE) Test among Healthy Adults

[Purpose] The purpose of this study was to determine the reliability of the active knee extension (AKE) test among healthy adults. [Subjects] Fourteen healthy participants (10 men and 4 women) volunteered and gave informed consent. [Methods] Two raters conducted AKE tests independently with the aid of a simple and inexpensive stabilizing apparatus. Each knee was measured twice, and the AKE test was repeated one week later. [Results] The interrater reliability intraclass correlation coefficients (ICC_2,1) were 0.87 for the dominant knee and 0.81 for the nondominant knee. In addition, the intrarater (test-retest) reliability ICC_3,1 values range between 0.78–0.97 and 0.75–0.84 for raters 1 and 2 respectively. The percentages of agreement within 10° for AKE measurements were 93% for the dominant knee and 79% for the nondominant knee. [Conclusion] The finding suggests the current AKE test showed excellent interrater and intrarater reliability for assessing hamstring flexibility in healthy adults.Key words: Hamstring, Flexibility, Range of movement