Involving patients in do not resuscitate (DNR) decisions: an old issue raising its ugly head.

A recent paper in this journal (1) suggests that involving terminally ill patients in choices concerned with Cardio-Pulmonary Resuscitation (CPR) produces 'psychological pain' and therefore is ill-advised. Such a claim rests on anecdotal observations made by the authors. In this paper I suggest that drawing conclusions in ethics, no less than in science, requires a rigorous framework and cannot be relegated to personal observation of a few cases. The paper concludes by suggesting that patients, if we acknowledge their valid interest in making their own choices, must themselves be allowed to make a prior choice about choosing. Those who may not wish to choose may properly be relieved of this burden and may allow another to choose for them. Routinely allowing others to make choices for competent adults, however, is likely to decrease communication with the dying patient and to introduce an atmosphere of suspicion and fear and to exclude the competent patient from his/her rightful place in the community.     

Embryotoxic effects of deoxynivalenol mycotoxin (vomitoxin) in rats]

Study of embryotoxic action of deoxynivalenol in levels of 0.2, 1, 5, 10 mg/kg from 7 to 15 day of rat pregnancy was worked up. The 0.2 mg/kg determined as a maximal acceptable dose without toxic effects.     

Chick nutritional encephalomalacia and prostanoid formation

Nutritional encephalomalacia (NE) was induced in young chicks using a diet low in vitamin E and containing 8% ethyl esters derived from safflower oil fatty acids (S-E group). The same diet with added alpha-tocopheryl acetate (S+E) failed to produce the pathology, and chicks receiving aerated linseed oil--high in alpha-linolenic acid and low in alpha-tocopherol (L-E)--did not develop symptoms. Formation of metabolites from labeled arachidonic acid (AA) by thrombocytes was similar in the S+E and S-E groups, yielding thromboxane B2 (TXB2) and hydroxy fatty acids as the major products. Collagen-induced thrombocyte aggregation and TXB2 production were not significantly different in the S-E and S+E groups, but aggregation values and TXB2 synthesis were significantly less in the L-E group than in the ataxic S-E chicks. Prostaglandin E2 production by aortal rings was significantly influenced by the diet; S-E yielded the highest value and L-E the lowest. These results show that alpha-linolenic acid causes alterations in the AA metabolism and thrombocyte function in young chicks.     

Thiamin status of incarcerated and nonincarcerated adolescent males: dietary intake and thiamin pyrophosphate response

We measured thiamin status in 137 incarcerated and 42 nonincarcerated adolescent males by use of both dietary intake data and a standard biochemical assay, thiamin pyrophosphate (TPP) response. Average thiamin intake of the total group was greater than 120% of the age-specific recommended dietary allowance (RDA). Ninety-two percent of incarcerated subjects and 93% of nonincarcerated subjects were consuming greater than or equal to 70% of RDA. Although average daily thiamin intake of nonincarcerated subjects was significantly higher than that of incarcerated subjects, both groups appeared to be at minimal risk for marginal thiamin status. Comparison of TPP response values indicated that there was no significant difference between groups. However, approximately 24% of the total population appeared to have less than adequate RBC thiamin on the basis of current standards for TPP response. Neither dietary intake nor reported previous alcohol intake was correlated with TPP response. These discrepant findings raise questions about the usefulness of the TPP response as the sole indicator of marginal thiamin status.     

Resting energy expenditure in patients with chronic obstructive pulmonary disease

Resting energy expenditure (REE) was measured in 68 patients with stable chronic obstructive pulmonary disease (COPD) and in 34 weight-stable, age-matched (65 +/- 8 y; means +/- SD) healthy control subjects. Fat-free mass (FFM) determined by bioelectrical resistance explained 84% of the variation in REE in the control group but only 34% in the COPD patients. REE could not reliably be predicted from regression equations either developed in healthy subjects or in COPD patients. REE adjusted for FFM was significantly higher (P less than 0.05) in weight-losing (n = 34) than in weight-stable (n = 34) patients (6851 +/- 781 and 6495 +/- 650 kJ/d, respectively). Pulmonary function was more compromised in weight-losing patients. Adjusted REE in weight-stable patients was significantly higher (P less than 0.01) than in the healthy control group (6131 +/- 405 kJ/d). In patients with COPD, factors in addition to FFM are important determinants of REE. A disease-related increase in REE develops, which may contribute to weight loss in COPD in combination with a lack of an adaptive response to undernutrition in weight-losing patients.     

Relative effects of diarrhea, fever, and dietary energy intake on weight gain in rural Bangladeshi children

Quantitative studies of morbidity, food intake, and somatic growth were done prospectively during 14 mo for 70 children aged 5-18 mo in two Bangladeshi villages. When random-effect regression models were used, monthly changes in weight were inversely related to proportions of days in the month with fever and diarrhea and positively related to energy intake per kilogram body weight. Interestingly, weight changes did not vary with age in this interval. Estimates indicate that increasing energy intakes to the recommended World Health Organization level would have a significantly greater effect on weight gain than would the elimination of diarrhea and fever. With energy at recommended intake and diarrhea and fever prevalence as found in US children, weight gain is predicted to be near that of the international reference population. Therefore, interventions aimed at improving dietary intake may be as important as infection-control programs for improving growth of children in poor developing nations.