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.     

Radium-226 dose to a boy from playing on mill tailings

Two boys born in September 1949 played on uranium mill tailings from about ages 8 to 12. One of these boys was diagnosed as having leukemia at age 15.5. The 226Ra body burden of the survivor was measured at age 38. The whole-body 226Ra content measured by counting in vivo was 0 +/- 17 Bq and independently by Rn breath analysis as 4.3 +/- 2.1 Bq. At the same time, a control subject with no known exposure to 226Ra, matched in age, height, and weight, was also measured. The whole-body content was estimated as 4 +/- 15 Bq and independently by Rn breath analysis as 5.5 +/- 3.7 Bq. The body burden of the control subject was not significantly different from that of the exposed person. The radiation dose to the marrow-free skeleton assuming a constant 226Ra:Ca ratio since birth was 0.49 and 1.33 mGy at ages 14 and 38, respectively. The radiation dose to the marrow-free skeleton assuming 226Ra intake only between ages 8 to 12 was 1.4 and 2.8 mGy at ages 14 and 38, respectively. The best estimate is the mean of these two estimates: 0.9 and 2.1 mGy at ages 14 and 38, respectively. The alpha-particle dose to the red marrow from 226Ra and its decay products was 0.05 mGy at age 14 and 0.10 mGy at age 38. Since no excess was found for the radium dial painters whose doses were much higher, the induction of leukemia by doses of this magnitude would seem quite unlikely.     

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.     

High propionic acid fermentations and mineral accumulation in the cecum of rats adapted to different levels of inulin

The digestive and metabolic effects of inulin (from chicory) were studied in rats adapted to semipurified diets containing 0, 5, 10 or 20% inulin (wt/wt). Moderate levels of inulin (5-10%) did not significantly affect food intake or body weight gain. Dietary inulin resulted in considerably greater cecal fermentation and a significantly greater intraluminal concentration of propionate (peaking at 58.4 mmol/L). A lower concentration of acetate (42.6 mmol/L) was observed in rats fed 20% inulin. Lactic fermentations were observed in rats fed the 10 or 20% inulin diets. The cecal pool of volatile fatty acids tended to reach a plateau in rats fed diets containing more than 10% inulin (up to 600-700 mumol), but volatile fatty acid absorption was a slightly hyperbolic function of the dietary inulin level. Butyrate absorption was proportionally lower than that of propionate. Inulin-containing diets induced an enlargement of the cecal pool of calcium, phosphate and (to a lesser extent) magnesium. There was also an enhanced absorption of these divalent cations. The cecal pool of bile acids was greater in rats fed inulin, and this oligosaccharide displayed a slight hypocholesterolemic effect, even in rats fed the 5% inulin diet. However, plasma triglycerides were depressed only in rats fed the 20% inulin diet. In conclusion, inulin seems very effective in promoting propionic fermentation and in enhancing the calcium content of the large intestine. However, high levels of inulin (greater than 10%) may affect growth in rats and lead to acidic (pH 5.65) cecal fermentation.     

Copper uptake and transfer to the mouse fetus during pregnancy

Accumulation of 64Cu in the 14-d mouse fetus was measured following intravenous injection of the dam with 64CuHis2. Concentration of 64Cu in the placenta increased rapidly over the first 4 h, thereafter remaining constant. Transfer to the fetus was linear over 48 h with little evidence of storage in the liver. Maternal serum levels decreased initially, concurrently with increased 64Cu levels in the maternal liver, but did not subsequently increase. Immediately following injection, as much as 40% of the radioactivity was in the nonalbumin fraction, and approximately 37% of that fraction (18% of total) was greater than 30,000 molecular weight. After 24 h, up to 60% of the 64Cu was still found in the albumin peak. The data suggest that the fetus can obtain its Cu from maternal ceruloplasmin but does not exclude the possibility that transfer occurs from the exchangeable (albumin/amino acid) Cu pool of the maternal plasma. In a second experiment, mice at different stages of gestation were injected with 64Cu and killed 4 h later. Total Cu levels and 64Cu uptake into the maternal tissues or into the placenta did not change with increasing gestation. Both total Cu and 64Cu uptake in the fetus and fetal liver increased to a maximum on d 16. Levels in the liver decreased thereafter to term, whereas levels in the rest of the fetus remained approximately constant. The pattern was similar whether the results were expressed per organ or per gram of fresh weight.(ABSTRACT TRUNCATED AT 250 WORDS)