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Background: Decisions to limit use of life-sustaining treatment occur frequently during hospitalizations, and portable medical orders (also known as Portable Orders for Life-Sustaining Treatment (POLST)) can ensure that patient preferences regarding resuscitation are followed after discharge. Objective: To determine the frequency and predictors of completion of POLST orders for adults with change during hospitalization in resuscitation status to Do Not Resuscitate. Design: Retrospective observational study at level 1 trauma and academic hospital in Minneapolis, MN, USA Participants: All adults (18 years or older) hospitalized between June 2017 and June 2018, inclusive, with code status changed from Full Code to DNR. For patients with more than one hospitalization during this study interval, only the first hospitalization when DNR was ordered was included in this analysis. Main Measures: Completion of POLST orders by time of discharge. Key Results: From 2017 to 2018, 160 adults had a change from Full Code to DNR status during index hospitalization and survived to discharge, most (156 patients) to a nursing care facility. Of these, only 50 (31.2%) had POLST orders provided at discharge. Documentation of informed refusal of intubation in addition to DNR status was a significant predictor (OR 4.1, 99% CI 1.5–11.0) of POLST orders on discharge, as was admission to a medical service compared with non-medical service (OR 3.2, 99% CI 1.1–12.2). Palliative care consultants, rather than primary providers on the hospital services, completed most POLST orders. Conclusions: Despite primary hospital providers engaging in conversations regarding resuscitation and entering DNR orders during hospitalization, the majority of patients in our study discharged to other care facilities without POLST orders. POLST orders are a simple palliative care tool available to primary hospital providers to help ensure continuity of plan of care at discharge for patients who wish to avoid invasive life-sustaining treatments and/or cardiopulmonary resuscitation. [ABSTRACT FROM AUTHOR]

Background: Combining orders for do-not-resuscitate (DNR) for cardiac arrest with do-not-intubate (DNI) orders into a DNR/DNI code status is not evidence-based practice and may violate patient autonomy and informed consent when providers discuss intubation only in the context of CPR.Research Question: How often do providers refer to patients with a DNR order as "DNR/DNI" without documentation of refusal of intubation for non-arrest situations?Methods: Retrospective observational study of adults (18 years of age or older) hospitalized in a Level 1 trauma/academic hospital between July 2017 and June 2018 inclusive with DNR orders placed during hospitalization.Results: Of 422 hospitalized adults with DNR orders, 261 (61.9%) had code status written in progress notes as DNR/DNI. Providers' use of the term DNR/DNI in progress notes was significantly (OR, 2.21; 99% CI, 1.12-4.37) more common on medical hospital services (hospitalist, family medicine, internal medicine) than on nonmedical ward services (medical/surgical ICUs, surgery, psychiatry, neurology services). Of 261 "DNR/DNI" patients, providers did not document informed refusal of intubation for nonarrest situations for 68 (26.0%) of patients. By comparison, of 161 patients for whom providers documented code status in progress notes as DNR alone, 69 (42.9%) did have documentation of refusal of intubation for nonarrest events. Therefore, if a DNR/DNI code status was used in a nonarrest emergency to determine whether to intubate a patient, 68 (16.1%) of 422 patients could inappropriately be denied intubation without informed refusal (or despite their informed acceptance), and 69 (16.4%) could inappropriately be intubated despite their documented refusal of intubation.Conclusions: Conflation of DNR and DNI into DNR/DNI does not reliably distinguish patients who refuse or accept intubation for indications other than cardiac arrest, and thus may inappropriately deny desired intubation for those who would accept it, and inappropriately impose intubation on patients who would not. [ABSTRACT FROM AUTHOR]

Background: Providers should estimate a patient's chance of surviving an in-hospital cardiac arrest with good neurologic outcome when initially admitting a patient, in order to participate in shared decision making with patients about their code status.Objective: To examine the utility of the "Good Outcome Following Attempted Resuscitation (GO-FAR)" score in predicting prognosis after in-hospital cardiac arrest in a US trauma center.Design: Retrospective observational study SETTING: Level 1 trauma and academic hospital in Minneapolis, MN, USA PARTICIPANTS: All cases of pulseless in-hospital cardiac arrest occurring in adults (18 years or older) admitted to the hospital between Jan 2009 and Sept 2018 are included. For patients with more than one arrest, only the first was included in this analysis.Main Measures: For each patient with verified in-hospital cardiac arrest, we calculated a GO-FAR score based on variables present in the electronic health record at time of admission. Pre-determined outcomes included survival to discharge and survival to discharge with good neurologic outcome.Key Results: From 2009 to 2018, 403 adults suffered in-hospital cardiac arrest. A majority (65.5%) were male with a mean age of 60.3 years. Overall survival to discharge was 33.0%; survival to discharge with good neurologic outcome was 17.4%. GO-FAR score calculated at the time of admission correlated with survival to discharge with good neurologic outcome (AUC 0.68), which occurred in 5.3% of patients with below average survival likelihood by GO-FAR score, 22.5% with average survival likelihood, and 34.1% with above average survival likelihood.Conclusions: The GO-FAR score can estimate, at time of admission to the hospital, the probability that a patient will survive to discharge with good neurologic outcome after an in-hospital cardiac arrest. This prognostic information can help providers frame discussions with patients on admission regarding whether to attempt cardiopulmonary resuscitation in the event of cardiac arrest. [ABSTRACT FROM AUTHOR]

Breakthrough pain (BTP), defined as "transitory episodes of sudden severe pain that occur on a background of otherwise controlled pain" is common and disturbing for cancer patients. Optimal management of sudden, severe, and transitory episodes of BTP requires analgesics with rapid onset and short duration of effect, ideally in convenient and easily administered formulations. BTP has traditionally been treated with immediate-release oral opioids, but these analgesics are too slow in onset and have prolonged duration of effect. Recently developed and emerging pharmacotherapies exploit the properties of transmucosal absorption of lipophilic opioids in transbuccal, sublingual, and intranasal delivery systems to provide rapid and effective relief of BTP in reliable, convenient, and acceptable preparations. [ABSTRACT FROM AUTHOR]

The article presents a study of an elderly man with chest pain and progressive miliary infiltrates. His medical history and physical examination are presented. Laboratory findings and imaging are discussed. He was diagnosed of miliary metastatic epithelioid mesothelioma, a rare tumor of which most are associated with prior exposure to asbestos.

Formoterol fumarate is an effective treatment for chronic obstructive pulmonary disease (COPD) patients with moderate or greater severity of airflow obstruction. Published studies indicate that formoterol has a rapid onset of bronchodilation, which may enhance compliance, and sustained bronchodilation over 12 h, which produces a cumulative effect when inhaled twice daily. With long-term use, formoterol fumarate increases trough forced expiratory volume in 1 s and improves measures of hyperinflation, which correlate with relief of symptoms and a decreased need for additional short-acting bronchodilators as rescue treatment. The combination of formoterol with anticholinergic bronchodilators, especially the long-acting anticholinergic tiotropium, appears to further improve bronchodilation, decrease hyperinflation, improve symptoms and decrease the need for rescue therapy, compared with either agent alone. The availability of formoterol fumarate inhalation solution (PerforomistTM) for treatment of COPD now extends these benefits to patients who prefer nebulizer therapy and/or cannot use metered-dose or dry-powder inhalers effectively. [ABSTRACT FROM AUTHOR]

This article focuses on a study related to comparison of the effect of lobectomy in elderly patients and younger patients on their pulmonary function and functional status 1 year following the surgery. An increasing number of elderly patients who meet the operative criteria for curative resection are presenting with early-stage lung carcinoma. The benefit of surgery and its impact on survival following surgery are unquestionable. The median survival time for patients with nonresected lung carcinoma has been found to be 7.7 months.

Presents a study which examined the immunogenicity and safety of reimmunization with the 23-valent polysaccharide pneumococcal vaccine in patients infected with HIV type 1. Characteristics of the patients; Data and methods used; Results and discussion.

Prevention of bacterial infection, which is a leading cause of morbidity in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), is a priority. However, the safety and immunogenicity of the pneumococcal vaccine in such patients remain controversial. We evaluated the currently available pneumococcal vaccine in patients with RA or SLE. Pneumococcal vaccination was not associated with an appreciable dete-rioration in any clinical or laboratory measure of disease activity in either group. One month after vaccination, patients in both groups had significant increases in geometric mean concentrations of pneumococcal poly-saccharide specific IgG to all 7 serotypes tested, as did control subjects. However, 14 (33.3%) of 42 patients with RA and 5 (20.8%) of 24 patients with SLE responded either to none or to only 1 of the 7 polysaccharides. Pneumococcal vaccination is generally safe and immunogenic in patients with RA or SLE, but a subset of patients may remain unprotected by the currently available vaccine. [ABSTRACT FROM AUTHOR]

The absence of expression of the p16[sup INK4a] gene product is observed in virtually all mesothelioma tumors and cell lines, whereas wild-type pRB expression is maintained. We have examined the potential therapeutic role of re-expressing the p16[sup INK4a] gene product in mice with established human mesothelioma xenografts. Experiments using Adp16 treatments in mesothelioma xenografts demonstrated prolonged survival and potential cure following treatment with p16[sup INK4a]-based gene therapy. These results demonstrate that p16[sup INK4a] gene transfer may play a therapeutic role in the treatment of mesothelioma. [ABSTRACT FROM AUTHOR]

Provides information on a study which identified clinical risk factors for and the clinical presentation of nosocomial pneumococcal bacteremia (NPB). Methods of the study; Clinical predictors of NPB; Clinical features of NPB; Treatment and outcome.

The suboptimal efficacy of the currently available 23-valent pneumococcal vaccine in the growing population of adults >65 years old may be related to the limited immunogenicity of the vaccine polysaccharides in this group. In this study, the majority of elderly outpatients with stable chronic illnesses generated a vigorous IgG response to seven vaccine serotypes comparable to that of healthy young adults at 1, 3, and 16 months after immunization. Moreover, the quality and function of anticapsular antibodies, measured as avidity and in vitro opsonization, were comparable between elderly and young subjects over time. However, a subset (∼20%) of elderly outpatients responded to fewer than two of seven serotypes tested 1 and 3 months after immunization, whereas none of the healthy young adults were such poor responders. Thus, despite the adequate mean immune responses of the elderly as a group, a substantial proportion of elderly persons may have poor responses to the currently available pneumococcal vaccine. [ABSTRACT FROM PUBLISHER]

Because chronic ethanol ingestion decreases pulmonary clearance of Streptococcus pneumoniae in rats, and extracellular antipneumococcal factors in rat surfactant are important in the early clearance of pneumococci from the rat alveolus, the effects of ethanol ingestion on surfactant bactericidal activity were investigated. Normal surfactant from chow-fed rats showed potent antipneumococcal activity, even against bacteria growing in nutrient-rich media under favorable conditions. In contrast, surfactant from ethanol-fed rats and from calorie-restricted control-fed rats had significantly reduced antipneumococcal activity compared with surfactant from chow-fed rats. The reductions in surfactant bactericidal activity produced by ethanol ingestion or caloric restriction did not appear to be mediated through changes in either the total amount or the distribution of fatty acids, the antipneumococcal factors in normal surfactant. Rather, ethanol ingestion, and to a lesser extent caloric restriction, produced a surfactant inhibitor of free fatty acids that was partially characterized as a hydrophobic protein. [ABSTRACT FROM PUBLISHER]

To determine whether defects in mucosal immunity were associated with invasive disease caused by a mucosal pathogen, Streptococcus pneumoniae, levels of salivary immunoglobulins and nonspecific immune factors were compared in subjects with human immunodeficiency virus type 1 (HIV-1) infection and in HIV-1-seronegative subjects with and without pneumococcal bacteremia. The IgA2 subclass may be of particular importance because S. pneumoniae produces IgA1 protease, which cleaves IgA1 but not IgA2. Levels (37–56 μg/mL) and proportions (11%–17%) of IgA2 were similar among groups. Serotype-specific capsular salivary 19A was present in a minority of patients with acute bacteremia. Levels of lactoferrin were increased with bacteremia. Neither selective mucosal IgA2 deficiency nor impaired nonspecific upper respiratory mucosal responses were associated with invasive pneumococcal disease during HIV-1 infection; thus, other defects in mucosal cellular responses and systemic immunity may predispose HIV-1-infected patients to invasive pneumococcal disease. [ABSTRACT FROM PUBLISHER]

Comments on the article of Sandra Romero-Steiner et al. in the August 1999 issue of 'Clinical Infectious Diseases' on the comparison of levels of capsule-specific immunoglobulin G (IgG) after pneumococcal vaccination in elderly and younger patients. Parameters which determine antibody avidity; Avidity of IgG for Streptococcus pneumoniae capsular polysaccharides; Duration of immune responses among the elderly patients following the vaccination.