Impact of stage 3B chronic kidney disease on thrombosis and bleeding outcomes after orthopedic surgery in patients treated with desirudin or enoxaparin: insights from a randomized trial.

BACKGROUND: Venous thromboembolism (VTE) remains a significant complication of major orthopedic surgery, and chronic kidney disease (CKD) is common among elderly patients undergoing total hip replacement (THR). OBJECTIVES: The purpose of this study was to evaluate thrombosis and bleeding outcomes in patients with stage 3B CKD treated with either desirudin or enoxaparin after elective THR. PATIENTS/METHODS: This was a post hoc subgroup analysis of a randomized, multicenter, double-blind study of desirudin vs. enoxaparin in patients undergoing elective THR. RESULTS: Patients received either subcutaneous desirudin 15 mg twice daily or subcutaneous enoxaparin 40 mg once daily. Of the 2078 randomized patients who received study medication, 577 had stage 3B CKD or worse (27.8%), and the proportion of these patients who experienced a major VTE in the enoxaparin treatment group was found to be much higher than in the desirudin treatment group (11.1% vs. 3.4%, model-adjusted odds ratio 3.52, 95% confidence interval 1.48-8.40, P=0.004). There was no statistically significant difference between treatment groups in terms of rates of major bleeding, regardless of stage of renal function. CONCLUSIONS: CKD has been reported previously to increase the risk of bleeding with anticoagulants, and these findings suggest that CKD may also increase the risk of major VTE for patients treated with enoxaparin, but not for patients treated with desirudin. Clinicians should consider the impact of CKD on the risk of VTE when choosing a prophylaxis agent.

Evaluating the role for the optical density in the diagnosis of heparin-induced thrombocytopenia following cardiac surgery.

The poor accuracy of the enzyme immune assay (EIA) contributes to the diagnostic challenge of heparin-induced thrombocytopenia (HIT) following cardiac surgery. We sought to determine if adjusting the threshold optical density (OD) defining a positive EIA improves the test's accuracy in subjects with an OD>0.40. We retrospectively analysed the results from both EIA and confirmatory serotonin release assays (SRAs) in cardiac surgery patients with EIA OD of >0.4. Employing the SRA as the standard, we compared the area under the receiver-operating characteristic (AUROC) curves of various OD measurements for identifying HIT. We examined baseline clinical variables associated with a positive SRA in the setting of a positive HIT EIA (OD >0.4). We then used logistic regression to identify baseline clinical variables independently associated with a positive SRA given a positive EIA. The cohort included 99 subjects with positive EIAs and 35% had positive SRAs. An OD>0.40 had moderate utility as a screening test for a positive SRA (AUROC: 0.68; 95% CI: 0.55-0.80). Increasing the OD threshold did not improve the HIT EIA's screening utility. Clinical variables independently associated with a positive SRA if the EIA were positive included female gender, absence of diabetes, and use of cardiopulmonary bypass. A relatively modest elevation in the OD measurement, when it is already known to be greater than 0.4, does not reliably exclude the potential for a positive SRA in this setting.

Understanding cost-effectiveness.

Healthcare delivery in the USA and abroad has changed dramatically over the last several decades. Along with the growth in diagnostic and therapeutic interventions, the costs of healthcare have escalated out of proportion relative to other aspects of the economy. This growth has fostered careful scrutiny of both the effectiveness and efficiency of healthcare delivery. Because of this emphasis on the economics of healthcare, physicians require an understanding not only of the efficacy and clinical utility of their interventions, but also of the relative value in an economic sense of their efforts. In other words, physicians in the modern era must now appreciate the concept of cost-effectiveness. Cost-effectiveness and cost-utility analyses are critical evaluative tools. Explicit data on comparative cost-effectiveness are useful for allocating the increasingly stretched healthcare resources. This article provides a primer for understanding the methods and applications of cost-effectiveness and cost-utility analyses.

The validation and reproducibility of the pulmonary embolism severity index.

SUMMARY BACKGROUND: Rapid, accurate risk stratification is paramount in managing patients with acute pulmonary embolism (PE). The PE Severity Index (PESI) is a simple tool that risk stratifies patients with acute PE. OBJECTIVES: We sought to validate the PESI as a predictor of short- and intermediate-term mortality and to determine the inter-rater variability. PATIENTS/METHODS: We retrospectively identified all patients with acute PE between October 2007 and February 2009. Two clinicians reviewed charts and independently scored PESI blinded to each other and to patient outcomes. Thirty- and 90-day mortality served as study endpoints and vital status was assessed via the Social Security Death Index. To facilitate analyses, raw PESI score was converted into risk class groups (I-V) and further dichotomized into low risk (I-II) vs. high risk (III-V) groups. Intraclass correlation and the kappa statistic were used to determine inter-rater variability. RESULTS: The cohort included 302 subjects (mean age, 59.7 +/- 17.2 years; 44% male). All-cause 30- and 90-day mortalities were 3.0% and 4.0%, respectively. The mortality rate increased as raw PESI score increased. Risk of death correlated with risk class (P < 0.001). There were no deaths in risk classes I-III, but 30- and 90-day mortality for class V were 9.2% and 10.5%, respectively. Overall, mean PESI scores were similar between observers: 103.3 +/- 39.3 and 96.5 +/- 37.6 (P = NS). The inter-rater variability was good (kappa = 0.69; P < 0.0001). CONCLUSIONS: The PESI correlates with 30- and 90-day mortality. It represents a reproducible scoring tool to risk stratify patients with acute PE.

Pulmonary hypertension in patients with pulmonary fibrosis awaiting lung transplant.

Pulmonary hypertension (PH) may complicate idiopathic pulmonary fibrosis (IPF) but the prevalence of PH in IPF remains undefined. The present authors sought to describe the prevalence of PH in IPF. The lung transplant registry for the USA (January 1995 to June 2004) was analysed and IPF patients who had undergone right heart catheterisation (RHC) were identified. PH was defined as a mean pulmonary arterial pressure ((Ppa)) > or =25 mmHg and severe PH as a (Ppa) >40 mmHg. Independent factors associated with PH were determined. Of the 3,457 persons listed, 2,525 (73.0%) had undergone RHC. PH affected 46.1% of subjects; approximately 9% had severe PH. Variables independently associated with mild-to-moderate PH were as follows: need for oxygen, pulmonary capillary wedge pressure (P(pcw)) and forced expiratory volume in one second (FEV(1)). Independent factors related to severe PH included the following: carbon dioxide tension, age, FEV(1), P(pcw), need for oxygen and ethnicity. A sensitivity analysis in subjects with P(pcw) <15 mmHg did not appreciably alter the present findings. Pulmonary hypertension is common in idiopathic pulmonary fibrosis patients awaiting lung transplant, but the elevations in mean pulmonary arterial pressure are moderate. Lung volumes alone do not explain the pulmonary hypertension. Given the prevalence of pulmonary hypertension and its relationship with surrogate markers for quality of life (e.g. activities of daily living), future trials of therapies for this may be warranted.

The yield of lumbar puncture to exclude nosocomial meningitis as aetiology for mental status changes in the medical intensive care unit.

We aimed to evaluate the diagnostic value of lumbar puncture in excluding nosocomial meningitis as the cause of mental status changes in medical intensive care unit patients. We retrospectively reviewed the records of all patients admitted to the medical intensive care unit at our institution over a four-year period who had a lumbar puncture performed during their stay. Patients with central nervous system devices were excluded. During the study period 63 lumbar punctures were performed, 31 to exclude nosocomial meningitis. Of these 31 patients, 25 (80.6%) received antimicrobials during hospitalization before performance of lumbar puncture. In one patient with human immunodeficiency virus (HIV) infection, Gram stain demonstrated yeast; in the remainder, Gram stain was negative. Cultures were negative for pathogenic bacteria in all 30 of these patients (overall yield: 0%, 95% CI: 0-10.0%). Five patients (16.1%) had a cerebrospinal fluid leucocytosis (>10 leukocytes/mm3); of these, all had received prior antibiotics, two had positive cryptococcal antigen results, and three had central nervous system infection suspected clinically without an evident alternative diagnosis. In no non-HIV subject did lumbar puncture alter management. Lumbar puncture performed in the medical intensive care unit to exclude nosocomial meningitis as the cause of mental status changes has a low yield and rarely changes management. These findings should not be generalized to patients who have sustained head trauma, have undergone neurosurgical procedures, or may be immunosuppressed.

Pulmonary hypertension in advanced sarcoidosis: epidemiology and clinical characteristics.

Pulmonary hypertension (PH) is a predictor of poor outcome in sarcoidosis. Little is known about the epidemiology of PH in sarcoidosis. The current authors reviewed the records of patients with sarcoidosis listed for lung transplantation in the USA between January 1995 and December 2002. PH was defined as a mean pulmonary artery pressure of >25 mmHg and severe PH as a mean pulmonary artery pressure of > or =40 mmHg. The cohort included 363 patients of whom 73.8% had PH. Neither spirometric testing nor the need for corticosteroids was associated with PH. Subjects with PH required more supplemental oxygen (2.7+/-1.8 L.min(-1) versus 1.6+/-1.4 L.min(-1)). The cardiac index was lower in individuals with PH, whereas the pulmonary capillary wedge pressure was higher. In multivariate analysis, supplemental oxygen remained an independent predictor of PH, whereas the relationship between cardiac index and PH was no longer significant. As a screening test, the need for oxygen had a sensitivity and specificity of 91.8% and 32.6%, respectively. Pulmonary hypertension is common in advanced sarcoidosis. The need for oxygen correlates with pulmonary hypertension. Since pulmonary hypertension is associated with poor outcomes and because simple clinical criteria fail to identify patients with sarcoidosis and pulmonary hypertension, more aggressive screening for this should be considered.

Acute respiratory distress syndrome after kidney transplantation: epidemiology, risk factors, and outcomes.

OBJECTIVE: To determine the rate of the acute respiratory distress syndrome (ARDS) after kidney transplantation and to identify risk factors associated with the development of ARDS after kidney transplantation and outcomes for patients diagnosed with ARDS in this setting. DESIGN: Retrospective analysis of the national registry for end-stage renal disease in the United States. PATIENTS: We studied all patients who underwent kidney transplantation between July 1, 1994 and June 30, 1998 and identified patients diagnosed with ARDS. The diagnosis of ARDS was based on coding of patients records. We also compared the rate of ARDS after kidney transplantation with the rate of ARDS in the remainder of the U.S. population based on the results of the National Hospital Discharge Survey for 1997. MEASUREMENTS AND MAIN RESULTS: During the study period, 42,190 kidney transplantations were performed in the United States and ARDS was diagnosed in 86 of these subjects (0.2%) resulting in an annualized rate of ARDS of 51.0 cases per 100,000 patients per year. The rate of ARDS after kidney transplantation was significantly higher than the reported rate of ARDS in the U.S. population (p <.050). Demographic factors, indications for transplantation, comorbid illness, antigen mismatch, cytomegalovirus status, and development of rejection did not correlate with the development of ARDS. Of the immunosuppressive agents (e.g., cyclosporine, FK-506, mycophenolate mofetil, azathioprine, OKT-3, antilymphocyte globulin), only the use of antilymphocyte globulin when used to treat rejection was linked with an increased risk for ARDS (odds ratio: 3.85; 95% confidence interval: 1.36 to 10.87). Subjects with graft failure were 2.70 (95% confidence interval: 1.33 to 5.52) times more likely to develop ARDS. The 28-day mortality in subjects with ARDS was 52.1%. The 3-yr survival after kidney transplantation was 88.9% in those without ARDS compared with 57.8% in persons with ARDS (p <.001). CONCLUSIONS: Although ARDS is a rare event after kidney transplantation, undergoing renal transplantation increases the risk for ARDS. Among patients receiving kidney transplants, graft failure and the use of antilymphocyte globulin for rejection are associated with the development of ARDS. Patients who develop ARDS after kidney transplantation face significant mortality.

Enoxaparin for thromboprophylaxis after major trauma: potential cost implications.

OBJECTIVE: To determine the cost-effectiveness of enoxaparin compared with low-dose-heparin (LDH) for thromboprophylaxis after major trauma and to assess the economic significance of major bleeding as a complication of the use of low-molecular-weight heparin (LMWH). DESIGN: Decision model analysis of the cost and efficacy of enoxaparin at preventing venous thromboembolism (VTE) and the risk and costs of major hemorrhage related to LMWH. The primary outcome was deep vein thromboses (DVTs) averted. Model estimates were based on data from prospective trials of LMWH and other studies of the financial ramifications of DVT and pulmonary embolism. SETTING AND PATIENTS: Hypothetical cohort of 1,000 critically ill trauma patients requiring thromboprophylaxis. INTERVENTIONS: In the model, patients were managed with either LMWH or LDH. MEASUREMENTS AND MAIN RESULTS: The marginal cost-effectiveness of enoxaparin was calculated as the savings resulting from cases of DVT averted less the additional costs of both 1) LMWH and 2) major bleeding. This result is expressed as cost (or savings) per DVT prevented. Sensitivity analysis of the impact of the major clinical inputs on the cost-effectiveness was performed. The base case assumed that the incidence of DVT with LDH was 14.7%, that LMWH resulted in a relative risk reduction of DVT of 50%, but that enoxaparin nearly quadrupled the risk of bleeding. Despite the higher costs of enoxaparin, this tactic yielded a net savings of $391.23 per DVT prevented. For sensitivity analysis, model inputs were adjusted by 25% individually and then simultaneously. This demonstrated the model to be most sensitive to the calculated cost of a DVT. With the efficacy of LMWH reduced by 25% of the base-case estimate, enoxaparin resulted in a cost of $311.77 per DVT avoided. When all variables were skewed against LMWH, total outlays were trivial (approximately $85 per patient in the cohort). Neither the rate of increased bleeding with LMWH nor the costs incurred as a result of bleeding significantly altered the model's financial outcomes. CONCLUSIONS: Reliance on enoxaparin represents a strategy for the prevention of VTE after trauma that may result in savings. Neither concerns about the higher cost of enoxaprin relative to LDH nor the financial implications of major bleeding should preclude the use of LWMH for thromboprophylaxis in trauma patients. Further studies are warranted to confirm the efficacy of enoxaparin.

Endobronchial involvement and airway hyperreactivity in patients with sarcoidosis.

STUDY OBJECTIVE: To determine the relationship between airway hyperreactivity (AHR) and endobronchial involvement in patients with sarcoidosis. DESIGN: Prospective series of consecutive patients. SETTING: Pulmonary clinic of a military, tertiary-care teaching hospital. PATIENTS: Patients with newly diagnosed sarcoidosis. INTERVENTIONS: All patients undergoing bronchoscopy for the diagnosis of sarcoidosis underwent an evaluation that included history, physical examination, chest radiography, and spirometry. Bronchoprovocation testing was done using methacholine. During bronchoscopy, six endobronchial biopsy (EBB) specimens were obtained. In patients with abnormal-appearing airways, four specimens were obtained from abnormal areas and two specimens were obtained from the main carina. In patients with normal-appearing airways, four specimens were obtained from a secondary carina and two specimens were obtained from the main carina. A biopsy specimen was considered positive if it demonstrated nonnecrotizing granulomas with special stains that were negative for fungal and mycobacterial organisms. Only patients with histologic confirmation of sarcoidosis were included in the data analysis. MEASUREMENTS AND RESULTS: The study cohort included 42 patients (57.1% were men, 61.9% were African American, and mean age [+/- SD] was 37.3 +/- 6.6 years). AHR was present in nine patients (21.4%), while EBB revealed nonnecrotizing granulomas in 57.1% of patients. All patients with AHR had positive EBB findings compared to 45.5% of individuals without AHR (p = 0.005). There was a trend toward lower lung volumes and flow rates in patients with AHR, but this did not reach statistical significance. The mean serum angiotensin-converting enzyme level was higher in patients with AHR (79.3 +/- 53.9 IU/L vs 37.5 +/- 26.7 IU/L, p = 0.05). No other clinical variable correlated with the presence of AHR. CONCLUSIONS: AHR may be seen in patients with sarcoidosis. Endobronchial involvement significantly increases the risk for AHR and may play a role in the development of AHR in patients with sarcoidosis. Other clinical factors are not clearly associated with AHR in patients with sarcoidosis.

Cholestatic jaundice associated with the use of metformin.

We report a patient who developed cholestatic jaundice shortly after initiation of treatment with metformin hydrochloride. Ultrasound of the liver and abdominal CT were normal. An ERCP showed normal biliary anatomy. A percutaneous liver biopsy was obtained showing marked cholestasis, with portal edema, ductular proliferation, and acute inflammation. Metformin hydrochloride was discontinued, and the patient's jaundice resolved slowly over a period of several months. Given the onset of his jaundice 2 wk after the initiation of metformin, we believe that this case represents an example of metformin-associated hepatotoxicity, the first such case reported.

Endobronchial biopsy for sarcoidosis: a prospective study.

STUDY OBJECTIVES: To determine the yield of endobronchial biopsy (EBB) for suspected sarcoidosis, and to evaluate if EBB increases the diagnostic value of fiberoptic bronchoscopy (FOB) when added to transbronchial biopsy (TBB). DESIGN: Prospective study of consecutive patients. SETTING: Pulmonary clinic of a tertiary-care, academic medical center. PATIENTS: Patients consecutively referred for suspected pulmonary sarcoidosis. INTERVENTIONS: All patients having FOB performed underwent an evaluation that included history, physical examination, a chest radiograph, and spirometry. During FOB, airway appearance was recorded and both TBB and EBB were performed in a standardized fashion. Six TBB specimens were obtained, as were six EBB samples. For patients with abnormal-appearing airways, four specimens were obtained from the abnormal-appearing airways and two specimens were obtained from the main carina. In patients with normal-appearing airways, four specimens were obtained from a secondary carina and two specimens were obtained from the main carina. A biopsy finding was considered positive if it demonstrated nonnecrotizing granulomas with special stains that were negative for fungal and mycobacterial organisms. MEASUREMENTS AND RESULTS: The study cohort included 34 subjects (mean +/- SD age, 37.9 +/- 6.8 years; 58.8% were male; 64.7% were African American). EBB findings were positive in 61.8% of patients, while TBB showed nonnecrotizing granulomas in 58.8% of subjects. The addition of EBB increased the yield of FOB by 20.6%. Although EBB findings were more frequently positive in abnormal-appearing airways (p = 0.014), EBB provided diagnostic tissue in 30.0% of patients with normal-appearing endobronchial mucosa. There were no complications resulting from the addition of EBB to TBB. CONCLUSIONS: Endobronchial involvement is common in sarcoidosis. EBB has a yield comparable to TBB and can safely increase the diagnostic value of FOB. Pulmonologists should consider routinely performing EBB in cases of suspected sarcoidosis.

Continuous subglottic suctioning for the prevention of ventilator-associated pneumonia : potential economic implications.

STUDY OBJECTIVE: To determine the cost-effectiveness of continuous subglottic suctioning (CSS) as a strategy to decrease the incidence of ventilator-associated pneumonia (VAP). DESIGN: Decision-model analysis of the cost and efficacy of endotracheal tubes that allow CSS at preventing VAP. The primary outcome was cases of VAP averted. Model estimates were based on data from published prospective trials of CSS and other prospective studies of the incidence of VAP. SETTING AND PATIENTS: Hypothetical cohort of 100 patients requiring nonelective endotracheal intubation and management in an ICU. INTERVENTIONS: In the model, patients were managed with either traditional endotracheal tubes (ETs) or ETs capable of CSS. MEASUREMENTS AND MAIN RESULTS: The marginal cost-effectiveness of CSS was calculated as the savings resulting from cases of VAP averted minus the additional costs of CSS-ETs, and expressed as cost (or savings) per episode of VAP prevented. Sensitivity analysis of the impact of the major clinical inputs on the cost-effectiveness was performed. The base case assumed that the incidence of VAP in patients requiring > 72 h of mechanical ventilation (MV) was 25%, that CSS-ETs had no impact on patients requiring MV for < 72 h, and that CSS-ETs resulted in a relative risk reduction of VAP of 30%. Despite the higher costs of ETs capable of CSS, this tactic yielded a net savings of $4,992 per case of VAP prevented. For sensitivity analysis, model inputs were adjusted by 50% individually and then simultaneously. This demonstrated the model to be only moderately sensitive to the calculated cost of VAP. With the relative risk reduction at 50% of the base-case estimate, CSS resulted in $1,924 saved per case of VAP prevented. When all variables were skewed against CSS, total outlays were trivial (approximately $14 per patient in the cohort). CONCLUSIONS: CSS represents a strategy for the prevention of VAP that may result in savings. Further studies are warranted to confirm the efficacy of CSS.

Aspergillus and endobronchial abnormalities in lung transplant recipients.

STUDY OBJECTIVE: To determine the relationship between aspergillus recovery from the airways of lung transplant recipients and the development of endobronchial abnormalities. DESIGN: Retrospective case series. SETTING: Tertiary-care hospital. PATIENTS: All patients who underwent lung transplantation between December 1991 and June 1999. MEASUREMENTS AND RESULTS: The study cohort included 38 patients. The primary end point was the bronchoscopic identification of an endobronchial abnormality. Aspergillus was isolated from the lungs of nine patients (23.7%). Most of these isolates occurred early after transplantation (mean, 8 weeks). Endobronchial abnormalities arose in seven of the patients (18.4%) and manifested as either exuberant granulation tissue or stricture formation. Six of the 9 (66.6%) patients with aspergillus developed airway lesions, compared to 1 of the 29 patients (3.4%) without aspergillus (p = 0.0002). Endobronchial abnormalities were 19.3 times more likely to occur in patients in whom aspergillus had previously been isolated. As a screening test for the subsequent diagnosis of an airway complication, the recovery of aspergillus had a sensitivity and specificity of 85.7% and 90.3%, respectively. These aspergillus-related endobronchial abnormalities were clinically relevant as evidenced by a mean increase of 25.9% in the FEV(1) after bronchoscopic intervention. CONCLUSION: The early isolation of aspergillus from the airways of lung transplant recipients identifies patients at increased risk for the development of clinically significant endobronchial abnormalities.

Regulatory and educational initiatives fail to promote discussions regarding end-of-life care.

We conducted an observational cohort study to determine if hospital-based, reinforcing regulatory and educational interventions could encourage physicians to discuss end-of-life (EOL) care with their patients. Specifically, we measured the effect of (1) administrative prompts to encourage discussions about EOL care and (2) a mandatory educational seminar focusing on EOL issues. Study subjects were patients consecutively admitted to the medicine service who faced an anticipated 3-year mortality rate of at least 50%. The main study endpoint was the frequency of documented EOL discussions between physicians and patients. In the inception cohort of 184 patients, physicians discussed EOL care with 64 patients (34. 8%), and in the follow-up cohort of 121 patients, 41 individuals (33. 9%) had documented discussions regarding EOL issues (P = 0.90). Actual "Do Not Resuscitate"(DNR) orders were written for 53 patients (28.8%) in the inception cohort and for 33 persons (27.3%) in the follow-up cohort (P = 0.71). We conclude that enhanced, mutually reinforcing regulatory and educational efforts focusing on EOL care proved ineffectual at promoting either discussions about EOL issues or the use of DNR orders.

Circulating D dimer in patients with sarcoidosis.

STUDY OBJECTIVES: To determine the relationship between D dimer (DD) status and markers of disease activity in patients with sarcoidosis. DESIGN: Prospective, observational analysis. SETTING: Pulmonary clinic of a tertiary care, university-affiliated hospital. PATIENTS: Consecutive individuals with newly diagnosed sarcoidosis. INTERVENTION: Determination of serum DD. MEASUREMENTS AND RESULTS: The study cohort included 28 subjects, and DD was present in 39.3%. DD status correlated with the radiographic stage of disease (p = 0. 035), diffusing capacity of the lung for carbon monoxide (p = 0.026), serum angiotensin-converting enzyme level (p = 0.006), and the presence of dyspnea (p = 0.034). Patients with circulating DD were 3. 8 times more likely to have radiographic evidence of interstitial involvement. DD was not associated with either FVC or the FEV(1). CONCLUSIONS: DD is frequently positive in patients with sarcoidosis. DD is associated with disease activity as measured by radiograph, pulmonary function tests, and serum markers of inflammation.

Osseous disease in patients with pulmonary sarcoidosis and musculoskeletal symptoms.

Little is known about the clinical manifestations and correlates of osseous sarcoidosis and few data exist to guide pulmonologists in their evaluation of patients for possible osseous involvement. To determine the relationship between pulmonary and osseous sarcoidosis, and to develop an algorithm for use by pulmonologists in assessing patients with suspected osseous sarcoidosis, we conducted a retrospective, case control study of patients with pulmonary sarcoidosis and musculoskeletal complaints who were evaluated for osseous disease. All patients underwent a standard evaluation to include physical examination, chest radiograph (CXR), spirometry (PFTs), bone scintigraphy and plain radiographs of the hands and feet. Patients completed a health assessment questionnaire and serum angiotenisin converting enzyme, erythrocyte sedimentation rate, and C-reactive protein were measured. Patients eventually diagnosed with osseous sarcoidosis were compared to those lacking osseous involvement. Osseous involvement in patients with pulmonary sarcoidosis and musculoskeletal symptoms was common and seen in 38.9% of subjects. Patients with osseous sarcoidosis were more likely to concomitantly suffer from cutaneous sarcoidosis and to have elevated ACE levels and ESRs. No measure of pulmonary involvement (CXR stage, PFTs or symptoms) differentiated patients with osseous sarcoidosis from those without this condition. In cases of osseous sarcoidosis, bone scintigraphy identified a mean of four sites of osseous involvement, some of which would have been missed with the use of plain radiographs limited to the hands and feet. We conclude that in patients with pulmonary sarcoidosis who have significant musculoskeletal complaints, osseous involvement is frequent. Pulmonary features of sarcoidosis do not differ between patients with and without osseous disease. Bone scintigraphy aids in the evaluation of these patients.

Impediments to writing do-not-resuscitate orders.

BACKGROUND: Physicians are frequently unaware of their patients' desires regarding end-of-life care. Consequently, opportunities to implement do-not-resuscitate (DNR) orders are often missed. OBJECTIVE: To determine the reasons attending physicians do not write DNR orders when patients face increased mortality. METHODS: Over 4 months, the medical records of all inpatients on the General Medicine Service were reviewed at the time of discharge to identify patients with conditions predicting increased mortality. These cases were presented to a 5-member panel who decided if a DNR order was indicated. Reasons for missing DNR orders were discussed with the attending physicians. RESULTS: Of 613 consecutive admissions, the panel identified 149 patients (24%) for whom DNR orders were indicated. In 88 (59%) of these, DNR orders were absent. The lack of a DNR order did not correlate with age (P = .95), sex (P = .61), or race (P = .80). The attending physicians' explanations for not writing DNR orders in these 88 cases included the belief that the patient was not in imminent danger of death (n = 49 [56%]), the belief that the primary physician should discuss DNR issues (n = 43 [49%]), and the lack of an appropriate opportunity to discuss end-of-life issues (n = 38 [43%]). In 11 (12%) of the 88 cases, patients or their families did not accept the recommendation for a DNR order. No physicians expressed concerns regarding the morality of DNR orders, discomfort discussing end-of-life issues, or the threat of litigation as reasons for not writing a DNR order. CONCLUSIONS: Limitations in the extent and depth of the physician-patient relationship appear to be the most frequent impediments to writing DNR orders in our institution.