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Biomedical subjects

R S Phillips

Publications and source records attributed to R S Phillips.

At least 91 records · Page 5Linked to original sources
PubMed1998

A comparison of generalist and pulmonologist care for patients hospitalized with severe chronic obstructive pulmonary disease: resource intensity, hospital costs, and survival. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment.

PURPOSE: Both generalist and pulmonologist physicians care for patients with severe chronic obstructive pulmonary disease (COPD). We studied patients hospitalized with severe COPD to explore whether supervision of care by pulmonologists is associated with greater costs or better survival. SUBJECTS AND METHODS: We studied 866 adults with severe COPD enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), a prospective study at five academic medical centers. Patients were admitted to the hospital or transferred to an intensive care setting for treatment of severe COPD, defined by hypoxia (PaO2 <60 mm Hg) and hypercapnia (PaCO2 >50 mm Hg) or hypercapnia alone if on supplemental oxygen. Resource intensity was measured using a modified version of the Therapeutic Intervention Scoring System and estimated hospital costs. To account for differences in the patient case mix, propensity scores were developed to represent each patient's probability of having a pulmonologist as attending physician and each patient's probability of being in an intensive care unit (ICU) at study admission. RESULTS: Of the 866 patients studied, 512 had generalists and 354 pulmonologists as their attending physicians. The median patient age was 70 years; 52% were male; 14% died within 30 days. After adjusting for baseline differences in patient characteristics, there were no differences in resource intensity and hospital costs in those treated by pulmonologists or generalists. Adjusted average resource intensity scores for the entire hospitalization were 16.5 for pulmonologists and 17.0 for generalists (P = 0.34). Estimated hospital costs were the same ($6,400) for patients treated by pulmonologists and generalists (P = 0.99). Patients with pulmonologists as attending physicians did not experience better survival. Comparing patients of pulmonologists to patients of generalists, the adjusted hazard ratio for 30-day mortality was 1.6 (95% confidence interval: 0.98, 2.5); the hazard ratio for 180-day mortality was 1.2 (0.9, 1.7). CONCLUSIONS: Our findings suggest that for patients hospitalized with exacerbation of severe COPD, those with pulmonologist attending physicians do not have higher hospital resource use or better survival than those with generalist attending physicians.

Adult↗
PubMed1998

Patient empowerment and feedback did not decrease pain in seriously ill hospitalized adults.

We tested a nurse clinician-mediated intervention to relieve pain in a group of seriously ill hospitalized adults using a randomized controlled trial at five tertiary care academic centers in the US. The study included 4804 patients admitted between January 1992 and January 1994 with one or more of nine high mortality diagnoses; 2652 were allocated to the intervention and 2152 to usual care. Specially-trained nurse clinicians assessed patients' pain, educated them and their families about pain control, empowered patients to expect pain relief, informed patients' nurses and physicians about level of pain and suggested or used other pain management resources. Patients' pain was determined from hospital interviews with patients and surrogates. Pain 2 and 6 months later or after death and satisfaction with its control at all time periods were also assessed. All analyses were adjusted for baseline risk of being in pain and propensity to be in the intervention group. Overall, 50.9% of patients reported some pain. After adjustment for other variables associated with pain, comparing the intervention to the control group, there was not a statistically significant difference in level of pain (OR for higher levels of pain 1.15; CI 1.00-1.32) or satisfaction with control of pain during the hospitalization (OR for higher levels of pain 1.12; CI 0.91-1.39), 2 or 6 months after discharge, or during the last 3 days of life. A multifaceted intervention using information, empowerment, advocacy, counseling and feedback was ineffective in ameliorating pain in seriously ill patients. Control of pain in these patients remains an important problem. More intensive pain treatment strategies addressing the needs of seriously ill hospitalized adults must be evaluated.

Aged↗
PubMed1998

Infective dose modulates the balance between Th1- and Th2-regulated immune responses during blood-stage malaria infection.

Plasmodium chabaudi infection of mice provides an excellent model for examining acquired immunity to the blood-borne stage of malaria infection. CD4+ T-cell receptor (TCR) alphabeta-bearing T lymphocytes play a critical role in mediating protection, ascribed to both T helper (Th) 1 and Th2 subsets. One factor that may influence the Th1/Th2 cell balance is infective dose. In this study, we found that the size of the infective dose of P. chabaudi, and thus the level of antigen presented to the immune system, correlated with the balance of responder CD4+ T-cell phenotypes. Increasing the infective dose in a resistant mouse strain enhanced the Th1 cytokine (interferon-gamma; IFN-gamma) response and reduced the Th2 cytokine (interleukin-4; IL-4) response. In contrast, increasing the infective dose in a susceptible mouse strain led to a prominent and accelerated up-regulation of IL-4 production. These data show that the dose of antigen can significantly affect the balance between Th1- and Th2-mediated immune functions during infection of the mammalian host with blood-stage malaria parasites. This demonstration that parasite numbers may modulate CD4+ T-cell regulation has novel implications for the successful implementation of antimalarial vaccination and chemotherapeutic strategies.

Animals↗
PubMed1998

Patients discharged against medical advice from a general medicine service.

This study compares the demographic features and hospital course of all 472 patients discharged against medical advice from the general medicine service of an urban teaching hospital between 1984 and 1995 and 1,113 control patients discharged with physician approval. In the multivariate analysis, younger age (odds ratio [OR] 0.97 per year; 95% confidence interval [CI] 0.96, 0.98), male gender (OR 1.9; 95% CI 1.4, 2.4), lack of health insurance (OR 2.0; 95% CI 1.3, 3.1), Medicaid applicant or recipient status (OR 2.2; 95% CI 1.6, 3.1), admission through the emergency department (OR 2.2; 95% CI 1.4, 3.5), and lack of a personal attending physician at the time of admission (OR 2.1; 95% CI 1.6, 2.8) increased the odds of discharge against medical advice. Fifty-four percent of patients who left against medical advice were readmitted to the hospital during the study period; 98% were then discharged with physician approval. Patients who left the hospital against medical advice included many disadvantaged individuals without ongoing primary care.

Case-Control Studies↗
PubMed1998

Antimalarial activity of unsaturated putrescine derivatives.

(E)-1,4-Diaminobut-2-ene dihydrochloride 1 (unsaturated putrescine) and some N-substituted derivatives of 1 have strong antifungal activity against a variety of plant pathogens. A series of N-alkylated putrescine derivatives was synthesised and evaluated for antimalarial activity in vitro against the asexual, intraerythrocytic stages of Plasmodium falciparum. (E)-N,N,N',N'-Tetraethyl-1,4-diaminobut-2-ene dihydrochloride 3 was the most active N-alkylated putrescine tested. Enhanced in-vitro activity was evident with the N,N'-bisbenzyl derivatives 7 and 11. Useful activity in vivo was observed only when the 7-chloroisoquinolyl moiety was present, as in 12 (an unsaturated analogue of chloroquine).

Animals↗
PubMed1998

Physician experience caring for dying patients and its relationship to patient outcomes.

BACKGROUND: The quality of end-of-life care has become important to care systems and the public. No research has assessed how physician factors affect patient and family experience. OBJECTIVE: The objective of this study was to examine whether physicians' experience with dying is associated with differences in their patients' experiences while dying. METHODS: This was a prospective cohort study. Data were obtained from five geographically diverse teaching hospitals. The survey population was composed of 765 attending physicians who had at least one patient enrolled in a study of those with a high risk of dying. The patients were 8203 hospitalized adults who were at least 80 years of age or had one of nine serious illnesses. The physician survey provided information about physician characteristics. Physician experience with death was stratified into five groups according to self-reported rate of dying patients in the physician's practice. Patient outcomes included pain, anxiety, depression, satisfaction with pain relief, presence and timing of do-not-resuscitate orders, concordance with their physicians about cardiopulmonary resuscitation, and hospital resource use. RESULTS: Oncologists and pulmonologists or critical care physicians had more frequent contact with death. Physician characteristics other than specialty were not associated with death experience. Compared with the physician group having no experience with death, the adjusted odds ratios for accord on resuscitation preferences were 1.38 (95% confidence interval [CI], 0.96 to 1.98), 1.47 (95% CI, 1.03 to 2.11), 1.58 (95% CI, 1.10 to 2.26), and 1.64 (95% CI, 1.09 to 2.46) for the other four physician groups with progressively increasing experience. Other outcomes for patients were not associated with increasing physician experience. CONCLUSION: Most physicians have little experience with dying, and physicians' experience with death has little effect on patient outcomes. The concentration of experience in a small segment of physicians offers opportunities for targeting improvements in the care of dying patients, including physician education.

Journal Article↗
PubMed1998

Perceptions of quality of care and the decision to leave a practice.

Little is known about how patients' perceptions of quality of care influence behavioral outcomes such as decisions to change the source of their care. We surveyed patients suspected of leaving a primary care internal medicine practice at an urban teaching hospital to examine their reasons for leaving, and to investigate whether decisions to leave were related to perceived quality of care. Of 185 respondents, 27 (15%) had left to follow their doctor to another practice. The other 98 (53%) patients who had left the practice cited reasons such as a change of insurance (51), physician care (31), practice operation (27), parking and transportation (24), physician departure (19), and geographic moves (17). Responses to global assessment items and a physician care rating scale were more closely associated with the decision to leave than were ratings of other specific aspects of care.

Adult↗
PubMed1997

Biophysical and mutagenic analysis of Thermoanaerobacter ethanolicus secondary-alcohol dehydrogenase activity and specificity.

The Thermoanaerobacter ethanolicus 39E adhB gene encoding the secondary-alcohol dehydrogenase (secondary ADH) was overexpressed in Escherichia coli at more than 10% of total protein. The recombinant enzyme was purified in high yield (67%) by heat-treatment at 85 degrees C and (NH4)2SO4 precipitation. Site-directed mutants (C37S, H59N, D150N, D150Eand D150C were analysed to test the peptide sequence comparison-based predictions of amino acids responsible for putative catalytic Zn binding. X-ray absorption spectroscopy confirmed the presence of a protein-bound Zn atom with ZnS1(imid)1(N,O)3 co-ordination sphere. Inductively coupled plasma atomic emission spectrometry measured 0.48 Zn atoms per wild-type secondary ADH subunit. The C37S, H59N and D150N mutant enzymes bound only 0.11, 0.13 and 0.33 Zn per subunit respectively,suggesting that these residues are involved in Zn liganding. The D150E and D150C mutants retained 0.47 and 1.2 Zn atoms per subunit, indicating that an anionic side-chain moiety at this position preserves the bound Zn. All five mutant enzymes had </= 3% of wild-type catalytic activity, suggesting that the T. ethanolicus secondary ADH requires a properly co-ordinated catalytic Zn atom. The His-59 and Asp-150 mutations also altered secondary ADH affinity for propan-2-ol over a 140-fold range, whereas the overall change in affinity for ethanol spanned a range of only 7-fold, supporting the importance of the metal in secondary ADH substrate binding. The lack of significant changes in cofactor affinity as a result of these catalytic Zn ligand mutations suggested that secondary ADH substrate-and cofactor-binding sites are structurally distinct. Altering Gly198 to Asp reduced the enzyme specific activity 2.7-fold, increased the Km(app) for NADP+ 225-fold, and decreased the Km(app) for NAD+ 3-fold, supporting the prediction that the enzyme binds nicotinamide cofactor in a Rossmann fold. Our data indicate therefore that, unlike the liver primary ADH,the Rossmann-fold-containing T. ethanolicus secondary ADH binds its catalytic Zn atom using a sorbitol dehydrogenase-like Cys-His-Asp motif and does not bind a structural Zn atom.

Alcohol Dehydrogenase↗
PubMed1997

Cloning, sequence, and expression of kynureninase from Pseudomonas fluorescens.

We have cloned the gene encoding kynureninase from Pseudomonas fluorescens using a restriction site polymerase chain reaction technique (RS-PCR) (G. Sarkar, R. T. Turner, and M. E. Bolander PCR Methods Appl. 2, 318-322, 1993) and expressed the enzyme in Escherichia coli DH5a F'. The kynureninase gene has an open reading frame (ORF) of 1251 base pairs that codes for a protein of 416 amino acids with a calculated molecular weight of 45,906. The protein purified from P. fluorescens has N-terminal threonine and an observed molecular weight of 45,787 by electrospray mass spectrometry, suggesting that the N-terminal methionine is removed by posttranslational processing. The complete gene was obtained by PCR and inserted into pTZ18U. The resultant plasmid was used to transform E. coli DH5alpha F', and these cells overexpressed kynureninase to about 37% of total soluble protein. The isolated recombinant protein has molecular weight and Km values identical to those of the native protein from P. fluorescens. The amino acid sequence exhibits 29% identity with those of rat and human kynureninases and 32% identity with the amino acid sequence translated from a Saccharomyces cerevisiae ORF. Alignment of the four sequences shows a highly conserved region which corresponds to the pyridoxal-5'-phosphate (PLP) binding site of rat kynureninase. Based on this alignment, we predict that Lys227 and Asp212 in P. fluorescens kynureninase are involved in pyridoxal-5'-phosphate binding. P. fluorescens kynureninase also exhibits significant homology to the nifS gene product, cysteine desulfurase, and to eucaryotic serine/pyruvate aminotransferases, suggesting that it is a member of subgroup IV of the aminotransferase family of PLP-dependent enzymes.

Amino Acid Sequence↗
PubMed1997

Outcomes and cost-effectiveness of initiating dialysis and continuing aggressive care in seriously ill hospitalized adults. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

BACKGROUND: Renal failure requiring dialysis in the setting of hospitalization for serious illness is a poor prognostic sign, and dialysis and aggressive care are sometimes withheld. OBJECTIVE: To evaluate the clinical outcomes and cost-effectiveness of initiating dialysis and continuing aggressive care for seriously ill hospitalized patients. DESIGN: Prospective cohort study and cost-effectiveness analysis. SETTING: Five geographically diverse teaching hospitals. PATIENTS: 490 patients (median age, 61 years; 58% women) enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) in whom dialysis was initiated. MEASUREMENTS: Survival, functional status, quality of life, and health care costs. Life expectancy was estimated by extrapolating survival data (up to 4.4 years of follow-up) using a declining exponential function. Utilities (quality-of-life weights) were estimated by using time-tradeoff questions. Costs were based on data from SUPPORT and published Medicare data. RESULTS: Median duration of survival was 32 days, and only 27% of patients were alive after 5 months. Survivors reported a median of one dependency in activities of daily living, and 62% rated their quality of life as "good" or better. Overall, the estimated cost per quality-adjusted life-year saved by initiating dialysis and continuing aggressive care rather than withholding dialysis and allowing death to occur was $128,200. For the 103 patients in the worst prognostic category, the estimated cost per quality-adjusted life-year was $274,100; for the 94 patients in the best prognostic category, the cost per quality-adjusted life-year was $61,900. CONCLUSIONS: For the few patients who survived, clinical outcomes were fairly good. With the exception of patients with the best prognoses, however, the cost-effectiveness of initiating dialysis and continuing aggressive care far exceeded $50,000 per quality-adjusted life-year, a commonly cited threshold for cost-effective care.

Aged↗
PubMed1997

Patient preferences for communication with physicians about end-of-life decisions. SUPPORT Investigators. Study to Understand Prognoses and Preference for Outcomes and Risks of Treatment.

BACKGROUND: Physicians are frequently unaware of patient preferences for end-of-life care. Identifying and exploring barriers to patient-physician communication about end-of-life issues may help guide physicians and their patients toward more effective discussions. OBJECTIVE: To examine correlates and associated outcomes of patient communication and patient preferences for communication with physicians about cardiopulmonary resuscitation and prolonged mechanical ventilation. DESIGN: Prospective cohort study. SETTING: Five tertiary care hospitals. PATIENTS: 1832 (85%) of 2162 eligible patients completed interviews. MEASUREMENTS: Surveys of patient characteristics and preferences for end-of-life care; perceptions of prognosis, decision making, and quality of life; and patient preferences for communication with physicians about end-of-life decisions. RESULTS: Fewer than one fourth (23%) of seriously ill patients had discussed preferences for cardiopulmonary resuscitation with their physicians. Of patients who had not discussed their preferences for resuscitation, 58% were not interested in doing so. Of patients who had not discussed and did not want to discuss their preferences, 25% did not want resuscitation. In multivariable analyses, patient factors independently associated with not wanting to discuss preferences for cardiopulmonary resuscitation included being of an ethnicity other than black (adjusted odds ratio [OR], 1.48 [95% CI, 1.10 to 1.99), not having an advance directive (OR, 1.35 [CI, 1.04 to 1.76]), estimating an excellent prognosis (OR, 1.72 [CI, 1.32 to 2.59]), reporting fair to excellent quality of life (OR, 1.36 [CI, 1.05 to 1.76]), and not desiring active involvement in medical decisions (OR, 1.33 [CI, 1.07 to 1.65]). Factors independently associated with wanting to discuss preferences for resuscitation but not doing so included being black (OR, 1.53 [CI, 1.11 to 2.11]) and being younger (OR, 1.14 per 10-year interval younger [CI, 1.04 to 1.25]). CONCLUSIONS: Among seriously ill hospitalized adults, communication about preferences for cardiopulmonary resuscitation is uncommon. A majority of patients who have not discussed preferences for end-of-life care do not want to do so. For patients who do not want to discuss their preferences, as well as patients with an unmet need for such discussions, failure to discuss preferences for cardiopulmonary resuscitation and mechanical ventilation may result in unwanted interventions.

Adult↗
PubMed1997

The crystal structure of Citrobacter freundii tyrosine phenol-lyase complexed with 3-(4'-hydroxyphenyl)propionic acid, together with site-directed mutagenesis and kinetic analysis, demonstrates that arginine 381 is required for substrate specificity.

The X-ray structure of tyrosine phenol-lyase (TPL) complexed with a substrate analog, 3-(4'-hydroxyphenyl)propionic acid, shows that Arg 381 is located in the substrate binding site, with the side-chain NH1 4.1 A from the 4'-OH of the analog. The structure has been deduced at 2.5 A resolution using crystals that belong to the P2(1)2(1)2 space group with a = 135.07 A, b = 143.91 A, and c = 59.80 A. To evaluate the role of Arg 381 in TPL catalysis, we prepared mutant proteins replacing arginine with alanine (R381A), with isoleucine (R381I), and with valine (R381V). The beta-elimination activity of R381A TPL has been reduced by 10(-4)-fold compared to wild type, whereas R381I and R381V TPL exhibit no detectable beta-elimination activity with L-tyrosine as substrate. However, R381A, R381I, and R381V TPL react with S-(o-nitrophenyl)-L-cysteine, beta-chloro-L-alanine, O-benzoyl-L-serine, and S-methyl-L-cysteine and exhibit k(cat) and k(cat)/Km values comparable to those of wild-type TPL. Furthermore, the Ki values for competitive inhibition by L-tryptophan and L-phenylalanine are similar for wild-type, R381A, and R381I TPL. Rapid-scanning-stopped flow spectroscopic analyses also show that wild-type and mutant proteins can bind L-tyrosine and form quinonoid complexes with similar rate constants. The binding of 3-(4'-hydroxyphenyl)propionic acid to wild-type TPL decreases at high pH values with a pKa of 8.4 and is thus dependent on an acidic group, possibly Arg404, which forms an ion pair with the analog carboxylate, or the pyridoxal 5'-phosphate Schiff base. R381A TPL shows only a small decrease in k(cat)/Km for tyrosine at lower pH, in contrast to wild-type TPL, which shows two basic pKas with an average value of about 7.8. Thus, it is possible that Arg 381 is one of the catalytic bases previously observed in the pH dependence of k(cat)/Km of TPL with L-tyrosine [Kiick, D. M., & Phillips. R. S. (1988) Biochemistry 27, 7333-7338], and hence Arg 381 is at least partially responsible for the substrate specificity of TPL.

Arginine↗
PubMed1997

Patient-physician communication at hospital discharge and patients' understanding of the postdischarge treatment plan.

BACKGROUND: The quality of discharge planning is an important determinant of patient outcomes following hospital discharge. Patients often report inadequate discussion prior to discharge regarding major elements of the postdischarge treatment plan, including medication and daily activities. OBJECTIVE: To determine whether this apparent lack of communication might be the result of differing perceptions on the part of patients and physicians regarding the patients' understanding of the treatment plan. METHODS: We surveyed 99 patients and their attending physicians. All patients had been discharged recently from an academic medical center with the diagnosis of acute myocardial infarction or pneumonia. We asked both patients and physicians about time spent prior to discharge discussing the postdischarge treatment plan and the patients' understanding of this plan. McNemar test was used to determine whether responses of patients and physicians differed. RESULTS: Physicians reported spending more time discussing postdischarge care than did patients (P = .10). Physicians believed that 89% of patients understood the potential side effects of their medications, but only 57% of patients reported that they understood (P < .001). Similarly, physicians believed that 95% of patients understood when to resume normal activities, while only 58% of patients reported that they understood (P < .001). CONCLUSIONS: Physicians overestimate patients' understanding of the postdischarge treatment plan. Steps should be taken to improve communication about postdischarge treatment.

Adult↗
PubMed1997

Effects of tyrosine ring fluorination on rates and equilibria of formation of intermediates in the reactions of carbon-carbon lyases.

The interactions of ring fluorinated analogs of tyrosine with tyrosine phenol-lyase and tryptophan indole-lyase (tryptophanase) were studied by rapid-scanning stopped-flow spectrophotometry. The reaction of L-tyrosine with tyrosine phenol-lyase resulted in rapid formation of a small absorbance peak at 500 nm, attributed to a quinonoid intermediate. The reaction of 3-fluoro-L-tyrosine with tyrosine phenol-lyase resulted in a peak at 500 nm with much higher absorbance, as did the reaction of 3,5-difluoro-L-tyrosine, due to increased accumulation of quinonoid intermediates. In constrast, complexes with 2-fluoro-L-tyrosine, 2,3-difluoro-L-tyrosine, 2,5-difluoro-L-tyrosine, and 2,6-difluoro-L-tyrosine exhibited much lower absorbance intensity at 500 nm. The rate constant for quinonoid intermediate formation from 3-fluoro-L-tyrosine was comparable to that for L-tyrosine. However, 3,5-difluoro-L-tyrosine reacted to form a quinonoid intermediate at about half the rate of L-tyrosine, while 2,3-difluoro-L-tyrosine reacted at twice the rate of L-tyrosine. In addition, the 2-substituted difluorotyrosines exhibited an intermediate, which was formed rapidly, absorbing strongly at about 340 nm, which is likely due to a gem-diamine intermediate. Tyrosine is not a substrate for tryptophan indole-lyase; the reaction of tryptophan indole-lyase with L-tyrosine resulted in formation of external aldimine, which absorbed at 420 nm, and a very small absorbance peak at 500 nm. 3-Fluoro-L-tyrosine reacted with tryptophan indole-lyase to produce a prominent quinonoid absorbance peak at 500 nm, whereas L-tyrosine, 2-fluoro-L-tyrosine, and all difluoro-L-tyrosines, had a much reduced intensity for this peak. Thus, the presence of ring fluorine substituents in L-tyrosine that are remote from the site of the chemical transformation has significant effects on the rates and equilibria of intermediate formation in the reactions with both tyrosine phenol-lyase and tryptophan indole-lyase. Although it is commonly thought that fluorine substitution will not result in any significant steric effects, our results suggest that the effects of fluorine substitution in the reactions of fluorinated tyrosines with tyrosine phenol-lyase and tryptophan indole-lyase are due to a combination of steric and electronic effects.

Citrobacter freundii↗
PubMed1997

Perceptions by family members of the dying experience of older and seriously ill patients. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

BACKGROUND: Alleviating the problems faced by dying persons and their families has drawn substantial public attention, but little is known about the experience of dying. OBJECTIVE: To characterize the experience of dying from the perspective of surrogate decision makers, usually close family members (89%). DESIGN: Prospective cohort study. SETTING: Five teaching hospitals. PATIENTS: Persons who had one of nine serious medical conditions or were 80 years of age or older who died and for whom a surrogate decision maker completed an interview about the death. MEASUREMENTS: Medical records were reviewed and surrogate decision makers were interviewed. RESULTS: 4124 of 9105 seriously ill patients died (46%); 408 of 1176 elderly patients died (35%). The patients' family members were interviewed after 3357 persons (73%) had died. Of 1541 patients who survived the enrollment hospitalization, 46% died during a later hospitalization. In the last 3 days of life, 55% of patients were conscious. Among these patients, pain, dyspnea, and fatigue were prevalent. Four in 10 patients had severe pain most of the time. Severe fatigue affected almost 8 in 10 patients. More than 1 in 4 patients had moderate dysphoria. Sixty-three percent of patients had difficulty tolerating physical or emotional symptoms. Overall, 11% of patients had a final resuscitation attempt. A ventilator was used in one fourth of patients, and a feeding tube was used in four tenths of patients. Most patients (59%) were reported to prefer a treatment plan that focused on comfort, but care was reported to be contrary to the preferred approach in 10% of cases. CONCLUSIONS: Most elderly and seriously ill patients died in acute care hospitals. Pain and other symptoms were commonplace and troubling to patients. Family members believed that patients preferred comfort, but life-sustaining treatments were often used. These findings indicate important opportunities to improve the care of dying patients.

Aged↗
PubMed1997

Functional status among survivors of in-hospital cardiopulmonary resuscitation. SUPPORT Investigators Study to Understand Progress and Preferences for Outcomes and Risks of Treatment.

OBJECTIVES: To describe functional outcomes of seriously III patients who survived 2 months after in-hospital cardiopulmonary resuscitation (CPR) and to identify patient and clinical characteristics associated with worse functional status after CPR. METHODS: Multicenter prospective observational analysis of 162 seriously ill hospitalized patients who survived 2 months after CPR. Analysis of clinical characteristics associated with worse functional outcome. RESULTS: Among 162 survivors of in-hospital CPR, 56% had the same or improved function and 44% had worse function at 2 months compared with functional status before CPR. Patients with worse function deteriorated by a mean of 3.9 activities of daily living and were less likely to survive to hospital discharge (P < .001) or to 6 months after study entry (P < .001). Worse functional outcome was associated with greater age and longer hospital stay before CPR. CONCLUSIONS: More than half of CPR survivors had preserved functional status 2 months after CPR. However, patients with worse function are profoundly disabled. In anticipation of possible severe disability after CPR, preferences for care in such health states should be discussed with patients before the need for CPR, particularly among older patients and those with long hospital stays.

Age Factors↗
PubMed1997

Pain during hospitalization is associated with continued pain six months later in survivors of serious illness. The SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

PURPOSE: To determine the level of pain reported by survivors of serious illness 2 and 6 months after study enrollment and to identify variables associated with later pain. PATIENTS AND METHODS: Observational cohort study of patients with interviews during hospitalization (5,652) and 2 (3,782) and 6 (2,984) months later admitted between June 1989 and January 1994 with 1 or more of 9 high mortality diagnoses admitted to 5 tertiary care academic centers in the United States. Patients' level of pain during the hospitalization and 2 and 6 months later was determined from interviews with patients and surrogates (most often family members). Separate ordinal logistic regressions were constructed with level of pain at months 2 or 6 as the dependent variable and 22 demographic, psychological, chronic, and acute illness measures at the time of hospitalization as independent variables. RESULTS: Of patients reporting level 4 (moderately severe pain occurring most of the time or extremely severe pain occurring half of the time) or 5 (moderately severe pain occurring most or all of the time or extremely severe pain occurring at least half of the time) pain to 5 during hospital interviews, 39.5% and 39.7% reported level 4 or 5 pain 2 and 6 months later, respectively. Level of hospital pain was the variable most strongly associated with later pain. Compared with patients with level 1 hospital pain, those with level 2 (not at all severe pain or moderate, occasional) had a 2.91 (95% confidence interval [CI] 2.50, 3.37) and 1.75 (CI 1.48, 2.07) times greater adjusted odds of increased levels of pain 2 and 6 months later, respectively. Compared with patients with level 1 hospital pain, those with level 5 pain had a 9.20 (CI 7.27, 11.65) and 4.40 (CI 3.39, 5.71) times greater adjusted odds of increased levels of pain 2 and 6 months later, respectively. Age, number of dependencies in activities of daily living, depression, and type of comorbid illnesses were also independently associated with level of pain both 2 and 6 months later. CONCLUSION: Survivors of the serious and common illnesses that we studied have a high level of pain during hospitalization and up to 6 months after hospitalization. Level of hospital pain was most strongly associated with later pain. Better pain control both during hospitalization and after discharge should be given a high priority. Pain during hospitalization should trigger future inquiries about pain and its treatment.

Adult↗