OBJECTIVES: To determine the frequency of do-not-resuscitate (DNR) orders in the chronically critically ill; to identify the differences in clinical and demographic characteristics of chronically critically ill patients who have DNR orders and those who do not; to identify the differences in the cost of care between patients with and without DNR orders; and to identify the differences in DNR practices between an experimental special care unit and the traditional intensive care unit (ICU). DESIGN: Randomized, prospective design with a block randomization scheme. SUBJECTS: Two hundred twenty patients who met the following eligibility criteria for enrollment in a parent study of the special care unit: an ICU stay of at least 5 days, an absence of pulmonary artery monitoring, an absence of frequent titration of intravenous vasopressors, an Acute Physiology and Chronic Health Evaluation II score of less than 18, and a Therapeutic Intervention Scoring System score of less than 39. SETTING: A large, urban academic medical center. MEASURES: Clinical and demographic variables describing the study populations, mental status, and timing of DNR orders, mortality rates, and cost of hospitalization. RESULTS: There was no difference in the frequency of DNR orders between the special care unit versus the intensive care unit--although patients in the special care unit had a longer interval between hospital admission and initiation of the DNR order. DNR patients differed from non-DNR in that they were older, less likely to be married, and had a higher Acute Physiology and Chronic Health Evaluation II score on admission to the study. The mortality rate in the DNR group was 71% versus 6% in the non-DNR group. There was no difference in total costs. DNR patients were also more likely to have an impaired mental status on admission, and more likely to have deterioration in mental status by the time of discharge than the non-DNR patients.

Aged↗

PubMedDate not supplied

Electrophilic substitution of (diamine)tetrahydroxoplatinum(IV) with carboxylic anhydrides. Synthesis and characterization of (diamine)platinum(IV) complexes of mixed carboxylates.

A novel series of (diamine)platinum(IV) complexes of mixed carboxylates have been synthesized by electrophilic substitution of the tetrahydroxoplatinum(IV) complex (dach)Pt(OH)4 (dach = trans-(+/-)-1,2-diaminocyclohexane) with three different carboxylic anhydrides, pivalic, acetic, and trifluoroacetic anhydrides. Consecutive two-step acylations with two different carboxylic anhydrides in acetone or dichloromethane gave the mixed carboxylate complexes (dach)Pt(O2CR)x(O2CR')4 - x (R = C(CH3)3 or CF3, R' = CH3, x = 1-4) including all the possible stereoisomers, which could be separated and identified by means of HPLC, column chromatography, 1H NMR, and X-ray crystallography. From analysis of the reaction products we have found that the positions of electrophilic substitution of (dach)Pt(OH)4 were influenced by the kinds of carboxylic anhydrides exhibiting different electrophilicity or steric effects. The initial substitution by the first reactant occurs more favorably on axial OH, but in the case of pivalic anhydride, equatorial substitution is favored probably because of the bulkiness of the pivalate group. Such a result seems to be related to their stereochemical factors rather than to differences in electrophilicity. The lipophilicity of the title complexes was affected not only by the carbon numbers of substituents but also by the conformation of the resulting compound.

Journal Article↗

PubMedDate not supplied

Effects of a 12-week cardiac rehabilitation exercise program on motivation and health-promoting lifestyle.

OBJECTIVE: The purpose of this study was to determine the effects of a 12-week cardiac rehabilitation exercise program on the motivation and lifestyle of persons recovering from a recent heart attack or cardiac-related procedures. DESIGN: The study design was a pretest and posttest quasi-experimental, nonrandom assignment. SETTING: The study was conducted at 4 cardiac rehabilitation centers in Northeast Ohio. SUBJECTS: The study included 57 participants in a cardiac rehabilitation exercise program (mean age = 64 years) and 57 comparisons (mean age = 64.6 years) who recently had a heart attack or underwent cardiac-related procedures. OUTCOME MEASURE: Motivation and health-promoting lifestyle were measured. INTERVENTION: A 12-week cardiac rehabilitation exercise program for small groups of participants (fewer than 12 persons) was conducted. The program provided arm and leg exercises 3 times a week for 30 to 60 minutes per session at an intensity of 60% to 90% of the maximum heart rate. RESULTS: Analysis of covariance was used to analyze the data. After controlling for education, income, and pretest scores, the exercise group scored significantly higher than the comparison group in most motivation-related variables. Regarding lifestyle, after adjusting for the control variables both groups showed positive changes during the 12-week period, but no significant difference was found between the 2 groups in overall lifestyle. CONCLUSION: The findings of the study confirmed that motivational variables were modifiable. Thus, when developing health promotion programs for initiating and maintaining a healthy lifestyle, the relative importance of different motivational variables should be considered.

Adult↗

PubMedDate not supplied

Survival experience of chronically critically ill patients.

Intensive care unit (ICU) patients were randomly assigned to either a traditional ICU or a special care unit (SCU) for chronically critically ill patients. The SCU used a low-technology, family-oriented environment, nursing case management, no physician house staff, and a shared governance model. In comparison, the ICU used high technology, limited family visiting, primary care nursing, and a bureaucratic management model. The survival experience of chronically critically ill patients in the two environments during hospitalization, as well as after hospital discharge, was examined. Using survival analytic techniques, the 1-year cumulative mortality for all patients in the study was found to be 59.9%. Risk of death was significantly lower after discharge than during hospitalization. Similar mortality experiences were found for SCU and ICU patients. Thus, the high-technology ICU environment did not produce better outcomes than the SCU environment.

Aged↗

PubMedDate not supplied

Patient outcomes for the chronically critically ill: special care unit versus intensive care unit.

The purpose of this study was to compare the effects of a low-technology environment of care and a nurse case management case delivery system (special care unit, SCU) with the traditional high-technology environment (ICU) and primary nursing care delivery system on the patient outcomes of length of stay, mortality, readmission, complications, satisfaction, and cost. A sample of 220 chronically critically ill patients were randomly assigned to either the SCU (n = 145) or the ICU (n = 75). Few significant differences were found between the two groups in length of stay, mortality, or complications. However, the findings showed significant cost savings in the SCU group in the charges accrued during the study period and in the charges and costs to produce a survivor. The average total cost of delivering care was $5,000 less per patient in the SCU than in the traditional ICU. In addition, the cost to produce a survivor was $19,000 less in the SCU. Results from this 4-year clinical trial demonstrate that nurse case managers in a SCU setting can produce patient outcomes equal to or better than those in the traditional ICU care environment for long-term critically ill patients.

Adolescent↗

PubMedDate not supplied

Overexpression of P-glycoprotein but not its mRNA in multidrug resistant cells selected with hydroxyrubicin.

Previous studies have revealed that cultured cells treated with lipophilic natural products containing aromatic rings and basic amino group usually yielded multidrug resistant (MDR) variants. These MDR cells overexpress P-glycoprotein (P-gp), most often due to gene amplification or transcriptional activation of mdr/P-gp genes. Doxorubicin (Dox) is an anthracycline that belongs to this group of compounds. To explore the possible resistance mechanism(s) to anthracyclines that do not involve P-gp, we use a Dox analog, hydroxyrubicin (HyR) or WP159, which contains a C3' hydroxy group in replacement of the amino group in the sugar moiety of Dox thereby reducing basicity and eliminating positive charge in the parental compound to establish HyR-resistant cell lines. These resistant cells displayed the MDR phenotype and overexpressed P-gp as analyzed by Western blot analyses and immunohistochemical staining using two different anti-P-gp antibodies. Strikingly, the levels of P-gp mRNA in the majority of these MDR cells remained comparable to those in the drug-sensitive counterparts by slot blot hybridization. These results implicate that the basic center of the selecting agent is a critical determinant for generating diverse MDR variants, and that HyR may have a posttranscriptional effect on P-gp biosynthesis. This is the first report suggesting that cultured cells exposed to a particular selecting agent may give rise to particular subtype of MDR variants.

ATP Binding Cassette Transporter, Subfamily B, Mem↗