BackgroundFormal writing of do not resuscitate (DNR) orders first appeared in the literature in the late 20th century. Recently, providers have also noticed the presence of partial DNR orders while caring for patients. We sought to determine the effect of these orders on the clinical outcomes of the patients.MethodsThe study was a retrospective chart review covering a period of approximately 30 months. Patients included in the study were over 18 years of age and had a partial DNR order (i.e., chemical code, do not defibrillate (DND), do not intubate (DNI), intubate only, no cardiopulmonary resuscitation (CPR)) entered during hospitalization. Primary medical problems were categorized by organ system and the outcome was stated in terms of their disposition and mortality.ResultsA total of 71,143 code orders were entered during the study period, with partial DNR orders accounting for 1.8% of these orders (chemical code 2%, DND 0.8%, DNI 48%, intubate only 38%, and no CPR 10%). About 38% of all patients were discharged to home, 32% were discharged to a facility, and 11% were discharged on hospice. More than half of the patients did not have a palliative care consult. Of all the patients having partial code orders, about 150 patients had a rapid response team called on them and five patients had a cardiac arrest with a code blue activated on them. The mortality of these patients was significantly higher than other patients possibly due to confusing code orders. Surprisingly, a higher percentage of patients (19%) with a mean age significantly lower (p < 0.001) than discharged patients had inpatient mortality. ConclusionOur study demonstrates the first reported prevalence of partial DNR orders in the general inpatient population and its possible detrimental effects on the patient clinical course. This study offers several opportunities for quality improvement, such as developing prompts for the healthcare team to involve palliative care services more often for such patients.

Free perforation is one of the most feared complications of the intestinal tuberculosis. The terminal ileum is the most common site of perforation, while the majority of (90%) perforations are solitary. Herein, we describe a case of a 25-year-old male who presented with generalized peritonitis requiring an emergency exploratory laparotomy, which revealed pan-enteric perforation characterized by multiple perforations of the small bowel extending 10–15 cm from the DJ flexure up to the terminal ileum. The perforations were primarily closed, while 6–8 cm of the diseased terminal ileum was resected and the two ends were brought out as double-barreled ostomy. To the best of our knowledge, such an extensive tuberculous perforation of the small bowel has not been previously reported in the literature before.

We hereby present the case of a 25-year-old man who presented at the emergency department of Civil Hospital Karachi, Pakistan with signs and symptoms of acute viral hepatitis. Serology tests revealed that the patient was suffering from hepatitis E viral (HEV) infection. Concurrently, the patient was also found to have thrombocytopaenia (TCP). His TCP became better after the resolution of his jaundice, with the patient requiring a transfusion of one mega unit of platelets. After ruling out other common causes of TCP and after a thorough literature search, we concluded that an immune-mediated mechanism secondary to HEV infection might have been the cause behind his low platelet counts. Hence, we propose considering the possibility of HEV infection in patients presenting with acute liver failure and TCP, irrespective of age, gender, and geographical location of the patient.