Prognostic/epidemiologic study, level III.

No abstract

The dose-dependent effects of daily estrogen (estradiol, ethinyl estradiol, diethylstilbestrol) administration on the activities of three hepatic androgen-dependent microsomal enzymes (3 alpha- and 3 beta-hydroxysteroid dehydrogenase and 5 alpha-reductase) in male rats were examined. Antiestrogens were then tested for their ability to block the feminizing action of 10 micrograms estradiol/day on these enzyme activities; nafoxidine and monohydroxytamoxifen were the most effective. The prevention of 5 alpha-dihydrotestosterone-induced changes in these activities in ovariectomized females was investigated. All three estrogens at a dose of 1 microgram blocked the action of 500 micrograms androgen. A similar androgenic blockade was achieved by daily administration of 5 mg flutamide or constant infusion of human GH (5 micrograms/h). Simultaneous administration of 200 micrograms monohydroxytamoxifen prevented the androgen-antagonizing action of estrogens, but not of flutamide nor of GH. Large doses of estrogens have the same repressive effect as androgens on 5 alpha-reductase activity in female castrates. Using the diethylstilbestrol-treated rat as a model, it is demonstrated that this effect can be prevented by antiestrogen, but not by GH. It is concluded that androgens and low doses of estrogens affect these enzyme activities by acting at different levels of central regulation, whereas large doses of estrogens act directly on the liver via hepatic estrogen receptors. These conclusions are corroborated by studies of hepatic estrogen receptor concentrations.

Prognostic/epidemiological, level III.

American Society of Anesthesiologists guidelines recommend that anesthesiologists revisit do-not-resuscitate orders preoperatively and revise them if necessary based on patient preferences. In patients without do-not-resuscitate orders or other directives limiting treatment however, “full code” is the default option irrespective of clinical circumstances and patient preferences. It is time to revisit this approach based on (1) increasing understanding of the power of default options in healthcare settings, (2) changing demographics and growing evidence suggesting that an expanding subset of patients is vulnerable to poor outcomes after perioperative cardiopulmonary resuscitation (CPR), and (3) recommendations from multiple societies promoting risk assessment and goal-concordant care in older surgical patients. The authors reconsider current guidelines in the context of these developments and advocate for an expanded approach to decision-making regarding CPR, which involves identifying high-risk elderly patients and eliciting their preferences regarding CPR irrespective of existing or presumed code status.

The long-term risk of infectious complications in patients with BSI who have NOM with SAE is similar to that in patients who are treated with OM, indicating the need for pro-active strategies to reduce long-term infectious complications after SAE.

Background Trauma surgeons face a challenge when deciding whether to resuscitate lethally injured patients whose organ donor status is unknown. Data suggests practice pattern variability in this setting, but little is known about why. Materials and Methods We conducted semi-structured interviews with trauma surgeons practicing in Level 1 or 2 trauma centers in Tennessee. Interviews focused on ethical dilemmas and resource constraints. Analysis was performed using inductive thematic analysis. Results Response rate was 73% (11/15). Four key themes emerged. All described resuscitating patients to buy time to collect more definitive clinical information and to identify family. Some acknowledged this served the secondary purpose of organ preservation. 11/11 participants felt a primacy of obligation to the patient in front of them even after it became apparent, they could not personally benefit. For 9/11 (82%), the moral obligation to consider organ preservation was secondary/balancing; 2/11 (18%) felt it was irrelevant/immoral. Resource allocation was commonly considered. All participants expressed some limitation to resources they would allocate. All participants conveyed clear moral agency in determining resuscitation extent when the goal was to save the patient’s life, however this was less clear when resuscitating for organ preservation. Across themes, perceptions of a “standard practice” existed but the described practices were not consistent across interviewees. Discussion Widely ranging perceptions regarding ethical and resource considerations underlie practices resuscitating toward organ preservation. Common themes suggest a lack of consensus. Despite expressed beliefs, there is no identifiable standard of practice amongst trauma surgeons resuscitating in this setting.

No abstract