No abstract

One hundred fifty-eight patients receiving Adriamycin underwent 226 transjugular biopsy procedures. The specimens were evaluated by electron microscopy for evidence of drug-related cardiotoxicity. Ejection fraction determinations using echocardiographic or nuclear techniques at rest were available for 69% and 81% of the patients, respectively. Analysis of the data revealed a correlation between cumulative Adriamycin dose and biopsy grade (p less than 0.02). No similar relationship existed between cumulative Adriamycin dose and ejection fractions obtained at rest or between biopsy grades and ejection fractions. In patients who underwent serial endomyocardial biopsies and serial ejection fraction determinations, the correlation between changes in biopsy grade and ejection fraction was poor. A change in resting ejection fraction detected by either method did not reliably predict a change in biopsy grade. The poor correlation between ejection fractions and biopsy grades could be due in part to the sensitivity and specificity of the Adriamycin-related structural changes in contrast to the wider range of disease processes that can affect myocardial function, and to the fact that structural changes often precede the ejection fraction abnormalities. The greater sensitivity and specificity of the biopsy grade should prove useful in reducing the risks associated with evaluating new anthracyclines and potential myocardial protectors of Adriamycin toxicity.

Technical variant techniques expand the pediatric donor pool and reduce time from listing to transplant, but they are associated with increased morbidity and mortality.

Diffuse alveolar hemorrhage (DAH) is a poorly understood complication of transplantation carrying a high mortality. Patients commonly deteriorate and require intensive care unit (ICU) admission. Treatment with high-dose steroids and aminocaproic acid (ACA) has been suggested. The current study examined 119 critically ill adult hematopoietic transplant patients treated for DAH. Patients were subdivided into low-, medium-and high-dose steroid groups with or without ACA. All groups had similar baseline characteristics and severity of illness scores. Primary objectives were 30, 60, 100 day, ICU and hospital mortality. Overall mortality (n = 119) on day 100 was high at 85%. In the steroids and ACA cohort (n = 82), there were no significant differences in 30, 60, 100, day, ICU and hospital mortality between the dosing groups. In the steroids only cohort (n = 37), the low-dose steroid group had a lower ICU and hospital mortality (P = 0.02). Adjunctive treatment with ACA did not produce differences in outcomes. In the multivariate analysis, medium-and high-dose steroids were associated with a higher ICU mortality (P = 0.01) as compared with the low-dose group. Our data suggest that treatment strategies may need to be reanalyzed to avoid potentially unnecessary and potentially harmful therapies.

Intensive care unit (ICU) resources are frequently utilized in the supportive care of hospitalized patients with cancer. Patients with cancer reportedly have poor outcomes from cardiopulmonary resuscitation (CPR). The goal of this study was to evaluate the effectiveness and patient care costs of CPR applied to patients already receiving life support in an ICU. The medical records of patients who developed cardiac arrest and underwent CPR in the ICU of a comprehensive cancer center between 1993 and 2000 were reviewed. ICU charges after the first episode of CPR were analyzed. There were 5,196 admissions to the ICU during this time; 406 (8%) of the patients underwent CPR; 67% had hematologic malignancies or had undergone hematopoietic stem cell transplantation: 256 patients (63%) died at the time of the arrest, and in 150 (37%) spontaneous circulation was restored. There were 104 patients (26%) who survived more than 24 hours but ultimately died during their hospitalization; their mean time to death was 4.3 days (95% confidence interval [CI] 2.9-5.6), and mean ICU charges were $45,877 (95% CI $24,802-$66,952). Seven patients (2%) survived to be discharged. Patients who survived after CPR and were discharged from the hospital were those who had acute ventricular dysrhythmias and were resuscitated promptly. The application of CPR to cancer patients receiving life support is costly and typically does not lead to long-term survival. Cancer patients requiring admission to an ICU should receive full supportive care short of resuscitation. Providing assurances that care will remain appropriate, aggressive, and in accordance with the patient's and family's wishes can optimize compassionate care while avoiding futile life-sustaining interventions.

No abstract

After controlling for type of malignancy, reason for admission to the ICU, severity of illness, and age, the decision to initiate life-supporting interventions did not differ significantly among patients with and without advance directives. The presence of an advance directive, however, may have helped guide decisions earlier regarding duration of therapy and resuscitation status.

This study provides a longitudinal view of ICU utilization rates, hospital and ICU length of stay, and severity-adjusted mortality rates. Although the data arise from a single institution, it encompasses a large number of hospital admissions over two decades and can serve as a point of comparison for future oncological studies at similar institutions. More studies of this nature are needed to determine whether consolidation of cancer care into specialized large-volume facilities may improve outcomes, while simultaneously sustaining appropriate resource utilization and reducing unnecessary healthcare costs.