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In This Issue of Archives of Internal Medicine
October 27, 2003

In This Issue of Archives of Internal Medicine

Arch Intern Med. 2003;163(19):2269. doi:10.1001/archinte.163.19.2269
Ethical Challenges of Partial Do-Not-Resuscitate (DNR) Orders: Placing DNR Orders in the Context of a Life-Threatening Conditions Care Plan

Do-not-resuscitate (DNR) orders are commonly found in treatment plans for patients near the end of life. Orders for partial resuscitation (eg, "do not intubate") have evolved from DNR orders. Although the ethics of DNR orders have been widely examined in the medical literature, little has been written about the ethics of partial resuscitation. This article explores the ethical implications of partial DNR orders and identifies the need to develop care plans addressing life-threatening conditions for patients with DNR orders.

Variations in Product Choices of Frequently Purchased Herbs: Caveat Emptor

Use of herbal medicines by the public has increased by 380% over the past decade, but over half of such use is not disclosed to a medical physician. Because herbs used for medicinal purposes are not regulated by the Food and Drug Administration, labeling of these products is not standardized. The purpose of this study of the top 10 selling herbals was to examine variations in label ingredients and directions for daily use. Results showed that product labels for each herb varied extensively in the quality and quantity of information provided. Within each herb, products showed surprisingly wide variations in plant part ingredients and label-recommended daily dosages. These results suggest that even when a physician knows that specific herbs are being used, patients should be asked to provide further details about ingredients as described on the label and the dosage they are taking.

Effectiveness of Bupropion Sustained Release for Smoking Cessation in a Health Care Setting

For this open-label trial, 1524 adults interested in quitting smoking were randomly assigned to receive 1 of 4 combinations of bupropion sustained release (SR) (150 mg or 300 mg) and behavioral counseling (minimal or moderate intensity) and assessed for point-prevalent smoking status at 3 and 12 months. At 3 months, a significantly higher rate of nonsmoking was observed among those receiving the higher bupropion SR dose. At 12 months, moderate counseling was associated significantly with a higher rate of nonsmoking than was minimal counseling, whereas no significant advantage was observed for the higher bupropion SR dose. In this actual practice setting, the combination of bupropion SR and minimal or moderate counseling was associated with 1-year quit rates of 24% to 33%. This suggests that existing health care systems can substantially decrease tobacco use rates among their enrollees if they provide these modest interventions.

"Successful Aging": Effect of Subclinical Cardiovascular Disease

In a longitudinal cohort study, 2932 men and women 65 years and older were followed up for 8 years to determine the likelihood of "successful aging." Lower starting age and a lower extent of subclinical cardiovascular disease were independently associated with the likelihood of maintaining successful aging. Regression analyses showed that the decline associated with subclinical disease was equivalent to 6.5 years of aging for women (95% confidence interval, 6.36-6.64 years) and 5.6 years of aging for men (95% confidence interval, 5.41-5.79 years). Prevention of subclinical vascular disease may increase the quality as well as the quantity of years in late life.

Effects of Lifestyle on Hemostasis, Fibrinolysis, and Platelet Reactivity: A Systematic Review

There have been abundant studies of the effects of exercise, weight loss, dietary lipids (especially omega-3 polyunsaturated fatty acids), smoking, alcohol, and psychosocial stress on the 3 main systems of thrombogenesis. The data from intervention and randomized clinical trials are largely fragmented, rarely complete, and inconsistent, mainly due to the differences in study design. However, the evidence from these studies suggests that lifestyle changes that adopt strategies to lose weight, stop cigarette smoking, engage in regular moderate exercise and relaxation, and regularly consume light to moderate alcohol and fatty fish would improve the hemostatic profile. The overall effects may translate into improved clinical outcomes in healthy individuals, those with cardiovascular risk factors, or those with established vascular disease. It follows that cardiac rehabilitation programs that incorporate a stepwise increment of physical training or exercise, patient education and advice, dietary and personal habit modifications, and psychosocial stress management would have a significant impact on patients' hemostatic profiles and beneficially influence the overall cardiovascular risk.