- Email: [email protected]
108. Aortic graft infection by Lactobacillus casei
Abstracts/Netherlands
Journal
105. Rogno&c Agniftcance of reduced red cell deformability in severe pplciponrm m&aria A.M. Dondorp, P.A. Kager, NJ. White, J. Vreeken. Department of Internal Medicine, Academic Medical
Center,
Amsterdam,
Netherlands.
Severe falciparum malaria is associated with microvascular obstruction resulting from sequestration of erythrocytes containing mature stages of the parasite. As reduced red cell deformability (RCD) can contribute to impaired microcirculatory flow, RCD was measured in 23 patients witb severe falciparum malaria (7 of whom died subsequently), 30 patients with uncomplicated malaria and 17 healthy controls. RCD, measured by ektacytometry, was significantly reduced in severe malaria and was particularly low in all fatal cases. At a low shear stress of 1.7 Pa, a red cell elongation index below 0.21 on admission to the hospital predicted fatal outcome with a sensitivity of 100% (C.I. .59%-100%) and a specificity of 88% (C.I. 61%-98%). The reduction in red cell deformability appeared to result mainly from changes in unparasitised erythrocytes. Reduced deformability of unparasitised red cells in severe malaria may contribute to impaired microcirculatory flow and a fatal outcome in severe falciparum malaria. It may provide a new target for intervention in this serious disease. 106. Tbe occurrence of Gram-negative bacilli other than Escoli in the bowel flora of patients in a psychogeriatric nursing home. J. van Kemenade, A.R. de Meijer, E.J. Vollaard.
cherichia
Departments sius-Wilhelmina
of Internal Hospital,
Medicine Nijmegen,
Clinical Netherlands.
and
Pharmacy,
Cani-
Gram-negative bacilli (GNB) of the bowel flora are an important source of endogenous infections. In most young healthy volunteers E. coli is the only species of GNB that colonizes the bowel. Colonization by other species of GNB (secondary GNB) will occur however if their colonization resistance is impaired by administration of antimicrobial agents. In this study we compared the bowel flora of 85 patients in a psychogeriatric nursing home and of 19 healthy young volunteers. None of them had used antimicrobial agents in the preceding month. We found no difference in the faecal concentration of yeasts, enterococci or GNB between both groups. In the young volunteers however we observed 8 secondary GNB in 19 samples, in the psychogeriatric patients 138 secondary GNB in 85 samples (P < 0.001). The secondary GNB in the faeces of patients consisted most frequently of Proteus mirabilis (36), Pseudomonas aeruginosa (23) and Klebsiella pneumoniue (20). Conclusion: Secondary GNB occur frequently in the faeces of patients in a psychogeriatric nursing home, even if they do not use antimicrobial agents. 107. Opiate anslgesia modulates the inflammatory, endocrine and metabolic responses to endotoxin in dogs. H.S. Moeniralam ‘, E. Endert i, J.J.B. van Lanschot *, H.P. Sauerwein ‘, J.A. Romijn ‘. Departments of Internal Medicine ’ and Surgery ‘, Academic
Medical
Center,
Amsterdam,
Netherlands.
Opiates are frequently used for analgesia in critically ill patients. Opiate receptors are present in many tissues. To evaluate whether exqenous opiates modulate the response to endotoxin, we measured the inflammatory and metabolic responses to E. coli
of Medicine
50 (1997)
Al -A44
A39
endotoxin (1.0 pg/kg, iv. bolus) in 6 awake dogs on 4 different occasions: (11 control (6 h saline infusion); (2) sufentanil infusion (6 h: 2 ug/kg.h); (3) endotoxin (at t = 2 h); (4) combined endotoxin and sufentanil. Interleukin-6 (IL-61 was measured by B9-bioassay, hormones by radio-immunoassay and glucose production by primed continuous infusion of 6,6-d,-glucose. The Newman-Keuls test was used for statistical analysis. All values are given as mean + SEM. Results: Endotoxin increased body temperature from 38.2, O.l”C to 40.6 f 0.5”C (P < 0.011, heart rate from 75 ri: 9 to 99 + 7 beats per minute (P < 0.05) and mean arterial blood pressure from 103 f 3 to 126&6 mmHg (P < 0.05). Plasma IL-6 levels increased from 0.1 + 0.1 to 26.5 + 3.4 rig/ml (P < O.Ol), insulin from 6 f 1 to 11 + 2 mU/l (P < 0.051, glucagon from 27 It 6 to 160 f 42 (P < 0.051, adrenaline from 0.5 t 0.2 to 1 1 + 0.3 nmol/l and cortisol from 0.06+0.02 pmol/l to 0.71 kO.07 pmol/l (P < 0.05). Glucose production increased from 13.8 f 1.2 to 24.2 + 3.2 pmol/kg.min (P < 0.05). Sufentanil infusion did not affect plasma levels of n-6, whereas all measured hormone levels were increased (P < 0.05 vs control). Glucose production was increased by - 44% compared with controls (P < 0.05). Endotoxin administration during sufentanil infusion did not induce fever nor tachycardia (both P < 0.05 vs endotoxin), but blood pressure increased from 107 & 7 to 125 *4 mmHg (ns vs endotoxin). Compared with endotoxin alone, plasma IL-6 levels increased more (to 45.0 f 4.7 rig/ml, P < 0.051, insulin and catecholamines were higher (P < 0.05). Glucose production did not change (from 16.4f 1.4 to 17.6 + 1.5 umol/kg.min) and was lower compared with endotoxin alone (P < 0.05). Conclusion: Exogenous opiates induce neuro-endocrine and metabolic activation. Opiate analgesia, such as used in critically ill patients, increases the effects of endotoxin on IL-6 production and neuro-endocrine activation, but attenuates the effects of endotoxin on glucose production. 108. Aortic g&t infection by Lactobacillus casei. Y. Schoon, B. Schuurman, S.E. Kranendonk, A. Buiting, S.J. Graafsma. Departments of Internal Medicine, Surgery and Medical Microbiology, Mariaziekenhuis, Tilburg, Netherlands. Introduction: Lactobucillus species are commensal organisms
of the gut, mouth and female genital tract. We present a case of Lactobacillus bacteraemia due to infection of an aortic bypass graft in a patient who had a abdominal aortic prosthesis operation in 1994. Presentation of case: A 68-year-old male presented with fever without other symptoms. Physical examination revealed an ill man with a temperature of 38.7”C and signs of generalized atherosclerosis as evidenced by scars of carotid artery- and abdominal aortic graft surgery. Routine laboratory tests did not reveal any abnormalities. Because of fever, blood culture was performed, which revealed Lactobacillus casei. CRP, measured 5 days after admission, was 36 mg (normal range < 10 mg/l)). Since the patient had fever of unknown origin a white blood cell scintigraphy was performed, using 68 MBq 11 l-In oxinate labelled leucocytes, which revealed a hot spot just above the aortic bifurcation, We postulated that the aortic prosthesis was the primary source of Lactobacillus bacteraemia. Bacteraemia was successfully treated
A40
Abstracts/Netherlands
Journal
by antibiotic therapy. During follow up a relapse occurred and only after surgical replacement of the graft, eradication of L.actobacillus casei was achieved. During surgery a aortoenteric fistula was found. We reviewed literature data on Lactobacillus casei infection. Results: Increasing numbers of cases indicate that Lactobacillus cusei can lead to serious infections, sometimes even with a lethal outcome, and can only be eradicated with great difficulty. Reported cases included: aortic graft infection (n = 2, described among a epidemiologic study), endocarditis (n = 441, fatal lung abscess due to Lactobacillus cusei (n = 4), thoracic empyema (n = 8, though not in isolation) and Lactobacillus septicaemia in gynaecological malignancy (n = 3). Conclusion: Lactobucillus casei bacteraemia in a patient with a former abdominal aortic bypass operation urges the physician to think of an infected abdominal aortic graft, by an aortoenteric tistula. White cell scintigraphy may aid to establish the diagnosis. Treatment should be directed at immediate replacement of the graft. Antibiotic therapy may aid in dissolving bacteraemia temporarily, but is insufficient to eradicate the micro-organism from infected prosthetic material. 109. Erythromycin suppresses the synthesis of cytokines in whole blood stimulated with heat-killed Streptococcus pneumoniue. M.J. Schultz, P. Speelman, S.J.H. van Deventer, T. van der Poll. Unit for Infectious Diseases, Tropical Medicine and AIDS; Laboratory of Experimental Internal Medicine, Academic Medical Center, Amsterdam, Netherlands. Background: Erythromycin (EM) and Penicillin (P) are widely used for the treatment of pneumococcal pneumonia. Cytokines may influence host defence during pneumonia. Aim: To determine the effect of EM and P on cytokine production in whole blood stimulated with heat-killed S. pneumoniae (HKSP). Methods: Heparinized whole blood obtained from 6 healthy donors and diluted 1:l in sterile RPM1 was incubated with HKSP (lo7 cfu/mLl, with or without EM and P (10m3 to 10-j Ml for 16 h at 37°C. Cytokines were measured in supematant plasma by ELISA. Statistics by Wilcoxon test. Results: HKSP induced production of tumor necrosis factor Q (TNF), interleukin (IL-16, IL-lo, IL-12 ~40, IL-12 p70 and interferon-y @N-?/J. P did not influence HKSP-cytokine production. By contrast, EM dose-dependently inhibited the production of all cytokines (P < 0.05). This was not caused by a toxic effect of EM, since EM did not affect cell viability as determined with trypan blue. Further, EM did not inhibit cytokine production primarily via reduction of TNF synthesis, since EM still inhibited cytokine production in the presence of saturating concentrations of a neutralizing anti-TNF monoclonal antibody (P < 0.05). Conclusion: EM inhibits cytokine production induced by HKSP, which may influence the host inflammatory response during pneumococcal pneumonia. 110. Type 2 immune response phenomena in patients infected with HIV. P.E. Spronk, F. Bergkamp, R.W. ten Kate. Kennemer Gasthuis, lot. EG, Haarlem, Netherlands. Replication of human immunodeficiency virus (HIV) occurs in
of Medicine
50 11997) AI-A44
CD4 + T-cells, eventually resulting in depletion of this subset and inherent disturbances in T-cell function. Besides the increased occurrence of opportunistic infections, skewing towards a so-called type-2 immune response seems to evolve (formerly called Thz response. In a cross-sectional study on consecutive HIV+ outpatients, we investigated the occurrence of type-2 immune response phenomena, and measured levels of lgG, IgE, and looked for the presence of antinuclear antibodies (ANA). These data were related to levels of soluble CD30 (sCD30, possibly a marker of type 2 responses), lymphocyte subsets as determined by FACS analysis and clinical variables. Fifty HIV + patients (5 women, 45 men) were included. Their mean age was 45. The mean number of CD4f T-cells was 0.219X 109/1. Eosinophilia was observed in 20/50 patients and associated with increased levels of IgE (P < 00.1). Increased IgE levels were found in 15/50 patients, These levels correlated with levels of sCD30 (r = 0.65; P < 0.02). Increased IgG was present in 24/50 patients, the presence of ANA in 15/50 patients (speckled pattern, low titres). No correlation could be found between levels of sCD30 and the number of CD30 + subsets, nor with the occurrence of allergic reactions or polyarthritis. In conclusion, type-2 immune response phenomena like eosinophilia, increased levels of IgE and IgG, and the presence of ANA occur frequently in patients with AIDS. Soluble CD30 may be a useful marker in this respect. Although no relation was found with CD30 expression on circulating CD4 + /CD8 + T-cells, circulating levels of sCD30 may reflect actual type-2 immune reactions in the lymphoid system.
IX. Miscellaneous 111. Attitude of elderly in-patients towards discussing cardiopulmonary resuscitation. J. Schuur, D.M. van Dijk, A.A. Capel, B.J. Potter van Loon. Department of General Medicine, St. Lucas Andreas Hospital, Amsterdam, Netherlands. Aim: Since the introduction of the WGBO, doctors are obliged to obtain patient’s informed consent to their treatment, including whether or not to be resuscitated. The purpose of this study was to assess elderly patient’s attitude towards discussing the issue of resuscitation. Methods: In a 4-month period 118 patients aged 65 years and over were interviewed by means of a 12-item questionnaire. Reasons for exclusion were: cognitive impairment, hearing loss, dysphasia and poor physical condition, prohibiting a clear conversation. Results: 77/l 18 patients (65%) felt it was easy to discuss the subject, 35 (30%) found it difficult but important enough to continue the interview whereas only 6 (5%) felt it was too hard to discuss the subject. 73/112 (65%) thought that this subject should always be discussed during admission, though 34 (30%) felt it should only be raised in certain situations related to the patients condition; 5 (4%) felt it should not be discussed with the patient at all. Fifty-five of 112 patients (49%) felt that the patient should make the final decision on CPR policy where 34 (30%) felt this
Journal
105. Rogno&c Agniftcance of reduced red cell deformability in severe pplciponrm m&aria A.M. Dondorp, P.A. Kager, NJ. White, J. Vreeken. Department of Internal Medicine, Academic Medical
Center,
Amsterdam,
Netherlands.
Severe falciparum malaria is associated with microvascular obstruction resulting from sequestration of erythrocytes containing mature stages of the parasite. As reduced red cell deformability (RCD) can contribute to impaired microcirculatory flow, RCD was measured in 23 patients witb severe falciparum malaria (7 of whom died subsequently), 30 patients with uncomplicated malaria and 17 healthy controls. RCD, measured by ektacytometry, was significantly reduced in severe malaria and was particularly low in all fatal cases. At a low shear stress of 1.7 Pa, a red cell elongation index below 0.21 on admission to the hospital predicted fatal outcome with a sensitivity of 100% (C.I. .59%-100%) and a specificity of 88% (C.I. 61%-98%). The reduction in red cell deformability appeared to result mainly from changes in unparasitised erythrocytes. Reduced deformability of unparasitised red cells in severe malaria may contribute to impaired microcirculatory flow and a fatal outcome in severe falciparum malaria. It may provide a new target for intervention in this serious disease. 106. Tbe occurrence of Gram-negative bacilli other than Escoli in the bowel flora of patients in a psychogeriatric nursing home. J. van Kemenade, A.R. de Meijer, E.J. Vollaard.
cherichia
Departments sius-Wilhelmina
of Internal Hospital,
Medicine Nijmegen,
Clinical Netherlands.
and
Pharmacy,
Cani-
Gram-negative bacilli (GNB) of the bowel flora are an important source of endogenous infections. In most young healthy volunteers E. coli is the only species of GNB that colonizes the bowel. Colonization by other species of GNB (secondary GNB) will occur however if their colonization resistance is impaired by administration of antimicrobial agents. In this study we compared the bowel flora of 85 patients in a psychogeriatric nursing home and of 19 healthy young volunteers. None of them had used antimicrobial agents in the preceding month. We found no difference in the faecal concentration of yeasts, enterococci or GNB between both groups. In the young volunteers however we observed 8 secondary GNB in 19 samples, in the psychogeriatric patients 138 secondary GNB in 85 samples (P < 0.001). The secondary GNB in the faeces of patients consisted most frequently of Proteus mirabilis (36), Pseudomonas aeruginosa (23) and Klebsiella pneumoniue (20). Conclusion: Secondary GNB occur frequently in the faeces of patients in a psychogeriatric nursing home, even if they do not use antimicrobial agents. 107. Opiate anslgesia modulates the inflammatory, endocrine and metabolic responses to endotoxin in dogs. H.S. Moeniralam ‘, E. Endert i, J.J.B. van Lanschot *, H.P. Sauerwein ‘, J.A. Romijn ‘. Departments of Internal Medicine ’ and Surgery ‘, Academic
Medical
Center,
Amsterdam,
Netherlands.
Opiates are frequently used for analgesia in critically ill patients. Opiate receptors are present in many tissues. To evaluate whether exqenous opiates modulate the response to endotoxin, we measured the inflammatory and metabolic responses to E. coli
of Medicine
50 (1997)
Al -A44
A39
endotoxin (1.0 pg/kg, iv. bolus) in 6 awake dogs on 4 different occasions: (11 control (6 h saline infusion); (2) sufentanil infusion (6 h: 2 ug/kg.h); (3) endotoxin (at t = 2 h); (4) combined endotoxin and sufentanil. Interleukin-6 (IL-61 was measured by B9-bioassay, hormones by radio-immunoassay and glucose production by primed continuous infusion of 6,6-d,-glucose. The Newman-Keuls test was used for statistical analysis. All values are given as mean + SEM. Results: Endotoxin increased body temperature from 38.2, O.l”C to 40.6 f 0.5”C (P < 0.011, heart rate from 75 ri: 9 to 99 + 7 beats per minute (P < 0.05) and mean arterial blood pressure from 103 f 3 to 126&6 mmHg (P < 0.05). Plasma IL-6 levels increased from 0.1 + 0.1 to 26.5 + 3.4 rig/ml (P < O.Ol), insulin from 6 f 1 to 11 + 2 mU/l (P < 0.051, glucagon from 27 It 6 to 160 f 42 (P < 0.051, adrenaline from 0.5 t 0.2 to 1 1 + 0.3 nmol/l and cortisol from 0.06+0.02 pmol/l to 0.71 kO.07 pmol/l (P < 0.05). Glucose production increased from 13.8 f 1.2 to 24.2 + 3.2 pmol/kg.min (P < 0.05). Sufentanil infusion did not affect plasma levels of n-6, whereas all measured hormone levels were increased (P < 0.05 vs control). Glucose production was increased by - 44% compared with controls (P < 0.05). Endotoxin administration during sufentanil infusion did not induce fever nor tachycardia (both P < 0.05 vs endotoxin), but blood pressure increased from 107 & 7 to 125 *4 mmHg (ns vs endotoxin). Compared with endotoxin alone, plasma IL-6 levels increased more (to 45.0 f 4.7 rig/ml, P < 0.051, insulin and catecholamines were higher (P < 0.05). Glucose production did not change (from 16.4f 1.4 to 17.6 + 1.5 umol/kg.min) and was lower compared with endotoxin alone (P < 0.05). Conclusion: Exogenous opiates induce neuro-endocrine and metabolic activation. Opiate analgesia, such as used in critically ill patients, increases the effects of endotoxin on IL-6 production and neuro-endocrine activation, but attenuates the effects of endotoxin on glucose production. 108. Aortic g&t infection by Lactobacillus casei. Y. Schoon, B. Schuurman, S.E. Kranendonk, A. Buiting, S.J. Graafsma. Departments of Internal Medicine, Surgery and Medical Microbiology, Mariaziekenhuis, Tilburg, Netherlands. Introduction: Lactobucillus species are commensal organisms
of the gut, mouth and female genital tract. We present a case of Lactobacillus bacteraemia due to infection of an aortic bypass graft in a patient who had a abdominal aortic prosthesis operation in 1994. Presentation of case: A 68-year-old male presented with fever without other symptoms. Physical examination revealed an ill man with a temperature of 38.7”C and signs of generalized atherosclerosis as evidenced by scars of carotid artery- and abdominal aortic graft surgery. Routine laboratory tests did not reveal any abnormalities. Because of fever, blood culture was performed, which revealed Lactobacillus casei. CRP, measured 5 days after admission, was 36 mg (normal range < 10 mg/l)). Since the patient had fever of unknown origin a white blood cell scintigraphy was performed, using 68 MBq 11 l-In oxinate labelled leucocytes, which revealed a hot spot just above the aortic bifurcation, We postulated that the aortic prosthesis was the primary source of Lactobacillus bacteraemia. Bacteraemia was successfully treated
A40
Abstracts/Netherlands
Journal
by antibiotic therapy. During follow up a relapse occurred and only after surgical replacement of the graft, eradication of L.actobacillus casei was achieved. During surgery a aortoenteric fistula was found. We reviewed literature data on Lactobacillus casei infection. Results: Increasing numbers of cases indicate that Lactobacillus cusei can lead to serious infections, sometimes even with a lethal outcome, and can only be eradicated with great difficulty. Reported cases included: aortic graft infection (n = 2, described among a epidemiologic study), endocarditis (n = 441, fatal lung abscess due to Lactobacillus cusei (n = 4), thoracic empyema (n = 8, though not in isolation) and Lactobacillus septicaemia in gynaecological malignancy (n = 3). Conclusion: Lactobucillus casei bacteraemia in a patient with a former abdominal aortic bypass operation urges the physician to think of an infected abdominal aortic graft, by an aortoenteric tistula. White cell scintigraphy may aid to establish the diagnosis. Treatment should be directed at immediate replacement of the graft. Antibiotic therapy may aid in dissolving bacteraemia temporarily, but is insufficient to eradicate the micro-organism from infected prosthetic material. 109. Erythromycin suppresses the synthesis of cytokines in whole blood stimulated with heat-killed Streptococcus pneumoniue. M.J. Schultz, P. Speelman, S.J.H. van Deventer, T. van der Poll. Unit for Infectious Diseases, Tropical Medicine and AIDS; Laboratory of Experimental Internal Medicine, Academic Medical Center, Amsterdam, Netherlands. Background: Erythromycin (EM) and Penicillin (P) are widely used for the treatment of pneumococcal pneumonia. Cytokines may influence host defence during pneumonia. Aim: To determine the effect of EM and P on cytokine production in whole blood stimulated with heat-killed S. pneumoniae (HKSP). Methods: Heparinized whole blood obtained from 6 healthy donors and diluted 1:l in sterile RPM1 was incubated with HKSP (lo7 cfu/mLl, with or without EM and P (10m3 to 10-j Ml for 16 h at 37°C. Cytokines were measured in supematant plasma by ELISA. Statistics by Wilcoxon test. Results: HKSP induced production of tumor necrosis factor Q (TNF), interleukin (IL-16, IL-lo, IL-12 ~40, IL-12 p70 and interferon-y @N-?/J. P did not influence HKSP-cytokine production. By contrast, EM dose-dependently inhibited the production of all cytokines (P < 0.05). This was not caused by a toxic effect of EM, since EM did not affect cell viability as determined with trypan blue. Further, EM did not inhibit cytokine production primarily via reduction of TNF synthesis, since EM still inhibited cytokine production in the presence of saturating concentrations of a neutralizing anti-TNF monoclonal antibody (P < 0.05). Conclusion: EM inhibits cytokine production induced by HKSP, which may influence the host inflammatory response during pneumococcal pneumonia. 110. Type 2 immune response phenomena in patients infected with HIV. P.E. Spronk, F. Bergkamp, R.W. ten Kate. Kennemer Gasthuis, lot. EG, Haarlem, Netherlands. Replication of human immunodeficiency virus (HIV) occurs in
of Medicine
50 11997) AI-A44
CD4 + T-cells, eventually resulting in depletion of this subset and inherent disturbances in T-cell function. Besides the increased occurrence of opportunistic infections, skewing towards a so-called type-2 immune response seems to evolve (formerly called Thz response. In a cross-sectional study on consecutive HIV+ outpatients, we investigated the occurrence of type-2 immune response phenomena, and measured levels of lgG, IgE, and looked for the presence of antinuclear antibodies (ANA). These data were related to levels of soluble CD30 (sCD30, possibly a marker of type 2 responses), lymphocyte subsets as determined by FACS analysis and clinical variables. Fifty HIV + patients (5 women, 45 men) were included. Their mean age was 45. The mean number of CD4f T-cells was 0.219X 109/1. Eosinophilia was observed in 20/50 patients and associated with increased levels of IgE (P < 00.1). Increased IgE levels were found in 15/50 patients, These levels correlated with levels of sCD30 (r = 0.65; P < 0.02). Increased IgG was present in 24/50 patients, the presence of ANA in 15/50 patients (speckled pattern, low titres). No correlation could be found between levels of sCD30 and the number of CD30 + subsets, nor with the occurrence of allergic reactions or polyarthritis. In conclusion, type-2 immune response phenomena like eosinophilia, increased levels of IgE and IgG, and the presence of ANA occur frequently in patients with AIDS. Soluble CD30 may be a useful marker in this respect. Although no relation was found with CD30 expression on circulating CD4 + /CD8 + T-cells, circulating levels of sCD30 may reflect actual type-2 immune reactions in the lymphoid system.
IX. Miscellaneous 111. Attitude of elderly in-patients towards discussing cardiopulmonary resuscitation. J. Schuur, D.M. van Dijk, A.A. Capel, B.J. Potter van Loon. Department of General Medicine, St. Lucas Andreas Hospital, Amsterdam, Netherlands. Aim: Since the introduction of the WGBO, doctors are obliged to obtain patient’s informed consent to their treatment, including whether or not to be resuscitated. The purpose of this study was to assess elderly patient’s attitude towards discussing the issue of resuscitation. Methods: In a 4-month period 118 patients aged 65 years and over were interviewed by means of a 12-item questionnaire. Reasons for exclusion were: cognitive impairment, hearing loss, dysphasia and poor physical condition, prohibiting a clear conversation. Results: 77/l 18 patients (65%) felt it was easy to discuss the subject, 35 (30%) found it difficult but important enough to continue the interview whereas only 6 (5%) felt it was too hard to discuss the subject. 73/112 (65%) thought that this subject should always be discussed during admission, though 34 (30%) felt it should only be raised in certain situations related to the patients condition; 5 (4%) felt it should not be discussed with the patient at all. Fifty-five of 112 patients (49%) felt that the patient should make the final decision on CPR policy where 34 (30%) felt this