the subject. It is obvious that the risk that patients with disseminated disease might receive local over-treatment will increase. The need for scientific documentation of benefit is and will remain absolute. Surgeons, as well as oncologists,2 need to counteract unrealistic expectations and "the desire to market an institution's wares." What we need from Catalona and many others are the scientific data that justify the use of a surgical procedure with significant side effects but no prov¬ en benefit. Jan-Erik Johansson, MD, PhD Swen-Olof Andersson, MD \l=O"\rebroMedical Center Hospital Hans-Olov Adami, MD, PhD Lars Holmberg, MD
1. Adami H-O, Norl\l=e'\nBJ, Meirik 0. Long-term survival in prostatic carcinoma, with special reference to age as a prognostic factor. Scand J Urol Nephrol. 1986;20:107\x=req-\
CO. Ovarian cancer\p=m-\unrealisticexpectations. N
Engl J Med. 1992;327:
The Medical Library as a Patient Aid To the Editor.\p=m-\Beingon the other side of the library door and in a busy office and hospital practice faced with anxious, ill, and well patients, I must add a note of caution to the concluding sentence of Ms Lindner's1 article in JAMA, which states, "Patients will be more satisfied with their care as they become more knowledgeable and participate in the decision\x=req-\
making process." This is certainly a popular philosophy as we veer away from the "paternalistic" role model of physician-assisted health
I believe that this sentence should have the word "some" in front of it. Many patients are not physically, intellectually, psychologically, or emotionally equipped to deal with a trip to the library. Such a trip may create a whole new subset of problems for the patient and those attempting to provide good health care. If this sort of activity is to be done and encouraged, it should also imply a responsibility on the part of the information providers to deal with the consequences— favorable or otherwise. care.
Jack
Fabian, MD Pensacola, Fla
1. Lindner K.
Encourage information therapy. JAMA. 1992;267:2592.
To the Editor.\p=m-\MsLindner's1 overall philosophy about proconsumer medical information is commendable; patients have the right to information. She does not, however, address the problem of financing such services in libraries that do not have grants such as the grant provided by the state of New Jersey. She also minimizes the issue of responsibility for the information or misinformation provided. The economic reality is that many hospital libraries find it difficult to serve their present constituency and are not in a position to add new services. Many libraries are one- or two-person departments and lack the resources to provide consumer health information. Health care personnel need certain levels of assistance and materials while consumers need different materials and often labor-intensive services. Furthermore, Lindner neglects to address the future of the Regional Consumer Health Information Center, if funding by the state of New Jersey ceases. Until hospital accreditation organizations mandate such services and funding is made available to libraries, providing health care information to the consumer is a nonissue. Institu¬ tional and library policies define access privileges and proce¬ dures. Responsibility for information supplied and services rendered is defined and shared accordingly. Libraries are not
viding
Ellen Rothbaum, MS Debra Eisenberg, MSLS North Shore University Hospital Cornell University Medical College Manhasset, NY
Encourage information therapy.
JAMA.
1992;267:2592.
Reply.\p=m-\Mycolleagues, Mss Rothbaum and Eisenberg, are certainly correct that I did not address the problem of financing consumer health information services. I wrote the In
Uppsala University
197-200.
patient as consumer and the ensuing economic ramifications, not ethics, will be the determining factors as to whether these services become reality.
1. Lindner K.
Sweden 112. 2. Granai
autonomous and must abide by institutional policies. Disclaim¬ ers may neither prevent nor protect individuals and/or insti¬ tutions from litigation. We do not question that it is appropriate "to advocate access to health information to all." However, the
article to increase awareness of the value of the service and to encourage physicians, hospital administrators, nurses, librarians, and the public to increase their efforts to find fi-
nancial resources for consumer information services. About 300 medical libraries in the United States have succeeded in gathering enough funds through grants, private contributions, or from their institutions to provide consumer health information services. It is up to the individual medical librarians to continually advocate resources and access for the consumer in order to develop further funds for such services. Fortunately, the Joint Commission on Accreditation of Healthcare Organizations is revising its standards for 1994 concerning information and will recognize the importance of information support in patient care and patient education. Now is the time for health personnel to plan and advocate further funds for developing the necessary patient and family education resources in order to meet these upcoming stan¬ dards. I also feel it is the ethical responsibility of the medical librarian to encourage changing library policies to allow con¬ sumer access and to advocate developing standards promot¬ ing such access. Rothbaum and Eisenberg also stated that "Disclaimers may neither prevent nor protect individuals and/or institutions from litigation." The journals and authors of medical literature are responsible for accuracy of information, not the medical librar¬ ian or institution. If a computer search is clone thoroughly on a subject with the disclaimer that more information may be avail¬ able if the client wishes to search further, then I find little to justify the argument that an individual or institution might be involved in litigation. It has not happened to my knowledge. In response to Dr Fabian's letter, I certainly agree with his statement that not "all" patients would choose to or would be able to take advantage of information in a medical library. Cer¬ tainly an awareness on the part of physicians was my intention, so that more consumers would be encouraged to use medical li¬ braries when possible. Medical information providers should ac¬ cept the responsibility of maintaining confidentiality, providing the latest research and alternative treatments, and abstain from diagnosing or giving medical advice. It is only by encouraging and advocating access to medical information that we will con¬ tinue to enhance the autonomy of the consumer as an active par¬ ticipant in his or her own health care.
Lindner, MLS, RN Englewood, NJ Katherine
Active
Compression-Decompression Cardiopulmonary Resuscitation To the Editor.\p=m-\Thestudy by Cohen et al1 on active compression-decompression (ACD) cardiopulmonary resuscitation (CPR) represents the first new variation of CPR in many years. However, several points concerning this modification
Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/01/2015
of standard CPR need attention. The authors present no data on complications from actively decompressing the chest wall with the ACD device. It would have been useful if the authors had autopsies performed on all patients receiving CPR, with specific attention directed to the thoracic cavity. Active compression-decompression with the ACD device may produce more trauma to the sternum than standard chest compressions alone. Unfortunately, the study's design and sample size does not allow for an adequate comparison of complications between ACD CPR and standard CPR. We would caution the use of this device until such data are available. While the investigators demonstrated improvement in several hemodynamic variables with ACD CPR, they failed to show an improvement in arterial diastolic pressure compared with standard CPR. In fact, the femoral diastolic pressures tended to be lower during ACD CPR than during standard CPR. Although right atrial pressure measurements were not reported, it is possible that the addition of active chest de¬ compression may decrease coronary perfusion pressure. It has been demonstrated that coronary perfusion pressures less than 15 to 20 mm Hg are invariably associated with failure to restore spontaneous circulation.2"4 Although the present study demonstrated an improvement in end-tidal C02 with ACD CPR compared with standard CPR (4.3±3.8 mm Hg vs 9.0±3.9 mm Hg), mean values in this range are not associated with favorable outcome from resus¬ citation. It was recently demonstrated that when end-tidal C02 is used to predict outcome from cardiac arrest, patients with restoration of a pulse had mean values of 19±14 mm Hg vs 5±4 mm Hg in patients unable to be resuscitated. An initial end-tidal C02 of 15 mm Hg correctly predicted eventual re¬ turn of a pulse with a sensitivity of 71%, a specificity of 98%, a positive predictive value of 9Ì%, and a negative predictive value of 91%.5 Hence, the data presented by Cohen et al would suggest that ACD CPR is unlikely to improve resuscitation outcome and survival compared with current standard CPR
techniques.
In view of this, we would like to see more data evaluating hemodynamics with ACD CPR in animals and humans prior to initiating any survival studies with the technique.
Jeffrey B. Sack, MD Richard S. Gerber, MD
UCLA Medical Center Los Angeles, Calif Michael B. Kesselbrenner, MD St Joseph's Hospital and Medical Center Paterson, NJ
to demonstrate any
adverse effect from ACD CPR. In ad-
dition, the ACD CPR device (Cardiopump) serves as a cush-
ion to the chest during compression, and the decompression phase uses the natural hingelike properties of the thoracic cage. Based on these data, we believe that this device and technique does not present any adverse effects to the patient. Second, the authors are correct regarding the importance of diastolic pressures, however, this only applies to the beatingheart model. In the arrested/flaccid heart (and during ven¬ tricular fibrillation) there is no systole or diastole except that which is created via compression-decompression. In fact, in our animal studies we demonstrated an increase in coronary perfusion pressure despite no significant increase in right atrial pressure.2 It is theoretically possible that most of the flow in the flaccid or fibrillating heart occurs during com¬ pression systole rather than decompression diastole. Third, as noted in our article, end-tidal C02 was increased from 4.3±3.8 mm of Hg with standard CPR to 9.0±3.9 mm of Hg with ACD CPR (P
1. Adami H-O, Norl\l=e'\nBJ, Meirik 0. Long-term survival in prostatic carcinoma, with special reference to age as a prognostic factor. Scand J Urol Nephrol. 1986;20:107\x=req-\
CO. Ovarian cancer\p=m-\unrealisticexpectations. N
Engl J Med. 1992;327:
The Medical Library as a Patient Aid To the Editor.\p=m-\Beingon the other side of the library door and in a busy office and hospital practice faced with anxious, ill, and well patients, I must add a note of caution to the concluding sentence of Ms Lindner's1 article in JAMA, which states, "Patients will be more satisfied with their care as they become more knowledgeable and participate in the decision\x=req-\
making process." This is certainly a popular philosophy as we veer away from the "paternalistic" role model of physician-assisted health
I believe that this sentence should have the word "some" in front of it. Many patients are not physically, intellectually, psychologically, or emotionally equipped to deal with a trip to the library. Such a trip may create a whole new subset of problems for the patient and those attempting to provide good health care. If this sort of activity is to be done and encouraged, it should also imply a responsibility on the part of the information providers to deal with the consequences— favorable or otherwise. care.
Jack
Fabian, MD Pensacola, Fla
1. Lindner K.
Encourage information therapy. JAMA. 1992;267:2592.
To the Editor.\p=m-\MsLindner's1 overall philosophy about proconsumer medical information is commendable; patients have the right to information. She does not, however, address the problem of financing such services in libraries that do not have grants such as the grant provided by the state of New Jersey. She also minimizes the issue of responsibility for the information or misinformation provided. The economic reality is that many hospital libraries find it difficult to serve their present constituency and are not in a position to add new services. Many libraries are one- or two-person departments and lack the resources to provide consumer health information. Health care personnel need certain levels of assistance and materials while consumers need different materials and often labor-intensive services. Furthermore, Lindner neglects to address the future of the Regional Consumer Health Information Center, if funding by the state of New Jersey ceases. Until hospital accreditation organizations mandate such services and funding is made available to libraries, providing health care information to the consumer is a nonissue. Institu¬ tional and library policies define access privileges and proce¬ dures. Responsibility for information supplied and services rendered is defined and shared accordingly. Libraries are not
viding
Ellen Rothbaum, MS Debra Eisenberg, MSLS North Shore University Hospital Cornell University Medical College Manhasset, NY
Encourage information therapy.
JAMA.
1992;267:2592.
Reply.\p=m-\Mycolleagues, Mss Rothbaum and Eisenberg, are certainly correct that I did not address the problem of financing consumer health information services. I wrote the In
Uppsala University
197-200.
patient as consumer and the ensuing economic ramifications, not ethics, will be the determining factors as to whether these services become reality.
1. Lindner K.
Sweden 112. 2. Granai
autonomous and must abide by institutional policies. Disclaim¬ ers may neither prevent nor protect individuals and/or insti¬ tutions from litigation. We do not question that it is appropriate "to advocate access to health information to all." However, the
article to increase awareness of the value of the service and to encourage physicians, hospital administrators, nurses, librarians, and the public to increase their efforts to find fi-
nancial resources for consumer information services. About 300 medical libraries in the United States have succeeded in gathering enough funds through grants, private contributions, or from their institutions to provide consumer health information services. It is up to the individual medical librarians to continually advocate resources and access for the consumer in order to develop further funds for such services. Fortunately, the Joint Commission on Accreditation of Healthcare Organizations is revising its standards for 1994 concerning information and will recognize the importance of information support in patient care and patient education. Now is the time for health personnel to plan and advocate further funds for developing the necessary patient and family education resources in order to meet these upcoming stan¬ dards. I also feel it is the ethical responsibility of the medical librarian to encourage changing library policies to allow con¬ sumer access and to advocate developing standards promot¬ ing such access. Rothbaum and Eisenberg also stated that "Disclaimers may neither prevent nor protect individuals and/or institutions from litigation." The journals and authors of medical literature are responsible for accuracy of information, not the medical librar¬ ian or institution. If a computer search is clone thoroughly on a subject with the disclaimer that more information may be avail¬ able if the client wishes to search further, then I find little to justify the argument that an individual or institution might be involved in litigation. It has not happened to my knowledge. In response to Dr Fabian's letter, I certainly agree with his statement that not "all" patients would choose to or would be able to take advantage of information in a medical library. Cer¬ tainly an awareness on the part of physicians was my intention, so that more consumers would be encouraged to use medical li¬ braries when possible. Medical information providers should ac¬ cept the responsibility of maintaining confidentiality, providing the latest research and alternative treatments, and abstain from diagnosing or giving medical advice. It is only by encouraging and advocating access to medical information that we will con¬ tinue to enhance the autonomy of the consumer as an active par¬ ticipant in his or her own health care.
Lindner, MLS, RN Englewood, NJ Katherine
Active
Compression-Decompression Cardiopulmonary Resuscitation To the Editor.\p=m-\Thestudy by Cohen et al1 on active compression-decompression (ACD) cardiopulmonary resuscitation (CPR) represents the first new variation of CPR in many years. However, several points concerning this modification
Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/01/2015
of standard CPR need attention. The authors present no data on complications from actively decompressing the chest wall with the ACD device. It would have been useful if the authors had autopsies performed on all patients receiving CPR, with specific attention directed to the thoracic cavity. Active compression-decompression with the ACD device may produce more trauma to the sternum than standard chest compressions alone. Unfortunately, the study's design and sample size does not allow for an adequate comparison of complications between ACD CPR and standard CPR. We would caution the use of this device until such data are available. While the investigators demonstrated improvement in several hemodynamic variables with ACD CPR, they failed to show an improvement in arterial diastolic pressure compared with standard CPR. In fact, the femoral diastolic pressures tended to be lower during ACD CPR than during standard CPR. Although right atrial pressure measurements were not reported, it is possible that the addition of active chest de¬ compression may decrease coronary perfusion pressure. It has been demonstrated that coronary perfusion pressures less than 15 to 20 mm Hg are invariably associated with failure to restore spontaneous circulation.2"4 Although the present study demonstrated an improvement in end-tidal C02 with ACD CPR compared with standard CPR (4.3±3.8 mm Hg vs 9.0±3.9 mm Hg), mean values in this range are not associated with favorable outcome from resus¬ citation. It was recently demonstrated that when end-tidal C02 is used to predict outcome from cardiac arrest, patients with restoration of a pulse had mean values of 19±14 mm Hg vs 5±4 mm Hg in patients unable to be resuscitated. An initial end-tidal C02 of 15 mm Hg correctly predicted eventual re¬ turn of a pulse with a sensitivity of 71%, a specificity of 98%, a positive predictive value of 9Ì%, and a negative predictive value of 91%.5 Hence, the data presented by Cohen et al would suggest that ACD CPR is unlikely to improve resuscitation outcome and survival compared with current standard CPR
techniques.
In view of this, we would like to see more data evaluating hemodynamics with ACD CPR in animals and humans prior to initiating any survival studies with the technique.
Jeffrey B. Sack, MD Richard S. Gerber, MD
UCLA Medical Center Los Angeles, Calif Michael B. Kesselbrenner, MD St Joseph's Hospital and Medical Center Paterson, NJ
to demonstrate any
adverse effect from ACD CPR. In ad-
dition, the ACD CPR device (Cardiopump) serves as a cush-
ion to the chest during compression, and the decompression phase uses the natural hingelike properties of the thoracic cage. Based on these data, we believe that this device and technique does not present any adverse effects to the patient. Second, the authors are correct regarding the importance of diastolic pressures, however, this only applies to the beatingheart model. In the arrested/flaccid heart (and during ven¬ tricular fibrillation) there is no systole or diastole except that which is created via compression-decompression. In fact, in our animal studies we demonstrated an increase in coronary perfusion pressure despite no significant increase in right atrial pressure.2 It is theoretically possible that most of the flow in the flaccid or fibrillating heart occurs during com¬ pression systole rather than decompression diastole. Third, as noted in our article, end-tidal C02 was increased from 4.3±3.8 mm of Hg with standard CPR to 9.0±3.9 mm of Hg with ACD CPR (P
