Predictors and outcomes of withholding and withdrawal of life-sustaining treatments in intensive care units in Singapore: a multicentre observational study

BACKGROUND

Clinical practice guidelines on limitation of life-sustaining treatments (LST) in the intensive care unit (ICU), in the form of withholding or withdrawal of LST, state that there is no ethical difference between the two. Such statements are not uniformly accepted worldwide, and there are few studies on LST limitation in Asia. This study aimed to evaluate the predictors and outcomes of withholding and withdrawal of LST in Singapore, focusing on the similarities and differences between the two approaches.

METHODS

This was a multicentre observational study of patients admitted to 21 adult ICUs across 9 public hospitals in Singapore over an average of three months per year from 2014 to 2019. The primary outcome measures were withholding and withdrawal of LST (cardiopulmonary resuscitation, invasive mechanical ventilation, and vasopressors/inotropes). The secondary outcome measure was hospital mortality. Multivariable generalised mixed model analysis was used to identify independent predictors for withdrawal and withholding of LST and if LST limitation predicts hospital mortality.

RESULTS

There were 8907 patients and 9723 admissions. Of the former, 80.8% had no limitation of LST, 13.0% had LST withheld, and 6.2% had LST withdrawn. Common independent predictors for withholding and withdrawal were increasing age, absence of chronic kidney dialysis, greater dependence in activities of daily living, cardiopulmonary resuscitation before ICU admission, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, and higher level of care in the first 24 h of ICU admission. Additional predictors for withholding included being of Chinese race, the religions of Hinduism and Islam, malignancy, and chronic liver failure. The additional predictor for withdrawal was lower hospital paying class (with greater government subsidy for hospital bills). Hospital mortality in patients without LST limitation, with LST withholding, and with LST withdrawal was 10.6%, 82.1%, and 91.8%, respectively (p < 0.001). Withholding (odds ratio 13.822, 95% confidence interval 9.987-19.132) and withdrawal (odds ratio 38.319, 95% confidence interval 24.351-60.298) were both found to be independent predictors of hospital mortality on multivariable analysis.

CONCLUSIONS

Differences in the independent predictors of withholding and withdrawal of LST exist. Even after accounting for baseline characteristics, both withholding and withdrawal of LST independently predict hospital mortality. Later mortality in patients who had LST withdrawn compared to withholding suggests that the decision to withdraw may be at the point when medical futility is recognised.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Chest compression quality and patient outcomes with the use of a CPR feedback device: A retrospective study

Feedback devices were developed to guide resuscitations as targets recommended by various guidelines are difficult to achieve. Yet, there is limited evidence to support their use for in-hospital cardiac arrests (IHCA), and they did not correlate with patient outcomes. Therefore, this study has investigated the compression quality and patient outcomes in IHCA with the use of a feedback device via a retrospective study of inpatient code blue activations in a Singapore hospital over one year. The primary outcome was compression quality and secondary outcomes were survival, downtime and neurological status. 64 of 110 (58.2%) cases were included. Most resuscitations (71.9%) met the recommended chest compression fraction (CCF, defined as the proportion of time spent on compressions during resuscitation) despite overall quality being suboptimal. Greater survival to discharge and better neurological status in resuscitated patients respectively correlated with higher median CCF (p = 0.040 and 0.026 respectively) and shorter downtime (p < 0.001 and 0.001 respectively); independently, a higher CCF correlated with a shorter downtime (p = 0.014). Overall, this study demonstrated that reducing interruptions is crucial for good outcomes in IHCA. However, compression quality remained suboptimal despite feedback device implementation, possibly requiring further simulation training and coaching. Future multicentre studies incorporating these measures should be explored.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Trauma-induced coagulopathy: Mechanisms and clinical management

INTRODUCTION

Trauma-induced coagulopathy (TIC) is a form of coagulopathy unique to trauma patients and is associated with increased mortality. The complexity and incomplete understanding of TIC have resulted in controversies regarding optimum management. This review aims to summarise the pathophysiology of TIC and appraise established and emerging advances in the management of TIC.

METHODS

This narrative review is based on a literature search (MEDLINE database) completed in October 2020. Search terms used were "trauma induced coagulopathy", "coagulopathy of trauma", "trauma induced coagulopathy pathophysiology", "massive transfusion trauma induced coagulopathy", "viscoelastic assay trauma induced coagulopathy", "goal directed trauma induced coagulopathy and "fibrinogen trauma induced coagulopathy'.

RESULTS

TIC is not a uniform phenotype but a spectrum ranging from thrombotic to bleeding phenotypes. Evidence for the management of TIC with tranexamic acid, massive transfusion protocols, viscoelastic haemostatic assays (VHAs), and coagulation factor and fibrinogen concentrates were evaluated. Although most trauma centres utilise fixed-ratio massive transfusion protocols, the "ideal" transfusion ratio of blood to blood products is still debated. While more centres are using VHAs to guide blood product replacement, there is no agreed VHA-based transfusion strategy. The use of VHA to quantify the functional contributions of individual components of coagulation may permit targeted treatment of TIC but remains controversial.

CONCLUSION

A greater understanding of TIC, advances in point-of-care coagulation testing, and availability of coagulation factors and fibrinogen concentrates allows clinicians to employ a more goal-directed approach. Still, hospitals need to tailor their approaches according to available resources, provide training and establish local guidelines.

Comparing organ donation decisions for next-of-kin versus the self: results of a national survey

OBJECTIVES

Intensive care audits point to family refusal as a major barrier to organ donation. In this study, we sought to understand refusal by accounting for the decision-maker's mindset. This focused on: (1) how decisions compare when made on behalf of a relative (vs the self); and (2) confidence in decisions made for family members.

DESIGN

Cross-sectional survey in Singapore.

SETTING

Participants were recruited from community settings via door-to-door sampling and community eateries.

PARTICIPANTS

973 adults who qualified as organ donors in Singapore.

RESULTS

Although 68.1% of participants were willing to donate their own organs, only 51.8% were willing to donate a relative's organs. Using machine learning, we found that consistency was predicted by: (1) religion, and (2) fears about organ donation. Conversely, participants who were willing to donate their own organs but not their relative's were less driven by these factors, and may instead have resorted to heuristics in decision-making. Finally, we observed how individuals were overconfident in their decision-making abilities: although 78% had never discussed organ donation with their relatives, the large majority expressed high confidence that they would respect their relatives' wishes on death.

CONCLUSIONS

These findings underscore the distinct psychological processes involved when donation decisions are made for family members. Amidst a global shortage of organ donors, addressing the decision-maker's mindset (eg, overconfidence, the use of heuristics) may be key to actualizing potential donors identified in intensive care units.

Association between lung compliance phenotypes and mortality in COVID-19 patients with acute respiratory distress syndrome

ABSTRACT Introduction: Acute respiratory distress syndrome (ARDS) in COVID-19 is associated with a high mortality rate, though outcomes of the different lung compliance phenotypes are unclear. We aimed to measure lung compliance and examine other factors associated with mortality in COVID-19 patients with ARDS. Methods: Adult patients with COVID-19 ARDS who required invasive mechanical ventilation at 8 hospitals in Singapore were prospectively enrolled. Factors associated with both mortality and differences between high (<40mL/cm H2O) and low (<40mL/cm H2O) compliance were analysed. Results: A total of 102 patients with COVID-19 who required invasive mechanical ventilation were analysed; 15 (14.7%) did not survive. Non-survivors were older (median 70 years, interquartile range [IQR] 67–75 versus median 61 years, IQR 52–66; P<0.01), and required a longer duration of ventilation (26 days, IQR 12–27 vs 8 days, IQR 5–15; P<0.01) and intensive care unit support (26 days, IQR 11–30 vs 11.5 days, IQR 7–17.3; P=0.01), with a higher incidence of acute kidney injury (15 patients [100%] vs 40 patients [46%]; P<0.01). There were 67 patients who had lung compliance data; 24 (35.8%) were classified as having high compliance and 43 (64.2%) as having low compliance. Mortality was higher in patients with high compliance (33.3% vs 11.6%; P=0.03), and was associated with a drop in compliance at day 7 (-9.3mL/cm H2O (IQR -4.5 to -15.4) vs 0.2mL/cm H2O (4.7 to -5.2) P=0.04). Conclusion: COVID-19 ARDS patients with higher compliance on the day of intubation and a longitudinal decrease over time had a higher risk of death. Keywords: ARDS, COVID-19-associated respiratory failure, high-flow nasal cannula therapy, HFNC, post-intubation, ventilation strategies

Rehabilitation of intubated COVID-19 patients in a Singapore regional hospital with early intensive care unit and sustained post-intensive care unit rehabilitation

Background

A proportion of patients with COVID-19 become critically ill, but few studies describe the functional outcomes and rehabilitation process of these patients.

Objective

To describe the complications encountered and functional outcomes of critically ill COVID-19 patients requiring intubation and subsequent intensive care unit (ICU) management and rehabilitation.

Methods

Retrospective case note review was conducted on all patients requiring intubation and ICU admission and subsequently discharged from our hospital from February 15, 2020 to May 1, 2020. Demographics, preexisting medical conditions, complications encountered in ICU, ICU and General Ward Length of Stay, number of therapy sessions delivered, nutritional data, and functional outcomes on discharge were collected from electronic medical records and entered in a deidentified database.

Results

Most patients developed significant breathlessness affecting post-ICU rehabilitation, a few patients developed ICU associated delirium while no patient developed ICU-associated weakness. All patients survived and could walk 20 m within 12 days post-extubation.

Conclusion

Early ICU and sustained post-ICU rehabilitation of critically ill, intubated COVID-19 patients is feasible. Further studies could look into the outcomes of this group of patients, in particular the effect of nutrition and pulmonary training on functional outcomes. We strongly recommend an interdisciplinary rehabilitation team approach in managing critically ill COVID-19 patients.

Clinical features and predictors of severity in COVID-19 patients with critical illness in Singapore

We aim to describe a case series of critically and non-critically ill COVID-19 patients in Singapore. This was a multicentered prospective study with clinical and laboratory details. Details for fifty uncomplicated COVID-19 patients and ten who required mechanical ventilation were collected. We compared clinical features between the groups, assessed predictors of intubation, and described ventilatory management in ICU patients. Ventilated patients were significantly older, reported more dyspnea, had elevated C-reactive protein and lactate dehydrogenase. A multivariable logistic regression model identified respiratory rate (aOR 2.83, 95% CI 1.24–6.47) and neutrophil count (aOR 2.39, 95% CI 1.34–4.26) on admission as independent predictors of intubation with area under receiver operating characteristic curve of 0.928 (95% CI 0.828–0.979). Median APACHE II score was 19 (IQR 17–22) and PaO2/FiO2 ratio before intubation was 104 (IQR 89–129). Median peak FiO2 was 0.75 (IQR 0.6–1.0), positive end-expiratory pressure 12 (IQR 10–14) and plateau pressure 22 (IQR 18–26) in the first 24 h of ventilation. Median duration of ventilation was 6.5 days (IQR 5.5–13). There were no fatalities. Most COVID-19 patients in Singapore who required mechanical ventilation because of ARDS were extubated with no mortality.

Low incidence of venous thrombosis but high incidence of arterial thrombotic complications among critically ill COVID-19 patients in Singapore

Background

Arterial and venous thrombosis are reported to be common in critically ill COVID-19 patients.

Method and results

This is a national multicenter retrospective observational study involving all consecutive adult COVID-19 patients who required intensive care units (ICU) admission between 23 January 2020 and 30 April 2020 in Singapore. One hundred eleven patients were included and the venous and arterial thrombotic rates in ICU were 1.8% (n = 2) and 9.9% (n = 11), respectively. Major bleeding rate was 14.8% (n = 16).

Conclusions

Critically ill COVID-19 patients in Singapore have lower venous thromboembolism but higher arterial thrombosis rates and bleeding manifestations than other reported cohorts.

Mobilising intensive care patients early

Background:

Early mobilisation in the intensive care unit has been suggested to improve outcomes. However, safety and practical concerns have led to the slow uptake of early mobilisation.

Objectives:

We designed a study to evaluate the practicability and efficacy of an early mobilisation protocol in intensive care unit patients.

Methods:

We performed a prospective non-blinded observational cohort study based on a quality improvement project. We implemented a protocol for early mobilisation of suitable patients admitted to medical and surgical intensive care units of a tertiary care hospital. All other aspects of patient care were managed as usual. Patients were followed up to discharge. Data were collected from July to August 2016 pre-implementation and from November 2016 to February 2017 following protocol implementation. The primary outcome measure was the mobilisation rate, defined as the number of days mobilised divided by the number of days each patient met mobilisation criteria. Secondary outcome measures included adverse event rate, length of mechanical ventilation, intensive care unit and hospital stay, intensive care unit and inhospital mortality and discharge destination.

Results:

A total of 312 patients were analysed, of which 60% were men with a mean age of 63.4 years. Following early mobilisation implementation, the mobilisation rate increased from 39% to 65% ( P=0.006). The percentage of patients discharged home increased from 49.0% to 75.9% ( P<0.001). Mortality, length of mechanical ventilation, length of stay and adverse event rate did not differ significantly.

Conclusion:

The implementation of an early mobilisation protocol in our intensive care unit was both safe and effective without requiring additional staffing. Efforts are ongoing to increase compliance with the protocol.

Lung ultrasound in a Singapore COVID-19 intensive care unit patient and a review of its potential clinical utility in pandemic

Background

Point-of-care bedside lung ultrasound is a diagnostic adjunct in the management of respiratory diseases. We describe the clinical progress and lung ultrasound findings of a Singaporean COVID-19 intensive care unit patient who was diagnosed with COVID-19 infection.

Methods

The clinical course of one COVID-19 patient managed in the intensive care unit was traced. The patient was diagnosed with COVID-19 virus infection and intubated after developing respiratory failure. Serial point-of-care bedside lung ultrasound was performed by the managing intensivist daily, and correlated with the clinical progress and chest X-ray imaging done for the patient.

Results

The patient exhibited lung ultrasound findings consistent with that described for viral pneumonias. This included numerous B-lines and subpleural consolidations with disrupted pleural lines distributed symmetrically, predominantly in bilateral upper BLUE points, and lower BLUE points bilaterally. Coalescing B-lines leading on to the development of bilateral “white lung” were associated with worsening acute respiratory distress syndrome. An increased density or reduction of the B-lines was associated with clinical improvement or deterioration, respectively.

Conclusions

Trained clinicians, who are familiar with point-of-care lung ultrasonography, may consider point-of-care bedside ultrasound as an important adjunct to history and physical examination for the diagnosis and management of COVID-19 when advanced imaging is not available because of logistical reasons or infectious control. This applies in particular to cases where resources are limited, and patient transfers to facilities offering such services may prove hazardous.

Missed opportunities for organ donation in patients with intracranial haemorrhage at the emergency department: A single-centre study

Background:

The demand for transplantable organs has increased in Singapore. However, organ donation has been consistently lower than international standards. Donation after brain death (DBD) most commonly follows intracranial haemorrhage (ICH).

Objective:

Our aim was to identify missed opportunities for organ donation among those who presented to the Emergency Department (ED) and died following ICH.

Methods:

A retrospective study was carried out for all cases of ICH presenting to the ED from 1 January 2013 to 31 December 2017. The patients’ medical records were reviewed for identification of potential donors and actualisation of organ donation.

Results:

There were 615 cases of ICH, with a mortality rate of 6.0%. Among those who died, 28 (75.7%) died in the Intensive Care Unit (ICU) and nine (24.3%) patients had withdrawal of care in the ED. Thirty patients (81.1%) were potential donors but organ donation was actualised in only three (8.1%) patients. Thirteen organs, as well as heart valves and iliac vessels were retrieved from the organ donors for transplantation.

Conclusion:

There were missed opportunities for organ donation. EDs have an important role to play in the national organ donation programme by identifying potential donors for organ donation and considering admitting these patients to ICU to facilitate organ donation.

Direct and indirect low skill fibre-optic intubation: A randomised crossover manikin study of six supraglottic airway devices

Background and Aims:

Fibre-optic intubation (FOI) through supraglottic airway devices (SADs) is useful in the management of the difficult airway. We compared two methods of FOI through seven SADs in a randomised crossover manikin study to assess each device's performance and discuss implications on SAD selection.

Methods:

Thirty anaesthetsiologists, 15 seniors and 15 juniors, each performed low skill FOI (LSFOI) with seven SADs using both 'direct' and 'indirect' methods. The order of method and device used were randomised. The primary end point was success rate of intubation; secondary end points were time taken for intubation, incidence of difficulties with direct and indirect LSFOI and operator device preference. Statistical analysis was with univariable analysis and comparison of proportions.

Results:

Data from six devices were analysed due to a protocol breach with one SAD. There was no difference in intubation success rate across all SADs and intubation methods. Intubation time was significantly shorter in AmbuAuragain than other SADs and shorter with the direct method of LSFOI than the indirect method (mean difference of 6.9 s, P = 0.027). Ambu Auragain had the least SAD and bronchoscope-related difficulties. Seniors had significantly shorter mean intubation times than juniors by 11.6 s (P = 0.0392). The most preferred SAD for both methods was AmbuAuragain.

Conclusion:

Low skill FOI consistently achieves a high intubation success rate regardless of experience, choice of method, or SAD used. SAD design features may significantly affect the performance of low skill FOI.

Observational in-vitro study comparing the efficacy of fluid warming devices: Ranger© 24500 versus ANIMEC AM-2S

Background:

Intraoperative hypothermia is detrimental to the patient. This, however, can be minimized with infusion of warmed fluids.

Objectives:

We investigated the warming capabilities of the Ranger© 24500 (Ranger) and ANIMEC AM-2S (ANIMEC) at various low infusion rates. We also examined the use of two ANIMEC warmers placed in series along the intravenous tubing.

Methods:

We had three comparative trial groups for our experiment. Trial group 1 involved the use of an ANIMEC fluid warmer. Trial group 2 involved the use of two ANIMEC fluid warmers placed in series. Trial group 3 involved the use of the Ranger. Three different infusion rates (1 ml/min, 5 ml/min and 10 ml/min) were examined.

Results:

The use of two ANIMEC fluid warmers delivered the warmest fluid in all three study infusion rates. The mean (SD) delivered temperature was 24.11 (0.62)°C at 1 ml/min, 29.59 (0.10)°C at 5 ml/min and 29.27 (0.10)°C at 10 ml/min. The Ranger delivered the lowest temperatures at infusion rates of 1 ml/min and 5 ml/min. The mean temperatures were 21.01 (0.38)°C and 23.87 (0.34)°C respectively. The mean temperatures of utilizing one ANIMEC fluid warmer were 21.49 (0.35)°C, 25.47 (0.08)°C and 24.78 (0.12)°C at infusion rates of 1 ml/min, 5 ml/min and 10 ml/min respectively.

Conclusion:

The ANIMEC performs better than the Ranger at low flow rates of up to 5 ml/min. A novel method of placing the two ANIMEC warming devices in series can further improve its warming capabilities.

Anaesthesia for Endoscopic Sinus Surgery: A Survey of Anaesthesiologists in Restructured Hospitals in Singapore

Introduction:

A cross-sectional survey of anaesthesiologists in Singapore's restructured hospitals was conducted to explore strategies employed to obtain a bloodless surgical field during endoscopic sinus surgery.

Methods:

All practicing anaesthesiologists in public institutions in Singapore were invited to answer an anonymous questionnaire. A point of contact per institution assisted in distribution and collection of questionnaire forms over a nine-month period.

Results:

A total of 114 anaesthesiologists completed the survey (response rate 60%). It was observed that 64.9% of respondents do not routinely employ controlled hypotension for endoscopic sinus surgery. Sixty-seven point five per cent chose general anaesthesia without nitrous oxide as the preferred anaesthetic technique for endoscopic sinus surgery. Forty-seven point four per cent opined that anaesthetic technique made no significant difference to outcomes in endoscopic sinus surgery. The most commonly used narcotics in endoscopic sinus surgery by the respondents were morphine (59.6%) and fentanyl (54.4%). However, where total intravenous anaesthesia was adopted, 86.0% of respondents opted to use remifentanil. The most commonly used class of antihypertensives for controlled hypotension was beta-blockers (66.7%). Factors limiting the use of total intravenous anaesthesia were also explored.

Conclusion:

This survey identifies variations from current evidence in the anaesthetic management of endoscopic sinus surgery among anaesthesiologists in Singapore's public institutions. The reasons behind these variations, which could include surgical preferences, financial, logistical, cultural, and educational factors, should be explored and any issues found addressed as necessary.

Difficult intubation in a patient with vallecular cyst

Although rare, vallecular cysts can have catastrophic consequences in an anaesthetised patient if airway management is inappropriate. We report a case of difficult intubation in a 46-year-old man with a vallecular cyst, and detail the methods and strategies for successful endotracheal tube insertion. Following a review of the current literature, we also discuss airway management options in adult patients with vallecular cysts.

Preliminary Report on Efficacy of Acupuncture versus meToclopramide for Management of Post-Operative Gastroparesis (EAT POSTOP Trial)

Introduction:

Gastroparesis is common in intensive care patients and may increase the incidence of malnutrition and nosocomial pneumonia, leading to poorer patient outcomes. Current pharmacotherapy has shown only modest efficacy. Acupuncture without pharmacotherapy has been shown to improve gastroparesis in animal studies and in recent clinical trials. However, no trials studying the efficacy of acupuncture as an adjunctive therapy for surgical intensive care patients have been done. This study aims to evaluate the effectiveness of adding electro-acupuncture therapy to pharmacotherapy in the management of gastroparesis in these patients.

Methods:

For this prospective block randomised controlled trial, we aim to recruit 200 adult surgical intensive care patients who require gastric enteral nutrition, and mechanical-assisted ventilation, and who have gastroparesis (gastric residual volumes more than 120 mL twice four hours apart). Patients will receive either metoclopramide 20 mg intravenously thrice daily (Group M) or electro-acupuncture comprising four sessions of 30-minute electro-acupuncture at specific sites over 48 hours in addition to intravenous metoclopramide 20 mg thrice daily (Group A). Gastroparesis resolution is defined as 24-hour cumulative gastric residual volumes less than 200 mL. Patients are followed-up for 48 hours from the commencement of therapy.

Results:

Three patients have been recruited in a four-month period thus far. Two are in Group A and one in Group M. All have met the study definition of gastroparesis resolution. The incidence of gastroparesis in this period among longer stayers in the unit (n = 92) is 8.7%.

Conclusions:

The trial is on-going. Reasons for the low incidence of gastroparesis are discussed. The study of the use of acupuncture in the treatment of intensive care patients with gastroparesis is worthwhile due to its excellent side-effect profile and if successful, will be a tool to improve nutritional support.

Drugs versus diets: disillusions with Dutch health care

Biology incorporated into other disciplines is often distorted, alarmingly so in some areas of medicine. Together with other forms of bias, this may have detrimental effects for patients depending on medical research for their health. A case study concerning omeprazole (Losec), one of the acid-suppressive drugs against gastric ulcers, and NSAIDs, non-steroid anti-inflammatory drugs, confirms that distorted biology together with biased health care policies foster disasters in current biomedicine and medical practice. In our country, The Netherlands, omeprazole is presumably the most commonly used medication. NSAIDs are also used in large quantities, increasingly since they have become available as analgesic over-the-counter drugs. Unofficial and official sources tend to inform the general public that the drugs promote human health. We argue that their being used on a massive scale is actually a medical disaster. The health of many patients would be served better if the drugs they take were replaced by proper forms of diet, but the pharmaceutical industry, the most potent force affecting medication policies, appears to prevent a shift in the balance from over-medicalization towards healthy life styles. The shift should come from government agencies responsible for regulation in the medication market. Policies of these agencies are now a dismal failure.