Total parenteral nutrition for patients with gastrointestinal cancers: a clinical practice review.

The use of total parenteral nutrition (TPN) in patients with gastrointestinal cancers is a well-established practice, yet there is substantial variability in its use across institutions. Decision-making around the initiation of TPN is complex. An interdisciplinary team can help identify patient factors and clinical situations that influence whether a patient is likely to benefit from parenteral nutrition. We present the case of a woman with a gastrointestinal cancer who benefited from the initiation of TPN as a bridge therapy to further cancer treatment. This case highlights the importance of establishing a plan for nutrition with specific goals in mind, such as optimizing patients for more cancer-directed therapy. Although patients with gastrointestinal cancers may be candidates for TPN, many patient-specific factors, such as functional status and opportunities for future treatments, must be considered prior to the initiation of parenteral nutrition. An interdisciplinary approach should be used to make recommendations based on patient goals, with a focus on patient and cancer characteristics that are associated with positive outcomes after initiation of TPN. These characteristics include functional status, nutritional status, degree of symptom control, and ability to safely administer nutrition. It is important to continually assess whether parenteral nutrition is beneficial in respect to a patient's preferences and prognosis.

Risk Factors for Hearing Loss in Patients with Cystic Fibrosis.

BACKGROUND: Patients with cystic fibrosis (CF) are at increased risk for sensorineural hearing loss (SNHL) due, at least in part, to the ototoxic side effects of routine CF therapies. However, the prevalence of SNHL and additional factors contributing to the development of SNHL are unknown. PURPOSE: To identify risk factors associated with the development of SNHL in a large cohort of CF patients who had been referred for audiometric testing. RESEARCH DESIGN: A retrospective study of audiometric results and medication information in a cohort of patients with CF. STUDY SAMPLE: Records of 178 CF patients seen at Boston Children's Hospital for audiometric testing from 2007 to 2010 were reviewed. Mean age of patients was 18 yr (standard deviation = 10 yr), and 98 (55%) of the patients were female. DATA COLLECTION AND ANALYSIS: Audiometric results, medications, and hospitalizations were recorded. Multivariable logistic regression was used to evaluate the association between SNHL and the number of hospitalizations and chronic antibiotic use in the year prior to the patients' audiometry. RESULTS: In this sample, 37/178 (21%) patients had SNHL. Twenty-nine (78%) of the 37 patients had bilateral SNHL and 8 (22%) had unilateral SNHL. Across all age groups, the majority of patients had a bilateral hearing loss (HL). A multivariable model showed that older age and more frequent hospitalizations were associated with SNHL. The number of courses of chronic antibiotics in the year prior to audiometric testing was not correlated with rate of HL. CONCLUSIONS: This study suggests that age and frequency of hospitalizations are key predictors of HL development. Increased awareness and regular screening for SNHL should be included in the routine care of CF patients, particularly those at the highest risk.

The Public Health Impact of Pediatric Deep Neck Space Infections.

OBJECTIVE: There is little consensus about the best management of pediatric deep neck space infections (DNSIs) and limited information about the national disease burden. The purpose of this study is to examine the health care burden, management, and complications of DNSIs from a national perspective. STUDY DESIGN: Retrospective administrative data set review. SETTING: National pediatric admission database. SUBJECTS AND METHODS: Pediatric patients diagnosed with a parapharyngeal space and/or retropharyngeal abscess were identified from the 2009 KIDS' Inpatient Database. Patient demographic, hospital, and clinical characteristics were compared between patients who received surgical and nonsurgical management. All results for the analyses were weighted, clustered, and stratified appropriately according to the sampling design of the KIDS' Inpatient Database. RESULTS: The prevalence of DNSIs was 3444 in 2009, and the estimated incidence was 4.6 per 100,000 children. The total hospital charges were >$75 million. The patients who were drained surgically had a 22% longer length of stay (mean = 4.19 days) than that of those who were managed without surgery (mean = 3.44 days). Mean hospital charges for patients who were drained surgically were almost twice those of patients who were managed medically ($28,969 vs $17,022); 165 patients (4.8%) had a complication. RESULTS: There are >3400 admissions for pediatric DNSIs annually, and they account for a significant number of inpatient days and hospital charges. A randomized controlled trial of management may be indicated from a public health perspective.

Pediatric sudden sensorineural hearing loss: diagnosed causes and response to intervention.

OBJECTIVE: Sudden sensorineural hearing loss (SSNHL) is an underappreciated issue in pediatric patient care. The goal of this study was to identify children who met the criteria for SSNHL and examine the etiologies, useful diagnostic studies, and treatment outcomes for these patients. METHODS: A retrospective medical records review was performed in patients meeting the criteria for SSNHL seen at a tertiary care pediatric hospital from 2007 to 2012. Information collected included age, gender, audiometric evaluations, onset and duration of hearing loss, additional symptoms, diagnostic studies and response to any medical management. The Institutional Review Board approved this project. RESULTS: 12/20 patients were male. Mean age was 11.41 years (3 months-24 years). Hearing loss was bilateral in 9/20 patients. Degree of hearing loss ranged from mild to profound across frequencies. Probable etiologies were viral of unknown type (n = 12), late presentation of congenital CMV (n = 1), noise-related (n = 1), non organic (n = 1), enlarged vestibular aqueduct (EVA) (n = 1), one with both acute Epstein-Barr virus (EBV) and significant ototoxic exposure (n = 1), one had significant ototoxic exposure and an inflammatory cerebrovascular incident (n = 1), and unknown (n = 2). Diagnostic studies included temporal bone computed tomography (CT) (n = 15) and/or magnetic resonance imaging (MRI) (n = 15), Lyme titers (n = 9), streptococcal throat culture (n = 1) and EBV (n = 1) and mumps titers (n = 1). Positive diagnostic studies included 1 MRI consistent with congenital CMV, and one CT that showed an EVA . 15/20 patients received systemic steroids, 3 received antivirals, and 4 got antibiotics. Response to steroids varied from complete resolution of SSNHL to worsening. Symptoms reported, in addition to the hearing loss included tinnitus (n = 9), vertigo (n = 9), sensation of a blocked ear (n = 6), and otalgia (n = 4). CONCLUSIONS: The incidence of SSNHL in pediatric patients is unknown. Etiologies of SSNHL include viral, EVA, ototoxicity, noise, and non-organic. Most studies were non-diagnostic although 2/22 CT/MRI provided an etiology. Identification of other causes required careful history review. The incidence of SSNHL in the pediatric population needs to be studied, and the timing, dosage, route and efficacy of steroids further evaluated.