Tight calorie control in geriatric patients following hip fracture decreases complications: a randomized, controlled study.

BACKGROUND & AIMS: Optimizing nutritional intake has been recommended for geriatric patients undergoing hip-fracture surgery. Whether nutritional support guided by repeated measurements of resting energy requirements (REE) improves outcomes in these patients is not known. METHODS: A randomized, controlled, unblinded, prospective, cohort study comparing provision of energy with a goal determined by repeated REE measurements using indirect calorimetry, with no intervention. Oral nutritional supplements were started 24 h after surgery and the amount adjusted to make up the difference between energy received from hospital food and measured energy expenditure. RESULTS: 50 Geriatric patients were included in the study. Patients in the intervention group (n = 22) received significantly higher daily energy intake than the control group (n = 28) (1121.3 ± 299.0 vs. 777.1 ± 301.2 kcal, p = 0.001). This was associated with a significantly less negative cumulative energy balance (-1229.9 ± 1763 vs. -4975.5 ± 4368 kcal, p = 0.001). A significant negative correlation was found between the cumulative energy balance and total complication rate (r = -0.417, p = 0.003) as well as for length of hospital stay (r = -0.282, p = 0.049). CONCLUSION: We have demonstrated that nutritional support actively supervised by a dietician and guided by repeated measurements of REE was achievable and improved outcomes in geriatric patients following surgery for hip fractures. Clinicaltrials.gov Identifier: NCT017354435.

The closure and the rings: when a physician disregards a patient's wish.

SUMMARY. Recent reports document that many physicians do not know their patients' preferences for life-sustaining interventions as part of end-of-life care, or fail to carry out those expressed preferences. This report describes a patient with cystic fibrosis who deteriorated unexpectedly; the physician chose to disregard his patient's preference not to be intubated. As an unintended result, the patient's family was able to achieve closure and find meaning in the apparent final phase of the patient's life. Thus, this report illustrates the delicate balance that must be struck between a physician's respect for a patient's wishes, his assessment of unexpected circumstances which arise as part of clinical care, and his responsibility to acknowledge and allow time for the family to psychosocially and spiritually prepare for a patient's impending death.

Quantitation of lipid-laden macrophages in evaluation of lower airway cytology specimens from pediatric patients.

Quantitation of lipid-laden macrophages has been used as a tool in the diagnosis of aspiration-related respiratory disorders. Fifty-six respiratory specimens from pediatric patients with lung diseases were retrospectively reviewed, and lipid-laden macrophage indices were evaluated according to modified published grading methods. The indices from patients at high risk for aspiration were significantly different from those at low risk. A simpler and more reproducible grading method was introduced. An important issue regarding sample adequacy was also addressed.

Self-hypnosis for patients with cystic fibrosis.

This report documents the utility of self-hypnosis in patients with cystic fibrosis (CF). Sixty-three patients 7 years of age or older were offered the opportunity to be taught self-hypnosis by their pulmonologist. Forty-nine agreed to learn it. Patients generally were taught hypnosis in one or two sessions. The outcome of hypnotherapy was determined by patients' answers to open-ended questions regarding their subjective evaluation of the efficacy of hypnosis. The average age of the 49 patients who were taught and used self-hypnosis was 18.1 years (range, 7-49 years). Many of the patients used hypnosis for more than one purpose, including relaxation (61% of patients), relief of pain associated with medical procedures (31%), headache relief (16%), changing the taste of medications to make the flavor more palatable (10%), and control of other symptoms associated with CF (18%). The patients successfully utilized self-hypnosis 86% of the time. No symptoms worsened following hypnotherapy. Sixteen patients chose to practice hypnosis on their own for a half year or longer. In conclusion, with the use of self-hypnosis, patients with CF can quickly learn to enhance their control over discomforts associated with therapy and their disease. Consideration should be given to making instruction in self-hypnosis available to patients with CF.

Hypnosis as a diagnostic modality for vocal cord dysfunction.

Vocal cord dysfunction (VCD) is a condition of paradoxical adduction of the vocal cords during the inspiratory phase of the respiratory cycle. VCD often presents as stridorous breathing, which may be misdiagnosed as asthma. The mismanagement of this disorder may result in unnecessary treatment and iatrogenic morbidity. An association with psychogenic factors has been reported, and a higher incidence of anxiety-related illness has been demonstrated in patients with VCD. Definitive diagnosis of VCD is made by visualization of adducted cords during an acute episode using nasopharyngeal fiber-optic laryngoscopy. Diagnosis can be problematic, because it may be difficult to reproduce an attack in a controlled setting. To maximize diagnostic yield during laryngoscopy, provocation of symptoms using methacholine, histamine, or exercise challenges have been used. We report a case of an 11-year-old boy, wherein hypnotic suggestion was used as an alternative method to achieve a diagnosis of VCD. The patient was admitted to the pediatric intensive care unit for elective fiber-optic laryngoscopy to confirm a diagnosis of VCD. The patient had a 4-year history of refractory asthma, severe gastroesophageal reflux disease (GERD) for which he had undergone a Nissen fundoplication, and suspected VCD. At 9 years of age the patient began manifesting monthly respiratory distress episodes of a severe character different from those that had been attributed to his asthma. Typically, he awoke from sleep with shortness of breath and difficulty with inhalation. He described a "neck attack" during which he felt as if the walls of his throat were "beating together." The patient was at times noted by his mother to exhibit a "suckling" behavior before onset of his respiratory distress episodes. On 4 occasions the patient became unconscious during an attack and then spontaneously regained consciousness after a few minutes. On these occasions, he was transported by ambulance to the hospital and the severe difficulty with inhalation resolved within a few minutes on treatment with oxygen and bronchodilators. Sometimes he was noted to manifest wheezing for several hours, which was responsive to bronchodilator therapy. Given the severity of the patient's disease, it was imperative to determine whether VCD was a complicating factor. It was proposed that an attempt be made to induce VCD by hypnotic suggestion while the patient underwent a fiberscopic laryngoscopy to establish a definitive diagnosis. The patient and his mother gave written consent for this procedure. He was admitted for observation to the pediatric intensive care unit for the induction attempt. The patient requested that no local anesthesia be applied in his nose before passage of the laryngoscope because he wanted to eat right after the procedure. Therefore, the nasopharyngeal laryngoscope was inserted while he used self-hypnosis as the sole form of anesthesia. He demonstrated no discomfort during its passing. Once the vocal cords were visualized, the patient was instructed to develop an episode of respiratory distress while in a state of hypnosis by recalling a recent "neck attack." His vocal cords then were observed to adduct anteriorly with each inspiration. The patient then was asked to relax his neck. When he did, the vocal cords immediately abducted with inspiration, and he breathed easily. After removal of the laryngoscope, the patient alerted from hypnosis and said he felt well. He reported no recollection of the procedure, thus demonstrating spontaneous amnesia that sometimes is associated with hypnosis. Because the diagnosis of VCD was confirmed, the patient was encouraged to use self-hypnosis and speech therapy techniques to control his symptoms. He also was referred for counseling. To our knowledge this is the first description in the medical literature of the use of hypnotic suggestion for making a diagnosis of VCD. (ABSTRACT TRUNCATED)

Effect of preterm birth on pulmonary function at school age: a prospective controlled study.

OBJECTIVE: To assess long-term pulmonary outcome of a regional cohort of children born at < 32 weeks' gestation compared with a matched term control group. STUDY DESIGN: All 125 surviving children born at 24 to 31 weeks' gestation during a 1-year period and a sociodemographically matched term control group were evaluated at age 7 years. RESULTS: Preterm children with previous bronchopulmonary dysplasia (BPD) were twice as likely to require rehospitalization during the first 2 years of life than were preterm children without BPD (53% vs 26%, P < .01). At 7 years of age the BPD group had more airway obstruction than did both preterm children without BPD and the term control group (significantly reduced mean forced vital capacity, forced expiratory volume in 1 second, and forced expiratory flow, 25% to 75% vital capacity, all, P < .001). Lung function among preterm children without previous BPD was similar to that of the term control group. Bronchodilator responsiveness was observed twice as often in preterm children with previous BPD (20 of 43, 47%) compared with preterm children without BPD (13 of 53, 25%) or the term control group (23 of 108, 21%, P < .001). These differences remained significant after adjustment was done for birth weight and gestational age. CONCLUSION: Preterm children without BPD demonstrate pulmonary function at school age similar to that of children in a healthy term control group, whereas preterm children with previous BPD demonstrate abnormal pulmonary function.

Does lithium carbonate affect the ion transport abnormality in cystic fibrosis?

Lithium is known to affect several aspects of cellular regulation which may be related to ion channel function in epithelial cells. To determine whether the ion transport abnormality in cystic fibrosis (CF) is affected by lithium with resultant changes in clinical status, 36 CF patients, 12-37 years old, were enrolled in a 14 week, double-blind, placebo-controlled trial. Eighteen patients were randomly assigned to receive lithium carbonate for 10 weeks. At the end of therapy their average serum lithium concentration was 0.56 +/- 0.06 mmol (SEM) per liter. Their sweat chloride concentration fell from 92.1 +/- 4.8 mmol per liter to 87.4 +/- 4.0 mmol per liter after 10 weeks of therapy (P = 0.07) and rose to 94.4 +/- 3.5 mmol per liter 4 weeks after end of therapy (P less than 0.001 compared to results at end of therapy). Their forced vital capacity (FVC) fell from 72 +/- 5.3% of predicted to 66 +/- 5.1% of predicted after 4 weeks of therapy (P less than 0.01), and their forced expiratory volume in one second (FEV1) fell from 56 +/- 5.5% of predicted to 51 +/- 5.5% of predicted after 4 weeks of therapy (P less than 0.01). In a non-blind assessment, performed 19 weeks after the end of therapy, their FVC and FEV1 had risen and were not significantly different from baseline. Sweat chloride, FVC, and FEV1 remained unchanged in the placebo group throughout the period of study.(ABSTRACT TRUNCATED AT 250 WORDS)