The effect of unselected post-operative nutritional supplementation on nutritional status and clinical outcome of orthopaedic patients.

BACKGROUND AND AIMS: Nutritional supplements are widely administered in hospitals and can benefit clinical outcome. The aim here was to determine the effect of routine post-operative nutritional supplementation on the nutritional status and clinical outcome of adult orthopaedic patients. METHODS: A prospective controlled study was conducted on two adult orthopaedic wards. Patients in the study group were prescribed two nutritional supplements/day post-operatively. Nutritional and biochemical indices and incidence of clinical complications were observed. RESULTS: Of 181 patients studied, 14 in the supplemented group and 34 in the control (P=0.005) developed major complications. There were 22 occurrences of major complications in the supplemented group and 55 in the control (P=0.0002). There was no significant difference in the number of minor complications between the two groups (P=0.2). There was no statistical difference in changes in nutritional parameters or in albumin or CRP between the two groups. There were significantly greater reductions in transferrin (P=0.002) and in haemoglobin (P=0.002) in the control group at week 1. The median costs of hospital stay were 2068 UK pounds in the supplemented group and 2199 UK pounds in the control. The median cost of additional treatments was 30.16 UK pounds in the supplemented group and 46.23 UK pounds in the control. CONCLUSION: A significant reduction in major complications and in number and costs of additional treatments was seen in the supplemented group.

Compliance of orthopaedic patients with postoperative oral nutritional supplementation.

BACKGROUND: Studies have shown clinical benefits of nutritional supplementation in orthopaedic and elderly patients in both under and well nourished groups. However, patient compliance with the supplementation has not been reported. AIM: To assess level of patient compliance with nutritional supplementation when prescribed postoperatively to unselected orthopaedic patients as part of a large controlled trial researching the clinical benefits of non-targeted nutritional supplementation. METHODS: Patients in the intervention group were prescribed two oral supplements each day of their hospital stay, in addition to usual meals. Information describing the supplements was given by the dietitian. Supplements were issued on drug rounds and the proportion of each drink consumed was recorded and collated. Patients could choose to change the type of drink or to discontinue the supplements completely at any time. Twenty-four hour food intake was analysed for a random sub-sample of 48 patients. RESULTS: Eighty-four patients (27 men, 57 women; mean age, 72 years) were prescribed supplements. Median length of stay was 14.4 days. Supplements were taken for a mean of 6.7 days. Median compliance was 14.9%. Despite this, median energy intake in the study group was 1523 kcal/day and 1289 kcal/day in the control (P= 0. 0214). CONCLUSION: Compliance with non-targeted, postoperative nutritional supplementation is poor in unselected orthopaedic patients but even low levels of supplementation significantly increase energy intake.

Severe aortic stenosis in patients 60 years of age or older: left ventricular function and 10-year survival after valve replacement.

From 1962-1977, 99 patients, mean age 65 +/- 0.5 years (range 60-81 years) underwent valve replacement for severe calcific aortic valve stenosis. Ninety-three percent of the patients were in New York Heart Association functional class III or IV. The aortic valve gradient was 76 +/- 3 mm Hg and the aortic valve area index was 0.34 +/- 0.01 cm2/m2. Left ventricular systolic pressure was 207 +/- 4 mm Hg, cardiac index was 2.5 +/- 0.1 l/min/m2, left ventricular ejection fraction was 0.57 +/- 0.02 and left ventricular end-diastolic volume index was 108 +/- 60 ml/m2; left ventricular ejection fraction and end-diastolic volume were normal in 63% of the patients. The operative mortality was 16%. Mean follow-up is 55 +/- 4 months. Using life-table analysis, the 10-year survival, excluding cardiac deaths, is 57.5 +/- 7%. Ninety-one percent of the survivors are in functional class I or II. We conclude that the left ventricular function is normal in two-thirds of elderly patients with severe aortic valve stenosis. After valve replacement, the 10-year survival is most encouraging and most of the survivors are functionally improved.

Elastofibroma dorsi. A case report.

A patient with elastofibroma dorsi, apparently the first recorded case in southern Africa, is described.

Acute coronary insufficiency with normal coronary arteriograms.

Two patients presenting with apparent symptomatic and electrocardiographic evidence of acute coronary insufficiency and found to have normal coronary arteriograms are documented. The patients remain symptom free at follow-up 9 and 14 months later although one requires 160 mg propranolol daily. The electrocardiographic, myocardial metabolic and haemodynamic data in 413 patients with angina and normal coronary arteriograms are reviewed and the suggested aetiologies documented. Follow-up of patients in these series indicates a good prognosis for symptom-free survival.

Bronchial adenoma: review of 18-year experience at the Brompton Hospital.

Continued uncertainty about the prognosis for patients with bronchial adenomata led to a review of the experience of this condition in the Brompton Hospital. Of 72 patients seen between January 1955 and December 1972, 39 were women and 33 men, mean age 45 years, range 9-73 years. The commonest presenting symptoms were haemoptysis, cough, sputum, and repeated chest infections. Positive bronchoscopic biopsy occurred in 35 of 43 cases; five of these were originally reported as carcinomata, of oat-cell type in four. Plain chest film abnormality occurred in 69 patients. Seventy-three operative procedures comprised two endoscopic removals, two wedge resections, six bronchotomies, five pneumonectomies, and 58 lobectomies (seven with sleeve resection). Recurrence in three of six bronchotomies--two with adenoid cystic carcinomata (cylindromata)--necessitated further surgery. Lobectomy and lymph node dissection is usually the operation of choice. Histology confirmed 67 carcinoids (eight with atypical histology or lymph node metastases), two adenoid cystic carcinomata, one muco-epidermoid, and two mucous gland adenomata. Prolonged follow-up is especially indicated in patients with adenoid cyst carcinoma and in those with atypical or metastatic carcinoid histology. Although such pathology is not incompatible with long survival, of 10 patients in these categories, all five late deaths were probably related to the tumour. However, of 57 patients considered to have had typical carcinoid histology and adequate removal of the tumour, there has to date been no tumour-related death, but one patient developed radiosensitive atypical carcinoid tracheal tumours nine years later. The actuarially assessed survival of 71 patients undergoing surgery for bronchial adenomata was 75% at 15 years. Specific tumour types should replace the term bronchial adenoma.

Late results of surgery for left ventricular outflow tract obstruction in children.

Forty-four patients, with a mean age at surgery of 10 years, were followed for 5 to 16 years (mean 9.7 years) after relief of left ventricular outflow tract obstruction. There were no early deaths, but 5 late deaths occurred, 3 following reoperation. Twenty-five patients were recatheterized from 1 to 16 years later (mean 6.6 years). In 21 of 32 patients (66 per cent), a new diastolic murmur followed relief of valvular stenosis; 25 (78 per cent) of these patients had a postoperative diastolic murmur. Seventeen of these 25 (68 per cent) were recatheterized, and 11 of the 17 (65 per cent) had moderate-to-severe aortic incompetence on angiography. Eight patients (18 per cent) have undergone reoperation and 9 more (20 per cent) will have to be reoperated upon soon. Although the aortic valve gradient and left ventricular stroke pressure were reduced in all obstructive types after surgery, left ventricular end-diastolic pressure significantly increased and cardiac index decreased after valvotomy. Cardiomegaly and electrocardiographic (ECG) abnormalities were present in 45 and 66 per cent, respectively, of all postoperative patients. Although 93 per cent of patients may be expected to survive and 82 per cent be reoperation free at 10 years, further surgery thereafter becomes increasingly common. Timely relief of obstruction prevents sudden death and produces excellent symptomatic improvement, but the operation is only palliative. Development of a reliable pediatric valve and ventriculo-aortic conduit may encourage earlier and more aggressive therapy.

Acute coronary insufficiency. An urgent surgical condition.

In 41 of 220 consecutive patients who had a coronary artery bypass operation between July 1973 and March 1974 the operation was for acute coronary insufficiency (recurrent chest pain with transient electrocardiographic changes persisting after admission to hospital). Their mean age was 54 (range 33-70 years). Eleven patients had had angina before, 14 had had at least one myocardial infarction, and 16 presented de novo. Eight of the latter 16 patients required only a single graft, usually to the left anterior descending artery, a significantly greater number than the two of the other 25 patients (P less than 0.01). Fourteen of these 16 patients had normal ventricular contraction, a significantly higher proportion than the 13 of the remaining 25 (p less than 0.05). No collaterals were seen in any of the 10 with single-vessel disease, which was significantly fewer than five out of 18 with double- and nine out of 13 with triple-vessel disease (P less than 0.005). Patients with rapidly developing obstruction, especially in the proximal left anterior descending artery, may not have time to develop collaterals, present acutely with good ventricular function, and may be particularly at risk. There was no operative mortality. The patients had a perioperative myocardial infarction, and there was one late death. At follow-up averaging 9-7 months (range 5-14 months) 32 (80%) patients were angina-free, no myocardial infarctions had occurred, and 85% were fully employed. Urgent coronary artery bypass grafting is a safe and effective treatment for acute coronary insufficiency.