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A case study of the treatment, management, and palliative care given to a patient with head and neck cancer to give the best quality of life is discussed.

The association of, timing of surgical repair, for hip fracture with functions and other outcomes are examined. The effects on mortality or functioning within 24 hours of surgery of surgical repair of hip fracture is discussed.

A model is presented to help doctors deal with their emotional reactions to critically ill patients. These reactions include feelings of failure, powerlessness, frustration, grief, fear of death, and a desire to avoid patients in order to prevent these feelings., Seriously ill persons are emotionally vulnerable during the typically protracted course of an illness. Physicians respond to such patients' needs and emotions with emotions of their own, which may reflect a need to rescue the patient, a sense of failure and frustration when the patient's illness progresses, feelings of powerlessness against illness and its associated losses, grief, fear of becoming ill oneself, or a desire to separate from and avoid patients to escape these feelings. These emotions can affect both the quality of medical care and the physician's own sense of well-being, since unexamined emotions may also lead to physician distress, disengagement, burnout, and poor judgment. In this article, which is intended for the practicing, nonpsychiatric clinician, we describe a model for increasing physician self-awareness, which includes identifying and working with emotions that may affect patient care. Our approach is based on the standard medical model of risk factors, signs and symptoms, differentia l diagnosis, and intervention. Although it is normal to have feelings arising from the care of patients, physicians should take an active role in identifying and controlling those emotions.

A low percentage of patients' advanced directives concerning their medical care appear to be available when patients are hospitalized. Of 114 patients averaging 83 years of age and accounting for 185 hospital admissions over a three-year period, only 47 (26%) advanced directives were duly noted in hospital charts. In 70 (39%) of the admissions, the admitting clerk had missed the patient's advance directive. In 53 cases where the patient was incapable of making a decision concerning their care, 39 (74%) did not have an advanced directive acknowledged and no attempt was made to secure one. Only one in four of these 53 patients' advanced directives were acknowledged. In the rest of the cases, medical decisions were made without checking previous proxies or living wills by the patients. Admitting clerks, physicians, patients, and families are responsible for finding and carrying out the advanced directives., Objective.--To investigate the accessibility of patients' previously executed advance directives during an acute hospitalization. Design.--Retrospective chart review. Setting.--A large metropolitan teaching hospital, a 514-bed skilled nursing facility, a geriatrics ambulatory care clinic, and a geriatrics group practice office. Patients.--One hundred fourteen geriatric patients who had previously executed an advance directive. Main Outcome Measures.--The medical records of 180 admissions over 3 years, 1991 through 1993, were reviewed for documentation of patients' advance directive status. Results.--Twenty-six percent of patients who had previously executed advance directives had their directives recognized during their hospitalization. Of the subgroup of patients who were judged not to have the capacity to make medical decisions during their admissions, 26% (14/53) had their directives recognized. When the advance directive was recognized, it appeared to influence treatment decisions in 12 (86%) of 14 cases. Conclusions.--Previously executed advance directives are not accessible when patients are admitted to hospitals for acute illness. When such directives are recognized, they are used to influence medical treatment decisions. Further research is needed to define and overcome barriers to this inaccessibility. (JAMA. 1995; 274:478-482)

Various baseline characteristics may predict a patient's outcome following a hip fracture. Treatments for hip fracture should affect both mortality and functional outcomes.

People with end-stage dementia who develop some other medical condition have a poor prognosis and should probably receive palliative care. Researchers analyzed mortality rates among 97 hospitalized for hip fracture and 119 hospitalized for pneumonia. In both groups, some patients had dementia and some did not. In both groups, half the patients with dementia died, compared to 13% of the patients who did not have dementia.

This Viewpoint summarizes some of the concerns and outlines the possible implications of the Medicare Advantage hospice carve-in for end-of-life care if existing trends continue. [ABSTRACT FROM AUTHOR]

This Viewpoint posits that advance care planning does not achieve the stated goal of end-of-life care nor serve as a reliable indicator of an end-of-life discussion. [ABSTRACT FROM AUTHOR]

The article examines the proposed titrating guidance model, which can be used by physicians in assisting patients and family members in making complex medical decisions. The new model matches the physician's role in decision making with the patient's likelihood of recovery. The 5-step process of the titrating guidelines model are discussed. These include determining the patient's point in the model, identifying cognitive factors and reflecting on the patients and their families' reaction on the decision at hand. Other existing models of medical decision making are also mentioned.

The article cites a study on brain dysfunction in patients with chronic critical illness which found that severe and permanent brain pathology is a key feature of chronic illness. The study showed that few of these patients survive from delirium or coma but suffer from severe forms of brain dysfunction. The study indicated that the decision to continue life-prolonging treatments for patients with critical illness should be made by some patients and families despite poor prognosis for survival.

A letter to the editor is presented in response to the article "Effectiveness of Specialized Palliative Care: A Systematic Review," by C. Zimmerman in the 2008:299 (14): 1696-1709 issue.

Importance: Cardiorespiratory fitness is an important marker of childhood health and low fitness levels are a risk factor for disease later in life. Levels of children's fitness have declined in recent decades. Whether school-based physical activity interventions can increase fitness at the population level remains unclear., Objective: To evaluate the effect of an internet-based intervention on children's cardiorespiratory fitness across a large number of schools., Design, Setting, and Participants: In this cluster randomized clinical trial, 22 government-funded elementary schools (from 137 providing consent) including 1188 students stratified from grades 3 and 4 in New South Wales, Australia, were randomized. The other schools received the intervention but were not included in the analysis. Eleven schools received the internet-based intervention and 11 received the control intervention. Recruitment and baseline testing began in 2016 and ended in 2017. Research assistants, blinded to treatment allocation, completed follow-up outcome assessments at 12 and 24 months. Data were analyzed from July to August 2020., Interventions: The internet-based intervention included standardized online learning for teachers and minimal in-person support from a project mentor (9-10 months)., Main Outcomes and Measures: Multistage 20-m shuttle run test for cardiorespiratory fitness., Results: Of 1219 participants (49% girls; mean [SD] age, 8.85 [0.71] years) from 22 schools, 1188 students provided baseline primary outcome data. At 12 months, the number of 20-m shuttle runs increased by 3.32 laps (95% CI, 2.44-4.20 laps) in the intervention schools and 2.11 laps (95% CI, 1.38-2.85 laps) in the control schools (adjusted difference = 1.20 laps; 95% CI, 0.17-2.24 laps). By 24 months, the adjusted difference was 2.22 laps (95% CI, 0.89-3.55 laps). The cost per student was AUD33 (USD26)., Conclusions and Relevance: In this study, a school-based intervention improved children's cardiorespiratory fitness when delivered in a large number of schools. The low cost and sustained effect over 24 months of the intervention suggests that it may have potential to be scaled at the population level., Trial Registration: http://anzctr.org.au Identifier: ACTRN12616000731493.

Thyroiditis with hyperthyroidism is a recognized early complication of intrathyroidal irridiation by orally ingested radiolabeled iodine I 131, but has seldom been described following external delivery of radiotherapy to the thyroid bed. We treated a man who was initially seen with a clinical picture suggestive of hyperthyroidism after receiving a course of radiotherapy for tonsillar carcinoma. Laboratory studies and thyroidal radioiodine uptake confirmed the diagnosis of thyrotoxic thyroiditis, having onset within 2 weeks of completion of the course of radiotherapy. The literature concerning thyroiditis and thyroid function following external beam radiotherapy is reviewed. Because several of the clinical features of thyrotoxic thyroiditis may resemble those resulting from the cancer under treatment or complications of its therapy, we recommend evaluation of thyroid function at the conclusion of the course of radiotherapy and 2 weeks thereafter to exclude this self-limited and treatable cause of weight loss.

The definition of ototoxicity in most clinical studies of aminoglycoside antibiotics is an increase in pure-tone threshold from a baseline audiogram greater than or equal to 15 dB at two or more frequencies, or greater than or equal to 20 dB at one or more frequencies. In this study, test-retest auditory threshold differences of this magnitude were found in a group of 20 normal volunteers who were not taking any known ototoxic drugs. Depending on which of the two criteria for ototoxicity are used, these data represent a 20% or 33% incidence of ototoxicity. We believe that many of the audiometric changes reported to represent aminoglycoside antibiotic ototoxicity may actually represent the normal test-retest variability of pure-tone audiometry. If this is true, the reported incidence of hearing loss due to aminoglycoside antibiotics may be exaggerated.

Herpes simplex virus type I was isolated from the CSF of a patient with atypical lumbosacral pain. The features of this case are unusual and important in light of the current understanding of herpes-simplex-virus-associated neurologic disease.

In recent years, an extensive medical literature has accumulated regarding the health hazards associated with boxing. As the evidence that boxing produces irreversible brain damage in boxers has become more compelling, physicians have begun to consider the larger issue of whether the sport is acceptable in its present form. This has resulted in a number of proclamations concerning boxing by various representatives of the medical community, which have both added information to and fueled the public debate over boxing. This article seeks to review the relevant medical literature concerning the health effects of boxing; to look at the contributions made in the last few years by the medical community to the public debate over boxing; and to suggest ways in which the objectives of the medical professional concerning boxing can best be achieved.