Nathan S. Seriff

The development of renal failure during respiratory failure is of grave prognostic significance. In 686 patients with respiratory failure, 74 developed renal failure; these had a mortality of 80%. The leading predisposing factors are: 1) gastrointestinal bleeding with hypovolemic shock; 2) sepsis with shock; 3) drug induced nephrotoxicity; and 4) hypotension. With antacid gastric neutralization, judicious use of nephrotoxic antibiotics, the incidence of renal failure can be reduced. Once renal failure occurs, early dialysis may increase the chances of recovery in these critically ill patients.

This report describes a 31-year-old woman who underwent a technically difficult left pneumonectomy for tuberculosis and developed thereafter a large left pleural effusion which was milky in colour. A traumatic chylothorax was suspected, and the diagnosis was confirmed by simultaneous fasting pleural and serum lipid studies and lipoprotein electrophoresis. The latter study was especially helpful in confirming the chylous nature of the fluid in that it revealed a marked chylomicron band at the origin; this was not present in the patient's serum nor in the pleural fluid of five patients with other disease states studied as controls.

Summary This paper describes the cases of primary or central alveolar hypoventilation syndrome that have been reported, as well as three previously unreported cases seen in our hospital. Although the presenting symptoms of the patients were quite different, physiologically they were quite similar. Significant neurological disease was noted to coexist in a majority of the patients. This fact, plus the physiological observations of essentially normal lung and chest bellows function, and a decreased to absent response to inhaled CO 2 , suggest that this disorder is the result of a disturbance in the medullary respiratory center. The mortality has been 20 per cent. Interesting neuropathological abnormalities have been noted in the area of the respiratory center and elsewhere, consisting of an increased number of capillaries. Whether this is a primary or secondary change is not clear. A variety of therapies has been used in an attempt to augment alveolar ventilation. These include pharmocological agents, hypnosis, implantation of pacemaker electrodes into the diaphragm and later the phrenic nerve, and the use of simulated breath sounds. The details and results of these modalities of therapy are described.

<p>Background: Hyperemesis gravidarum (HG) leads to dehydration, poor nutritional intake, and weight loss. HG has been associated with adverse pregnancy outcomes such as low birth weight. Information about the potential effectiveness of treatments for HG is limited. Objective: We hypothesized that in women with HG, early enteral tube feeding in addition to standard care improves birth weight. Design: We performed a multicenter, open-label randomized controlled trial [Maternal and Offspring outcomes after Treatment of HyperEmesis by Refeeding (MOTHER)] in 19 hospitals in the Netherlands. A total of 116 women hospitalized for HG between 5 and 20 wk of gestation were randomly allocated to enteral tube feeding for ≥7 d in addition to standard care with intravenous rehydration and antiemetic treatment or to standard care alone. Women were encouraged to continue tube feeding at home. On the basis of our power calculation, a sample size of 120 women was anticipated. Analyses were performed according to the intention-to-treat principle. Results: Between October 2014 and March 2016 we randomly allocated 59 women to enteral tube feeding and 57 women to standard care. The mean ± SD birth weight was 3160 ± 770 g in the enteral tube feeding group compared with 3200 ± 680 g in the standard care group (mean difference: -40 g, 95% CI: -230, 310 g). Secondary outcomes, including maternal weight gain, duration of hospital stay, readmission rate, nausea and vomiting symptoms, decrease in quality of life, psychological distress, prematurity, and small-for-gestationalage, also were comparable. Of the women allocated to enteral tube feeding, 28 (47%) were treated according to protocol. Enteral tube feeding was discontinued within 7 d of placement in the remaining women, primarily because of its adverse effects (34%). Conclusions: In women with HG, early enteral tube feeding does not improve birth weight or secondary outcomes. Many women discontinued tube feeding because of discomfort, suggesting that it is poorly tolerated as an early routine treatment of HG.</p>