Calorie Malnutrition Research Articles

Chronic energy deficiency and its association with dietary factors in adults of drought affected desert areas of Western Rajasthan, India.

To asses the impact of drought on nutritional status of adults of a rural population in desert area. Threestage sampling technique. 24 villages belonging to 6 tehsils (sub units of district) of Jodhpur district, a drought affected desert district of Western Rajasthan, in 2003. 1540 adults were examined for their anthropometry, dietary intake and nutritional deficiency signs. Overall chronic energy deficiency (CED) was found high (42.7 %). Severe CED was 10.7 percent, significantly higher in males than females. Regarding vitamin A deficiency, overall prevalence of Bitot spot and night blindness was 1.8 and 0.2 percent respectively, higher in females than males. Regarding vitamin B complex deficiency, angular stomatitis, cheliosis, and glossitis was 1.0, 2.6 and 5.4 percent. Anemia was 35.6 percent. Overall mean calorie and protein intake deficit was very high (38 and 16.4 %). The comparison of present drought results with earlier studies in desert normal and desert drought conditions showed higher deficiencies of calories and proteins in their diet. Severity of malnutrition is critical as CED was more than the cut-off point of 40 percent stated by World Health Organization. Vitamin A and B complex deficiencies, anemia, protein calorie malnutrition along with deficit in calories and proteins in their diet were higher in comparison to non desert areas, which may be due to the harsh environmental conditions in desert areas. Efforts should be made to incorporate intervention measures to ensure the supply of adequate calories and proteins to all age groups.

Cachexia: Common, Deadly, With an Urgent Need for Precise Definition and New Therapies

Cachexia--sometimes also referred to as wasting disease, malnutrition, or hypercatabolism--has been described for centuries and has always raised ominous thoughts that "the end is near." The disease is encountered in many malignant and nonmalignant chronic, ultimately fatal, illnesses. Yet, although cachexia is a deadly syndrome, little is known about its pathophysiology, and the debate regarding its definition is ongoing. Thus, the data on epidemiology can be contested, but a few things are certain: Cachexia is associated with exceedingly high mortality once the syndrome has fully developed, irrespective of the definition we apply, and it is associated with weakness, weight loss, muscle wasting, and inflammation. It is not simply an ancillary event, and it may contribute to the death of the patient either through effects on neuroendocrine and immune defense mechanisms or through protein calorie malnutrition. The therapeutic standard of care for cachexia remains undefined to date, with a few exceptions. Among the recognized approaches, exogenous oral amino acid supplementation appears very promising. Further research efforts are needed and they are ongoing.

The systemic inflammatory response and its impact on iron nutriture in end-stage renal disease.

In most chronic disease conditions, the systemic inflammatory response and its mediators play an essential pathogenic role. Protein calorie malnutrition, a prominent feature of end-stage renal disease (ESRD), also develops, largely as a consequence of the systemic inflammatory response. ESRD (uremia), dialysis, systemic metabolic acidosis, and infections activate the systemic inflammatory response. Elevations in C-reactive protein and depressions of serum albumin below 4 g/dL are found in more than 50% of ESRD patients undergoing dialysis. In many patients receiving dialysis, the impact of this acute-phase response on measures of iron metabolism limits the ability to diagnose iron deficiency. Furthermore, there are risks to iron administration, although data linking iron overload to risk of infection in dialysis patients is suggestive, not definitive. It seems reasonable to hypothesize that the greatest risk of iron administration is in patents who are already infected, and the greater risk would be to raise the serum iron level and transferrin saturation precipitously. The total-dose infusion method, which provides all iron required to correct deficiency in 1 dose, is more likely to produce side effects and rapidly raise serum iron levels and transferrin saturation. The use of low-dose intravenous iron supplementation (10 to 20 mg per dialysis treatment or 100 mg every second week) avoids iron overtreatment and should reduce adverse events. In ESRD patients receiving dialysis, the importance of the systemic inflammatory response in the development of protein calorie malnutrition, the impact of the acute-phase response on iron nutriture, and the response to erythropoietin therapy must be considered to achieve an understanding of the altered responses to nutritional therapy in this setting.

Systemic Response to Inflammation

The systemic inflammatory response represents a coordinated set of physiologic actions that serve to fight infection, heal wounds, and promote recovery from external stressors. Thus, under most circumstances an intact systemic inflammatory response increases the likelihood of a successful outcome following acute injury or infection. However, under certain conditions, such as in major trauma, an excessive proinflammatory response may arise that worsens the prognosis. Conversely, protein calorie malnutrition can result in immunodeficiency, leaving the individual at risk of infection. Finally, low-grade chronic inflammation that is persistent, as can be seen in obesity, diabetes, and the metabolic syndrome, can lead to serious health risks. Thus, inflammatory states within a range from chronic low-grade to acute severe responses can have profound effects on morbidity and manifest an increased risk of mortality. Therapies to down-regulate the systemic inflammatory response by targeting the source of inflammation may dramatically improve patient outcome in chronic inflammatory states and some acute inflammatory conditions.

Gastric bypass: increased restriction for poor weight loss

Gastric bypass, the most common bariatric procedure performed in the United States, is becoming increasingly popular worldwide. Currently, gastric bypass is most often performed laparoscopically, and anecdotal experience has helped to evolve this operation, minimizing complications and optimizing long-term weight management. With better visualization and video documentation, we can compare outcomes based on anatomic differences between centers. As we debate the nuances concerning the optimal size and configuration of the gastric pouch and the amount of intestine that can or should be bypassed, it is clear that we are only on the verge of understanding the mechanism by which this procedure produces weight loss. Anatomic manipulation is important only if it produces a physiologic response. Whether one subscribes to the theory of a mediated incretin or a purely mechanical mechanism for sustained weight loss, it is agreed that there almost certainly is a metabolic effect associated with the gastric bypass as opposed to the adjustable gastric band or the vertical-banded gastroplasty. Creation of a standard ‘‘gastric reservoir’’ and ‘‘stoma’’ independent of the initial size, energy requirements, gender, or age of the patient is standard for most surgeons. Yet, patients respond with a predictable percentage of excess weight loss. This should be sufficient evidence to refute a purely mechanical mechanism of action for the gastric bypass. In addition, MacLean [3] has shown stoma dilation after gastric bypass to be a consistent finding not necessarily corresponding to inadequate weight loss or weight recidivism. In separate studies, Fobi et al. [2] and Capella and Capella [1] have achieved greater weight loss and maintenance with the banded approach, stabilizing at least one aspect of the anatomy: pouch diameter. Despite long-term data, few surgeons have adopted the banded gastric bypass as a primary operation compared with the majority who have embraced the laparoscopic approach. Debate continues as to the risks and benefits of a reinforced stoma, or more correctly, a stabilized gastric pouch, but most agree that initial, if not, permanent restriction is at least one important aspect of the gastric bypass. More controversial is whether increased restriction is appropriate for patients with inadequate initial weight loss or weight recidivism. Evaluation of patients with inadequate weight loss or recidivism after gastric bypass begins with defining the current anatomy in the context of the potential for optimization. Horizontal pouches will dilate along with the stoma due to the inclusion of the gastric fundus. Surgeons differ concerning the actual size and consistency of the anatomy. Therefore, both upper gastrointestinal and flexible endoscopies are useful and complementary studies. If the current anatomy appears optimal, then other options such as conversion to a duodenal switch or alteration of the intestinal limb lengths should be considered. However, increasing malabsorption with maintenance of restriction may impart a higher risk of protein–calorie malnutrition [4]. Presented at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in Las Vegas, NV, 20 April 2007

Antrinis imunodeficitas klinikinėje praktikoje

Imunitetas yra organizmo apsaugos būdas, kurio pagrindinė užduotis – išsaugoti vidinę homeostazę, apsaugoti nuo visko, kas genetiškai svetima. Sutrikus šiam gerai sustyguotam apsaugos mechanizmui, ryškėja imuninės sistemos nepakankamumas – imunodeficitas. Imunodeficitas – tai savarankiškų ligų ar lydinčių sindromų grupė, kurioms būdingas imuninės sistemos nepakankamumas. Pagal imuninės sistemos sutrikimo priežastį skiriamas pirminis (įgimtas) ir antrinis (įgytas) imunodeficitas. Medicinos literatūroje aprašomos kelios dažniausios antrinio imunodeficito priežastys. Viena iš jų – virusų, grybelių, bakterijų ar pirmuonių sukeltos infekcijos. Šių priežasčių grupėje labiausiai ištirtas ŽIV sukeltas įgyto imunodeficito sindromas (AIDS). Imuninės sistemos sutrikimų nustatoma ir navikinėmis ligomis sergantiems pacientams. Pastebėta, kad sergant Valdenštremo makroglobulinemija, mielomine liga, lėtine limfoleukemija mažėja B limfocitų kiekis, tuo tarpu sergant Hodžkino limfoma ar solidiniais navikais pažeidžiama T limfocitų funkcija. Antrinį imunodeficitą sukelia imunosupresantai, chemoterapiniai vaistai, sisteminės ligos, nudegimai, cukrinis diabetas, inkstų ligos ir kt. Visi šie veiksniai lemia skirtingų imuninės sistemos grandžių pažeidimus.

Celiac disease in children with persistent diarrhea and failure to thrive.

To determine the frequency of celiac disease (CD) in children with failure to thrive (FTT) and/ or persistent diarrhea (PD) not responding to conventional therapy. Cross-sectional study. Gastroenterology Unit of Sindh Institute of Urology and Transplantation (SIUT), from January 2002 to January 2004. Forty nine children and adolescents with PD (defined as diarrhea greater than 14 days duration) and / or FTT (based on anthropometrical indicators, i.e. weight for length below the 5th centile) were included in the study. Demographic data, weaning practices, breast feeding and family history of CD were documented. Laboratory workup included tissue transglutaminase antibody IgA (tTGA), IgA and IgG antigliadin antibodies (IgA AGA and IgG AGA), HLA typing, upper gastrointestinal endoscopy (EGD) with distal duodenal biopsy (where allowed by parents) and anthropometric data. CD diagnosis was in accordance with the "Guidelines for the diagnosis of and treatment of CD for children" by NASPGHAN. Mann-Whitney U-test, Chi-square test and Fisher's exact test were used for analysis as applicable. Forty nine patients (25 [51%] males) with FTT and or PD were included. The mean (+/-SD) age, height, weight and BMI were: 10.1+/-6.2 years (range, 1-20 years), 107.0 +/- 31.7 cm (45-180 cm), 19.04 +/- 12.5 kg (3-68 kg) and 16.12+/-12.58 kg/cm2 respectively. FTT was present in 30 (61%) patients. Thirty four (69%) children had a history of PD, 38 (77%) had a significant history of weight loss and 32 (65%) children had short stature. Majority of the children (88%) were breast fed. Weaning was started at 6 months of age in 40% and included mixed diet according to age. Protuberant abdomen was present in 26 (53%). Elevated tTGA was significantly (p < 0.001) more frequent in patients with CD. HLA-DQ2 and DQ8 haplotypes were positive in 18 (60%) of these patients. Thirty (61%) patients were positive for CD based on Marsh criteria. CD diagnosis was supported by positive tTGA and/ or AGA tests. Majority i.e. 28/30 patients had Marsh stage 3 disease, while 22/30 patients with CD also had PD. Four CD patients were found to suffer from protein calorie malnutrition (PCM). Children who fail to thrive with or without PD may have CD. A positive tTGA test in these children is a useful aid in making a CD diagnosis. Majority of CD positive children were found to carry HLA DQ2 or DQ8 genes. Thus, HLA typing could be used to determine genetic disposition to CD. Majority of FTT had Marsh stage 3 changes on histopathology.

Dysautonomia, a heuristic approach to a revised model for etiology of disease.

Dysautonomia refers to a disease where the autonomic nervous system is dysfunctional. This may be a central control mechanism, as in genetically determined familial dysautonomia (Riley-Day Syndrome), or peripherally in the distribution of the sympathetic and parasympathetic systems. There are multiple reports of a number of different diseases associated with dysautonomia. The etiology of this association has never been explained. There are also multiple publications on dysautonomia associated with specific non-caloric nutritional deficiencies. Beriberi is the prototype of autonomic dysfunction. It is the best known nutritional deficiency disease caused by an imbalance between ingested calories and the vitamins required for their oxidation, particularly thiamin. Long thought to be abolished in modern medical thinking, there are occasional isolated reports of the full-blown disease in developed Western cultures.Apart from genetically and epigenetically determined disease, evidence is presented that marginal high calorie malnutrition, particularly with reference to simple carbohydrates, is responsible for widespread dysautonomia. The brain and heart are the organs that have a fast rate of oxidative metabolism and are affected early by any mechanism that reduces oxidative efficiency. It is hypothesized that this results in a chaotic state of the hypothalamic/autonomic/endocrine axis. Due to the lack of adequate automatic controls, this may be responsible in some cases for breakdown of organ systems through long-standing energy deficiency, thus leading eventually to organic disease.

Desnutrición como factor pronóstico en ancianos con fractura de cadera

Hip fracture occurs frequently in elderly patients, with devastating effects on the quality of life due to the high financial burden and the high mortality rate in patients with this condition. Malnutrition is prevalent in the elderly and it can negatively influence patients' recovery from hip fracture. Our proposal was to assess the relationship between malnutrition and the recovery of patients with hip fracture.A total of 110 patients with hip fractures who were admitted to the orthopedic unit at the Reina Sofía Hospital were reassessed one year after discharge. A prospective cohort design and logistic regression analysis was used.Mean age was 81.4, and 80% of patients were women. After one year 19.7% of patients had died. A multivariate analysis showed a significant relationship between a poor functional recovery and age (odds ratio [OR] = 1.19), caloric malnutrition (OR = 290), protein malnutrition (OR = 125); and there was a significant relationship between being confined to bed and a worse situation before fracture (OR = 10.02); caloric malnutrition (OR = 9.57) and protein malnutrition (OR = 15.23).Caloric and protein malnutrition were associated with a worse functional recovery in elderly patients with hip fracture.

TEXTURAL PROFILE ANALYSIS OF SUNFLOWER–SESAME KERNEL CONFECTION (CHIKKI)

ABSTRACT Models capable of predicting textural quality of sunflower–sesame kernel confection (chikki) have been developed using response surface methodology. The model can be used to determine the effect of sunflower–sesame kernel proportions on texture profile analysis (TPA) parameters of the product. The quality attributes measured were hardness, cohesiveness, springiness, chewiness and resilience, whose values varied from 100–183 N, 1.01–2.82, 1.00–1.18, 21.7–495.1 N and 0.297–0.436, respectively. The highest values of hardness, chewiness and resilience were attained for the snacks prepared using jaggery (brown sugar) : sunflower kernel : sesame kernel in the ratio of 50:35:25. The highest values of cohesiveness and springiness were observed with 50:25:15 (jaggery : sunflower : sesame) proportions. The sensory term overall acceptability of the snacks is significantly correlated with instrumental cohesiveness, springiness and chewiness, which are the desired quality attributes of the snacks.PRACTICAL APPLICATIONSPopularizing sunflower kernel in the diet can help combat protein–calorie malnutrition in children to a certain extent in developing countries. This research may provide an opportunity to consider sunflower kernel as an ingredient in new products by manufacturers of baked goods and snack foods. The objective of the study was to quantify characteristics of textural profile of sunflower–sesame kernel chikki prepared using various proportions of sunflower and sesame kernels. Models developed using response surface methodology for predicting the textural quality of snacks can be used to determine the effect of sunflower–sesame kernel proportions on texture profile analysis parameters of the product. The confection (chikki) prepared taking jaggery, sunflower and sesame kernels as ingredients is an organoleptically accepted product.

Non Alcoholic Fatty Liver Disease: Correlation With Clinical Hormonal and Biochemical Parameters

BACKGROUND: Non alcoholic fatty liver disease (NAFLD) refers to a wide spectrum of liver damage, ranging from simple steatosis to steatohepatitis (NASH) and cirrhosis. The aim of this study was to describe the variance of clinical and laboratory parameters that could play a role in the development of NASH in a group of patients with NAFLD. PATIENTS AND METHODS: Clinical, biochemical and histological features of 36 patients with NAFLD were analyzed. Insulin and leptin serum levels were measured and Body Mass Index (BMI) and insulin resistance (HOMA index) were calculated. The same parameters were analyzed in 10 healthy controls. RESULTS: Signs of chronic liver disease and histological findings of advanced fibrosis were detected in 2 patients (5,5%), while hepatomegaly was a frequent finding (21 patients, 58,3%). NASH was confirmed in 21 patients (58,3%).Statistically significant difference was found between patients and controls in BMI (32 vs 25, p=0,002), insulin levels (33,3 vs 9,5, p=0,015) and HOMA index (9,4 vs 2,3 p=0,006). In comparing NASH patients with fatty liver (FL) patients, we observed similar levels (31,1 vs 32) of BMI, while insulin levels were higher in NASH patients (42 vs 22 p=0,044), as well as HOMA (11 vs 7,5) and leptin levels (22 vs 16,6) although this differences did not reach a statistical significance. CONCLUSIONS: This study confirms the important role of obesity and insulin resistance in a group of greek NAFLD patients. A positive correlation is also found between severity of liver damage and degree of insulin resistance. I N T R O D U C T I O N NAFLD is an increasingly recognized condition that refers to a wide spectrum of liver damage, ranging from simple fatty liver to steatohepatitis, which can progress to advanced fibrosis and cirrhosis. NAFLD should be differentiated from steatosis resulting from secondary causes such as genetic disorders (lipodystrophy, dysbetalipoproteinemia, etc), nutritional disorders (starvation, total parenteral nutrition, protein caloric malnutrition etc), drugs (estrogens, glucocorticoids, amiodarone, valproic acid Department of Internal Medicine, “SOTIRIA” Hospital, Athens, Greece Laboratory of Biochemistry, 401 Hospital, Athens, Greece Department of Pathology , “Sotiria” Hospital, Athens, Greece List οf AbbreviAtions: NAFLD: Non alcoholic fatty liver disease NASH: Steatohepatitis BMI: Body Mass Index FL: Fatty liver HOMA: Homeostatic Model Assessment

Total Nitrogen and Free Amino Acid Losses and Protein Calorie Malnutrition of Hemodialysis Patients: Do They Really Matter?’

Background/Aims: Protein calorie malnutrition (PCM) in patients on hemodialysis (HD) is multifactorial; however, HD per se induces nutrient losses. The aim of the present study was to characterize the losses of total nitrogen (TN) and free amino acids (FAs) through the dialysate and to determine the relationship between this loss and PCM, food ingestion, and the characteristics of the hemodialyzer in patients on HD. Methods: In a prospective study, 21 patients submitted to low-flux HD 3 times a week were evaluated within a period of 6 months regarding nutritional status, dietary calorie and protein intake, and losses through the dialysate of TN, FA, and urea nitrogen (UN). The type, surface area and reuses (up to 12) of the dialysis membrane were determined on each occasion, and the adequacy of dialysis was estimated by Kt/V. Results: 50% of the patients were considered malnourished, although the mean protein and energy intakes were similar for the malnourished and nourished patients. Mean TN losses through the dialysate were 16 g/session (60% UN). FA losses varied from 3.8 to 4.2 g/total volume. TN and FA in the dialysate did not differ significantly between malnourished and nourished patients. There was a positive correlation between membrane (polysulfone) area and TN (p <0.05) and ultrafiltrate volume and TN (p < 0.05), and a nonsignificant correlation between reuse of the dialysis membrane and TN. Conclusions: TN and FA losses through the dialysate were similar for malnourished and non-malnourished patients on chronic HD, thus they do not act as indicators of nutritional status impairment.

Testing of the Individual Nutrition Rx assessment process among nursing home residents

The purpose of this article is to describe the Individual Nutrition Rx (INRx) assessment process and to report preliminary findings on baseline nutritional status, common nutrition problems, and specific individualized interventions. The INRx utilizes a predictive model for participant identification, a systematic assessment process, and evidence-based interventions to improve the nutritional status of at-risk residents. Nineteen percent of participants had abnormal serum albumin levels, and 32.8% had abnormal serum prealbumin levels, indicating diminished protein stores and protein–calorie malnutrition. Frequent nutritional problems identified through the INRx assessment process are appetite change, poor positioning while eating, and oral status concerns.

Preventive strategy for Candida gut translocation during ischemia–reperfusion injury supervening on protein–calorie malnutrition

The aim of the present study was to test the hypothesis that protein-calorie malnutrition aggravates the gut translocation of Candida albicans triggered by mesenteric ischemia-reperfusion (IR) injury in an experimental model while testing a natural product containing the antifungal anethole/polygodial mixture (Kolorex). MFI strain white mice (n = 90) were randomly allocated to a 4-week dietary regimen: (1) standard pellet diet containing 25% casein; (2) low-protein (2.5%) casein diet; (3) as group 2 plus oral supplementation with 20 microL of a 5% solution of Kolorex during the last 4 days. Twenty rats from each of these groups (termed 1a, 2a and 3a) were orally inoculated with Candida suspension 6 h prior to mesenteric IR injury. Animals of each group but without Candida inoculation (termed 1b, 2b and 3b) served as control. A colon permeability study was carried out as well. Rats were killed prior to the IR injury and 3 h afterwards. Control rats were killed at the same time. Over 60% of the mesenteric lymph nodes and 30% of kidney samples were positive for C. albicans in the low-protein-fed rats after IR injury. Kolorex significantly decreased that rate of positivity and also significantly reduced the concentration of C. albicans per gram of each positive tissue sample examined. Protein-calorie malnourished animals showed a statistically significant increase in colon permeability and this phenomenon further increased after IR injury. The groups of rats treated with Kolorex compound showed a partial, although significant, improvement of this parameter. These results suggest that Kolorex might exert a competitive effect against with C. albicans colonization. The present study represents the first experimental in vivo investigation of the anethole/polygodial-containing compound under the specific conditions of calorie-protein malnutrition and the results have potential clinical interest.

A Review of the Biochemistry, Metabolism and Clinical Benefits of Thiamin(e) and Its Derivatives

Thiamin(e), also known as vitamin B1, is now known to play a fundamental role in energy metabolism. Its discovery followed from the original early research on the ‘anti-beriberi factor’ found in rice polishings. After its synthesis in 1936, it led to many years of research to find its action in treating beriberi, a lethal scourge known for thousands of years, particularly in cultures dependent on rice as a staple. This paper refers to the previously described symptomatology of beriberi, emphasizing that it differs from that in pure, experimentally induced thiamine deficiency in human subjects. Emphasis is placed on some of the more unusual manifestations of thiamine deficiency and its potential role in modern nutrition. Its biochemistry and pathophysiology are discussed and some of the less common conditions associated with thiamine deficiency are reviewed. An understanding of the role of thiamine in modern nutrition is crucial in the rapidly advancing knowledge applicable to Complementary Alternative Medicine. References are given that provide insight into the use of this vitamin in clinical conditions that are not usually associated with nutritional deficiency. The role of allithiamine and its synthetic derivatives is discussed. Thiamine plays a vital role in metabolism of glucose. Thus, emphasis is placed on the fact that ingestion of excessive simple carbohydrates automatically increases the need for this vitamin. This is referred to as high calorie malnutrition.

Effects of cysteine on the pharmacokinetics of oltipraz in rats with protein–calorie malnutrition

Effects of cysteine on the pharmacokinetics of oltipraz were investigated after iv (10mg/kg) and oral (30mg/kg) administration to male control, protein–calorie malnutrition (PCM), and PCM with oral cysteine supplementation (PCMC) rats. It was reported that oltipraz was mainly metabolized via hepatic CYP1A1/2, 2B1/2, 2C11, 3A1/2, and 2D1 in male rats. The expression and mRNA levels of CYP1A2, 2C11, and 3A1/2 were also reported to decrease in male PCM rats compared with controls. Interestingly, the decreased CYP isozymes in PCM rats returned fully or partially to controls by oral cysteine supplementation (PCMC rats). Hence, it would be expected that in PCM rats, some pharmacokinetic parameters of oltipraz are fully or partially returned to controls by cysteine. This was proven by the following parameters in PCMC rats: the AUC (328, 782, and 416 μg min/mL for control, PCM, and PCMC rats, respectively, after iv administration, and 223, 456, and 242 μg min/mL after oral administration), terminal half-life (130, 212, and 143 min), mean residence time (MRT) (149, 299, and 189 min), and in vitro CLint (0.181, 0.107, and 0.153mL/min/mg protein) were fully returned to controls, and CL and CLNR values were partially returned to controls. © 2005 Wiley-Liss, Inc. and the American Pharmacists Association.

Valoración nutricional en ancianos frágiles en atención primaria

To determine in primary care the nutritional status of elderly people at risk of malnutrition and to evaluate their evolution after an intervention. Descriptive, with follow-up. Urban health centre. Patients over 65, with criteria as fragile elderly or incapacitated and registered on a doctor's list (N=131). Nutritional risk factors were identified in the consultation or at home in 46 of those included in the study (March-September 2003). Age, sex. Factors in risk of malnutrition: loss of weight, acute or chronic illness associated with malnutrition, social factors. Anthropometric indices: Body Mass Index (BMI), tricipital fold (TF) and percentage, brachial perimeter (BP), calf perimeter (CP), arm muscular circumference (AMC), and percentage. Analytic indices: lymphocytes, transferrin, albumin. Malnutrition: when at least 2 of the above parameters were disturbed. Type: calories, protein, mixed. Degree: light, moderate, or severe. special diets and/or nutritional supplements. Parameters were re-assessed at 6 months (t test, paired samples). Average age of 83, with 63% women. Nutritional risk factors: loss of weight 41%, acute illness 39%, chronic illness 10.5%, cognitive deterioration 4%, social risk 2%. 80.4% suffered malnutrition (32.5% calories, 46% mixed, 21.5% protein; 27% light, 56.7% moderate, 16.3% severe). Mean values on anthropometric parameters: BMI 21, TF 11.3 mm (TF% 72%), BP 22 cm, AMC 19.4 (%AMC 90%), CP 28 cm (%CP 87%). Mean analytic values were: transferrin 243, albumin 3.7, lymphocytes 1600. Nutritional supplements were indicated in 11 cases. 32 cases were re-evaluated later and no significant improvement was found for any parameter (=.05). Malnutrition is common in the elderly with risk factors (loss of weight and acute illness), with calorie or mixed malnutrition the most common kinds. There was no improvement in anthropometric parameters at 6 months follow-up.

Perioperative Morbidity and the Rush to Chemotherapy

Since the seminal study published by Griffiths over 30 years ago, it has been customary in the treatment of ovarian cancer to begin with a major surgical procedure that is designed both to stage the patient and to remove as much tumor bulk as possible. Some form of adjuvant chemotherapy then follows debulking surgery, except in patients with low-risk stage I disease. The study by Griffiths suggested that patients who underwent major tumor debulking had outcomes similar to patients who presented with low tumor bulk, and had outcomes significantly better than their counterparts, who presented with large volume tumor and did not, or could not, undergo debulking. It remains controversial as to whether the ability to debulk tumor, with its associated outcome improvement, is due to differential tumor biology or to differential surgical skill. More recently, neoadjuvant chemotherapy has been used based on the finding that it remains possible to perform major surgery following preoperative chemotherapy without any apparent increase in operative or postoperative morbidity. To date, no randomized trial has reported outcomes comparing adjuvant and neoadjuvant approaches. Debulking surgery typically includes total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, sampling of pelvic and para-aortic nodes, and major bowel resections with primary anastomosis or creation of an ostomy. Typical postoperative complications include development of deep venous thrombosis and embolic events, delays in return of bowel function, anastomotic leaks, and poor wound healing, particularly in those patients who are nutritionally deprived, which is common in advanced disease due to protein and calorie malnutrition and large-volume ascites containing non-nutritional proteins. Gynecologic and medical oncologists have typically initiated chemotherapy as soon as feasible after postoperative recovery, and it is not uncommon for patients to have the first cycle of chemotherapy before discharge following debulking surgery. Some protocols even exclude patients who have chemotherapy initiated more than 4 to 6 weeks after debulking surgery. This rush to administer cytotoxic therapy is based on tumor growth and tumor kinetic models suggesting tumor kill is logarithmic and chemotherapy is most effective when tumor burden is low and tumor cells are in a synchronized growth phase. Additionally, randomized studies performed over 35 years ago, in which a single dose of thiotepa or a placebo was administered intraoperatively into the axillary vein of women undergoing modified radical mastectomy for breast cancer, demonstrated superior recurrence-free and overall survival for the treated group, especially in those patients with the greatest amount of tumor preoperatively (tumors 3 cm and those patients with 4 involved axillary nodes). A more modern study, however, showed no effect of interval between surgery and adjuvant chemotherapy in patients treated with fluorouracil, doxorubicin, and cyclophosphamide chemotherapy for breast cancer. In ovarian cancer, one randomized trial explored the value of adding doxorubicin to the cisplatin and cyclophosphamide doublet in ovarian cancer patients (n 349) who had undergone surgical debulking to an optimal volume ( 2 cm). In this trial, the interval between surgery and the initiation of adjuvant chemotherapy was predictive of survival in a multivariate analysis. Other factors predictive of survival were younger age, non–clear-cell histology, and lower-volume residual disease after debulking surgery. With the hazard ratio set at 1.0 for a 1-week interval between surgery and chemotherapy, hazard ratios for 2, 3, 4, 5, and 6 weeks were 1.2, 1.4, 1.5, 1.7, and 1.8, respectively. Time interval to initiation of chemotherapy was also the least powerful predictor of survival. Finally, the study did not explore reasons for the delays in initiation of chemotherapy in some patients, and one might therefore wonder if patients with more extensive surgery or nutritional deprivation had more postoperative complications, slower recovery of bowel function, and subsequent recovery to an acceptable performance status to allow patients to proceed with chemotherapy. JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 23 NUMBER 4 FEBRUARY 1 2005

Nutrients, neurodevelopment, and mood

Human neurodevelopment is the result of genetic and environmental interactions. This paper examines the role of prenatal nutrition relative to psychiatric disorders and explores the relationship among nutrients, mood changes, and mood disorders. Epidemiologic studies have found that adults who were born with a normal, yet low birth weight have an increased susceptibility to diseases such as coronary heart disease, diabetes, and stroke in adulthood. Prenatal caloric malnutrition, low birth weight, and prematurity also increase the risk for neurodevelopmental disorders, schizophrenia, affective disorders, and schizoid and antisocial personality disorders. Placebo-controlled studies in medicated patients suggest that add-on treatment with omega-3 fatty acids, particularly eicosapentaenoic acid, may ameliorate symptoms of major depressive disorder. Additional studies are necessary to confirm any benefits for bipolar disorders.

An Interventional Approach to Block Brain Damage Caused by Shiga Toxin–ProducingEscherichia coliInfection, by Use of a Combination of Phosphodiesterase Inhibitors

We tested the combination of phosphodiesterase (PDE) 3 and PDE4 inhibitors as an interventional approach to prevent the development of brain damage after Shiga toxin (Stx)-producing Escherichia coli (STEC) infection, using mice with protein calorie malnutrition. The combination consisted of pentoxifylline and rolipram; the dose of each inhibitor was 7.5 mg/kg. Treatment with this combination, which was administered intraperitoneally twice daily at 12-h intervals, increased serum concentrations of each inhibitor to >2 microg/mL and afforded significant levels of protection when it was continued for 3 days, starting on day 2 (95% survival rate; P<.001) or day 3 (63% survival rate; P<.01) of infection. The treatment reduced plasma levels of Stx2; consequently, immunoreactions of Stx2 were not found in the brain, and survivors did not show neurologic symptoms. Protection was associated with decreased levels of tumor necrosis factor (TNF)- alpha and increased production of interleukin-10 in serum, the brain, and the cecum. Although the combination at doses >2 microg/mL reduced Gb3 content of and Stx2 binding to Caco-2 cells, its ability to suppress production of TNF- alpha seemed to be more important for the decrease in cell-bound Stx2 in intestinal epithelial cells. Therefore, the combination of PDE3 and PDE4 inhibitors might be used as an interventional approach to prevent brain damage caused by STEC infection.