Well-nourished Patients Research Articles

Poor nutritional status prior to peripheral blood stem cell transplantation is associated with increased length of hospital stay

The nutritional status of patients prior to peripheral blood stem cell transplantation (PBSCT) and its impact on length of hospital stay is not well described in the literature. The nutritional status of 66 consecutive patients (46 m:20 f); and the mean age 58.7+/-12.0 years was determined a maximum of 2 weeks pre-transplantation using the scored Patient-Generated-Subjective Global Assessment (PG-SGA). According to the global assessment, 73% patients were well nourished, 23% moderately malnourished and 4% severely malnourished. There was a significant difference in post transplant length of stay (mean difference+/-s.e.m. -7.0+/-2.1 days) between well-nourished and malnourished patients and a trend towards higher mortality in the malnourished group (2 vs 20%). Although 89% of patients described no problems eating, two or more nutrition impact symptoms were reported in 30% of patients. From stepwise multiple regression analysis, nutritional status as determined by PG-SGA score was significantly associated with length of stay, accounting for 12% of the variance. In conclusion, malnutrition prior to PBSCT is associated with increased length of stay. Routine nutrition assessment of patients prior to PBSCT should be undertaken.

Fast and simple screening for nutritional status in hospitalized, elderly people

Undernutrition has been frequently reported among hospitalized elderly patients. The aim of this study was to evaluate the mini nutrition assessment (MNA) and a screening sheet for malnutrition (SSM) by full nutritional assessment (FNA) in elderly people, and to construct a shorter screening method by combining important questions from MNA and SSM. Having a screening tool as fast and simple as possible could increase its use in clinical routines. FNA, MNA and SSM were carried out on 60 hospitalized patients (>65 years). Sensitivity and specificity for MNA and SSM were calculated in comparison with FNA. In order to construct a short and simple screening tool, questions from the two screening tools, which differed significantly between mal- and well-nourished patients, were used in a multivariate, stepwise linear regression. The regression model was simplified to be suitable in clinical routines. Malnourishment was diagnosed by FNA in 58.3% of the elderly patients, with no gender difference. Body mass index, unintended weight loss, recent surgery and loss of appetite were predictors of malnutrition in the regression model (R(2) = 60.1%). The sensitivity and specificity of the simplified regression model were 89 and 88%, respectively, which was more precise than MNA (77 and 36%) and SSM (89 and 60%). According to FNA, malnutrition is frequent in elderly hospitalized patients. Four questions are sufficient to conduct precise nutritional screening for malnutrition in elderly hospitalized patients. This new screening tool should be verified in other samples.

Preoperative Immunonutrition: Cost‐Benefit Analysis

To evaluate whether preoperative immunonutrition might lead to a savings in patient care. Data on resources consumed to treat postoperative complications are scanty, but morbidity costs continue to be a major burden for any health care system. A recent randomized clinical trial carried out in well-nourished patients with gastrointestinal cancer showed that a 5-day preoperative oral immunonutrition reduced postoperative morbidity compared with conventional treatment (no supplementation). The abovementioned trial was the basis for the economic evaluation. In-hospital related costs of routine surgical care and costs of nutrition were calculated. Estimates of complication costs were based on both resources used for treatment and additional length of hospital stay. Cost comparison and cost-effectiveness analysis were then carried out. Total cost of nutrition was 3407 euro in the conventional group and 14,729 euro in the preoperative group. In patients without complication, the cost of in-hospital routine care was similar in both groups. The mean cost of complication was 6178 euro in the conventional group and 4639 euro in the preoperative group (p = .05). Total cost of patients with complications was 535,236 euro in the conventional group and 334,148 euro in the preoperative group. Total costs consumed 93% of the diagnosis-related-group (DRG) reimbursement rate in the conventional group and 78% in the preoperative group. Cost-effectiveness was 6245 euro for the conventional group and 2985 euro for the preoperative group. The costs of postoperative morbidity consumed a large amount of the DRG reimbursement rate. Preoperative immunonutrition was cost-effective in our series.

Hyperhomocysteinemia and macromolecule modifications in uremic patients

Hyperhomocysteinemia is present in the majority of well-nourished chronic renal failure and uremic patients. Most observations reported in the literature come from studies carried out in end-stage renal disease patients treated with hemodialysis. The underlying mechanisms of the toxic effects of homocysteine in uremia related to cardiovascular disease and other disturbances are still under scrutiny. As a consequence, macromolecules (i.e., proteins and DNA) have been found to be altered to various extents. One of the mechanisms of homocysteine toxicity is related to the action of its metabolic precursor, S-adenosylhomocysteine, a powerful methyltransferase competitive inhibitor. Disruption of DNA methylation has been demonstrated to occur as a result of hyperhomocysteinemia, and/or is associated with vascular damage. DNA hypomethylation has been found in the mononuclear cell fraction of uremic patients with hyperhomocysteinemia. Proteins are also targets of homocysteine-dependent molecular damage. The formation of oxidative products with free cysteinyl residue thiol groups has been demonstrated to occur in blood. The latter also represents a mechanism for the transport of homocysteine in plasma. In addition, homocysteine thiolactone has been shown to react with free amino groups in proteins to form isopeptide bonds, in particular at the lysine residue level. Another type of isopeptide bond in proteins may result from the deamidation and isomerization of asparaginyl residues, yielding abnormal isoaspartyl residues, which have been demonstrated to be increased in uremic patients. Folate treatment exerts a partial, but significant, homocysteine-lowering effect in uremic patients and has been shown to improve the changes in macromolecules induced by high homocysteine levels. In conclusion, both DNA and proteins are structurally modified in uremia as a consequence of high homocysteine levels. The role of these macromolecule changes in inducing the clinical complications of hyperhomocysteinemia in these patients, although still conjectural in some respects, is at present sustained by several pieces of evidence.

Deficiency in systemic interleukin-1 receptor antagonist production as an operative risk factor in malnourished elderly patients with colorectal carcinoma

Aging and tumor-related malnutrition are associated with increased inflammatory cytokine levels. However, it is unclear whether this influences the outcomes of surgery. We explored the relationships between cytokines and surgical complications among patients undergoing surgery for colorectal cancer. Laboratory experiment. Surgery department of school of medicine. One hundred patients with colorectal cancer. The perioperative circulating levels of interleukin (IL)-1beta, IL-6, and IL-1 receptor antagonist (Ra) were determined, and the numbers of circulating lymphocytes and neutrophils were counted. Trends toward increasing postoperative infection were observed among patients who were older and had lower body mass index. Preoperative IL-1Ra and intraoperative blood loss, however, remained the only two independent predictors of postoperative infection. Clinically, patients with low preoperative IL-1Ra most frequently were the elderly with low body mass index. Postoperatively, elderly patients with low body mass index showed an exaggerated IL-6 response, followed by an exaggerated postoperative inflammatory response and increased postoperative loss of body weight. In contrast, normal immunoreactivity was preserved in well-nourished elderly patients. In colorectal cancer patients undergoing surgery, low preoperative IL-1Ra is associated with postoperative infection. In our patient population, lower IL-1Ra level is commonly observed in the elderly with low body mass index. These findings suggest that postoperative infection, frequently seen in the nutritionally deficient elderly, may be the result of defective immunoinflammatory adaptation system.

Truncal fat mass as a contributor to inflammation in end-stage renal disease

An activated inflammatory response is a common feature of end-stage renal disease (ESRD) and predicts outcome. Adipose tissue is an endocrine organ that may contribute to an inflammatory burden by secreting adipocytokines such as interleukin 6 (IL-6). The objective was to relate plasma concentrations of IL-6 in ESRD patients to body composition, regional fat mass distribution, and blood lipid profiles. One hundred ninety-seven ESRD patients (123 men; +/- SE age: 52 +/- 1 y) were evaluated shortly before dialysis started. Lean body mass and truncal and nontruncal fat mass were estimated by dual-energy X-ray absorptiometry. Nutritional status was evaluated on the basis of subjective global assessment and handgrip strength. Inflammatory biomarker and blood lipid concentrations were also evaluated. Median IL-6 (8.5 compared with 4.5 pg/mL; P < 0.001) concentrations were significantly greater in malnourished than in well-nourished patients. Moreover, negative correlations were observed between IL-6 and serum creatinine (rho = -0.19, P < 0.01), handgrip strength (rho = -0.24, P < 0.001), and serum albumin (rho = -0.34, P < 0.001). A significantly higher truncal fat mass (12.8 +/- 0.7 compared with 10.5 +/- 0.4 kg; P < 0.005) was observed in ESRD patients with inflammation (C-reactive protein >/= 10 mg/L). Inverse correlations were observed between plasma IL-6 and HDL cholesterol (rho = -0.16, P < 0.05) and apolipoprotein A (rho = -0.23, P < 0.001). Plausible relations exist between inflammatory biomarkers, such as IL-6 and high-sensitivity C-reactive protein, and regional fat distribution in ESRD patients. Moreover, the strong inverse relations between HDL cholesterol and apolipoprotein A and biomarkers of inflammation suggest that the chronic inflammatory response observed in ESRD patients is an important contributor to the atherogenic lipoprotein profile in uremia.

Risk factors for mucosal manifestation of American cutaneous leishmaniasis

A case-comparison study was carried out to identify risk factors for mucosal manifestations of American cutaneous leishmaniasis (ACL) in southeast Brazil, using a series of 2820 patients, diagnosed with ACL between 1966 and 1999. The significant factors independently associated with mucosal leishmaniasis were: gender, age, nutritional status and length of disease. Mucosal leishmaniasis occurred 1.7 times more frequently among males than females; twice as often in individuals older than 22 years compared with the younger group; almost four times as often in individuals with severe malnutrition compared with those who were well nourished; and almost four times more frequently in individuals reporting the disease for more than 4 months compared with those reporting a shorter duration of the disease. Among individuals older than 22 years the risk of mucosal leishmaniasis increased significantly (from 1.9 to 9.6) as the nutritional status decreased, when compared with younger and well-nourished patients. The characteristics herein described and correlated with severe forms could be used as diagnostic markers as part of clinical screening in areas endemic for ACL.

The relationship between quality of life and nutritional status in advanced colorectal cancer

3697 Background: Recently, there has been an increasing awareness about the role of Quality of Life (QoL) in advanced cancer. As a result, QoL measurements are increasingly being incorporated into clinical oncology practice. Nutritional intervention has been hypothesized to have a positive impact on QoL in patients with advanced colorectal cancer, however, little is known about the relationship between nutritional status and QoL. The goal of this study was to investigate the association between baseline nutritional status and QoL in advanced colorectal cancer. Methods: We examined a case series of 30 histologically confirmed stages III-IV colorectal cancer patients treated at Cancer Treatment Centers of America® at Midwestern Regional Medical Center between March 2001 and January 2003. Nutritional status was evaluated using the Subjective Global Assessment (SGA), a validated nutritional assessment tool in clinical oncology. QoL was evaluated using the EORTC QLQ-C30 (EORTC) and the Ferrans and Powers Quality of Life Index (QLI). The mean scores for all QoL domains were compared across the two classes of nutritional status using Analysis of Variance. Results: Twenty-one (70%) patients were identified as well nourished and nine (30%) as moderately malnourished by the SGA. The mean scores in well-nourished patients were higher (suggesting better function) than those in malnourished patients for most QoL functional domains in both EORTC and QLI. The results achieved statistical significance (at p<=0.10) for role and social function (p=0.046 and 0.069 respectively) in EORTC and family function (p=0.023) in QLI. Similarly, the mean scores in malnourished patients were higher (suggesting worse symptoms) than those in well-nourished patients for most symptom scales in EORTC. The results achieved statistical significance for pain (0.079) and appetite loss (0.022). Conclusions: This study suggests that malnutrition in advanced colorectal cancer is associated with poor QoL for some functional and symptom domains. Future studies with larger sample sizes should focus on evaluating the impact of nutritional intervention on the QoL outcomes of these patients. No significant financial relationships to disclose.

The relationship between quality of life and nutritional status in advanced colorectal cancer

3697 Background: Recently, there has been an increasing awareness about the role of Quality of Life (QoL) in advanced cancer. As a result, QoL measurements are increasingly being incorporated into clinical oncology practice. Nutritional intervention has been hypothesized to have a positive impact on QoL in patients with advanced colorectal cancer, however, little is known about the relationship between nutritional status and QoL. The goal of this study was to investigate the association between baseline nutritional status and QoL in advanced colorectal cancer. Methods: We examined a case series of 30 histologically confirmed stages III-IV colorectal cancer patients treated at Cancer Treatment Centers of America® at Midwestern Regional Medical Center between March 2001 and January 2003. Nutritional status was evaluated using the Subjective Global Assessment (SGA), a validated nutritional assessment tool in clinical oncology. QoL was evaluated using the EORTC QLQ-C30 (EORTC) and the Ferrans and Powers Quality of Life Index (QLI). The mean scores for all QoL domains were compared across the two classes of nutritional status using Analysis of Variance. Results: Twenty-one (70%) patients were identified as well nourished and nine (30%) as moderately malnourished by the SGA. The mean scores in well-nourished patients were higher (suggesting better function) than those in malnourished patients for most QoL functional domains in both EORTC and QLI. The results achieved statistical significance (at p<=0.10) for role and social function (p=0.046 and 0.069 respectively) in EORTC and family function (p=0.023) in QLI. Similarly, the mean scores in malnourished patients were higher (suggesting worse symptoms) than those in well-nourished patients for most symptom scales in EORTC. The results achieved statistical significance for pain (0.079) and appetite loss (0.022). Conclusions: This study suggests that malnutrition in advanced colorectal cancer is associated with poor QoL for some functional and symptom domains. Future studies with larger sample sizes should focus on evaluating the impact of nutritional intervention on the QoL outcomes of these patients. No significant financial relationships to disclose.

Dépistage et stratégies préventives préopératoires des carences nutritionnelles

Nutritional deficiencies have to be considered as an independent risk factor for postoperative morbidity. Peri-operative nutritional support reduce this risk in elective abdominal surgery for cancer and cardiac surgery. Preoperative nutritional support for 7–10 days reduce postoperative complications in undernourished patients by 10% but is not operant when administered after surgery. Enteral route is as effective. Recent studies using immunonutrients conclude that a short preoperative oral intake is able to reduce complications even in well-nourished patients. Then, a preoperative nutritional screening must be routinely performed leading to a nutritional programme.

The body mass index paradox and an obesity, inflammation, and atherosclerosis syndrome in chronic kidney disease.

The association of high body mass index (BMI) with better survival in chronic kidney disease (CKD) is considered a "risk factor paradox" or "reverse epidemiology." Since malnutrition is a powerful predictor of death and cardiovascular disease is its leading cause, it has been suggested that malnutrition and atherosclerosis must be associated. Thus the current paradigm is that malnutrition is a risk factor for atherosclerosis and obesity is protective in CKD patients. We recently showed that high-BMI patients with inferred high body fat have an increased prevalence of atherosclerosis and subsequent cardiovascular and all-cause mortality. Prior cross-sectional studies also showed that high BMI in CKD is associated with higher C-reactive protein (CRP) levels and increased coronary calcification on electron beam computed tomography (CT) scan. These apparently conflicting data on better survival but increased inflammation and atherosclerosis in high-BMI CKD patients could be explained as follows. It is hypothesized that nutrition exerts a much stronger influence on survival than atherosclerosis in CKD. Malnutrition strongly augments the hazard of death from coexistent diseases, while better nutrition has the opposite effect. Thus the risk of death is highest in malnourished patients (low muscle and low fat mass) and lowest in well-nourished patients (high BMI, high muscle mass). Obesity (high BMI, high fat mass) is associated with inflammation and atherosclerosis. The risk of death from obesity and atherosclerosis is increased, but not so much as occurs with malnutrition. Therefore high body fat patients have intermediate survival. Thus it is postulated that an association of obesity, inflammation, and atherosclerosis (OIA syndrome) might exist in CKD.

Effect of nutritional status on clinical outcome in a population of geriatric rehabilitation patients.

In a geriatric patient, nutritional status (NS), particularly in the case of malnutrition (M), may influence not only clinical results but also achievement of targets expected by geriatric rehabilitation. The aim of this study was to evaluate the effect of nutritional status (NS) on the occurrence of Adverse Clinical Events (ACE) and on mortality in geriatric rehabilitation patients. We retrospectively examined the clinical records of 278 elderly subjects (154 women, 124 men), admitted to a geriatric hospital between September 2000 and December 2001 and evaluated for clinical, functional, cognitive and NS within the first 48 hours of admission. Clinical outcomes (ACE, mortality) were recorded during follow-up. Logistic regression analysis estimated models having mortality or the occurrence of ACE as outcome variables. Malnutrition was detected upon admission in 56.1% of the sample population. Incidence of ACE in malnourished subjects was higher than that in well-nourished patients (28.2 vs 13.1%). Equally, mortality among malnourished subjects was higher than among those whose NS was normal (23.1 vs 9.8%). The logistic regression models were able to predict: 1) mortality from comorbidity (OR 1.43; 95% CI 1.16-1.78; p=0.001) and NS (OR 2.64; 95% CI 1.29-5.4; p=0.008), and 2) occurrence of ACE from comorbidity (OR 1.69; 95% CI 1.36-2.1; p=0.000), cognitive (OR 1.22; 95% CI 1.11-1.35; p=0.000) and nutritional status (OR 2.38; 95% CI 1.19-4.8; p=0.015). NS emerged as the main independent predictor of both mortality and occurrence of ACE. Although most patients fell into the category of mild/moderate (energy) malnutrition (148/156), a mild deterioration of NS, for instance, reduction in triceps skinfold thickness (TSF) seemed to be sufficient to cause an increase in the incidence of ACE and in mortality.

Desnutrición en pacientes en atención domiciliaria

To find the nutritional status of people >65 years old included in a Home Care programme, using the Mini Nutritional Assessment (MNA), to describe the parameters discovered and to identify their relationship with risk factors. Descriptive, cross-sectional study. Primary care centre. 104 patients, who were over 65 and at the time of the study within the centre's home care programme, were included. The assessment was conducted by nursing staff in patients' homes. To assess the scores on the MNA, to describe the social and demographic variables of patients and carers, and to determine the medical, social and pathological factors of risk of malnutrition. Patients' mean age was 84.04 (SD, 8.76). 72.1% of carers were close relatives, with an average age of 61.88 (SD, 13.53). 20.2% of patients suffered from malnutrition and 51.9% were at risk of malnutrition. In both groups there was a low level of autonomy, significantly below that of well-nourished patients. No significant differences were found for the presence of more chronic illnesses, or social or psychological risk factors between these 2 groups and well-nourished patients. There is an extensive risk of malnutrition and actual malnutrition in the home care population.

Is serum albumin a marker of nutritional status in hemodialysis patients without evidence of inflammation?

Hypoalbuminemia, a strong predictor of morbidity and mortality in hemodialysis patients, can be a consequence of a combination of malnutrition and inflammatory reactions. The purpose of this study was to analyze serum albumin as a marker of nutritional status in maintenance hemodialysis patients with no signs of inflammation. In a cross-sectional study, we selected 40 stable hemodialysis patients with normal levels of C-reactive protein (<0.8 mg/dL). The patients were classified as well nourished (65%) or malnourished (35%) according to the subjective global assessment. No significant differences were observed in serum albumin concentrations (immunoturbidimetric method) between well-nourished (4.3 +/- 0.3 g/dL) and malnourished (4.0 +/- 0.5 g/dL) patients, and the mean values were within the normal range in both groups. Albumin was inversely correlated with age (n=40; r=-0.32; P=0.02) and directly with energy intake (n=28; r=0.43; P=0.04). In this study, serum albumin did not discriminate well-nourished and malnourished hemodialysis patients without evidence of inflammation.

Nutritional assessment of demented patients: a descriptive study.

It is well-known that subclinical and overt malnutrition are strong predictive indices of morbidity and mortality in old subjects, particularly in demented ones, and may deeply affect the quality of life. The aim of this study was evaluation of nutritional status in demented patients, as a whole and according to type of dementia, at the moment of hospital admission and before discharge. The study concerns 174 old demented patients, aged 80.2 +/- 8 SD, diagnosed as having Alzheimer's disease, vascular dementia, degenerative and vascular dementia, reversible dementia, and other types of dementia. In each subject, anthropometric measures, body composition analysis by the bioelectric impedance technique, Mini Nutritional Assessment (MNA) and cognitive, functional and affective assessment by conventional geriatric instruments were performed. A blood sample allowed assay of the main biochemical nutritional markers. At the end of the hospitalization period, the same cognitive, functional and nutritional assessment was repeated, in order to evaluate the effects of vitamin and protein supplements and of care during meals. In all subgroups of demented patients, obtained according to type of dementia, the mean MNA score was indicative of risk for malnutrition. Furthermore, the MNA score was significantly related to severe cognitive impairment, functional status, comorbidity, BMI values, and transferrin and total protein serum levels. Malnourished patients and demented elderly at risk for malnutrition (according to the MNA score) were given oral nutritional supplements during hospitalization, lasting a mean of 45 days. Before discharge, these two subtypes of demented patients showed substantial maintenance of their cognitive, functional and nutritional status, whereas the subgroup of well-nourished demented patients exhibited significant worsening of the nutritional pattern. Demented patients show a high percentage of malnutrition, particularly evident in subjects with deeper cognitive impairment. Nutritional status seems to be linked more to functional abilities than to duration of disease. However, nutritional intervention or special care during meals may act in synergy with specific pharmacologic therapy of dementia.

Prevalence of Malnutrition in Hospitalized Medical Patients: Impact of Underlying Disease

Background/Aims: Malnutrition is common among hospitalized patients. We investigated whether certain diseases predispose more frequently for malnutrition than others. Methods: Nutritional state was assessed by clinical scores, anthropometry and bioimpedance analysis in 502 consecutively admitted patients in the departments of internal medicine in two hospitals in Berlin (n = 300, university hospital; n = 202, district hospital). The prevalence of malnutrition was compared in patient groups with a different diagnosis. Results: Malnutrition was present in 24.2% of all patients. A clear association between diagnoses and malnutrition was found: the prevalence of malnutrition was significantly higher in malignant than in non-malignant diseases (50.9 vs. 21.0%, p < 0.0001). High prevalence rates >30% were observed in subgroups of patients with inflammatory bowel diseases, chronic heart failure and benign lung diseases. Patients with gastrointestinal diseases, however, were not more frequently malnourished than other medical patients (28.8 vs. 22.0%). Malnourished patients were significantly older (70.0 ± 13.6 vs. 58.3 ± 15.6 years, p < 0.0001) and had a 40% longer hospital stay (13.1 ± 8.1 vs. 9.3 ± 6.8 days, p < 0.0001) than well-nourished patients. Conclusions: Patients with malignancies, inflammatory bowel disease, chronic heart failure and benign lung diseases need special attention due to the high prevalence of malnutrition.

Preoperative albumin and surgical site identify surgical risk for major postoperative complications.

Although malnutrition contributes to morbidity, studies of pre- and postoperative nutrition often include well-nourished patients unlikely to benefit from therapy and usually do not stratify by the site of surgical pathology. This study evaluates whether perceived preoperative markers of nutritional status recorded in charts correlates with postoperative complications and resource use in patients who receive no preoperative nutrition support and reinterprets the results of several conflicting randomized, prospective studies in this context. This is a retrospective cohort study of 526 surgical patients who had preoperative serum albumin levels measured and were undergoing elective esophageal, gastric, pancreaticoduodenal, or colon surgery between 1992 and 1996 who could have received preoperative nutrition but did not. Most medical records contained inadequate analysis of preoperative nutritional status, but preoperative albumin correlated inversely with complications, length of stay, postoperative stay, intensive care unit (ICU) stay, mortality, and resumption of oral intake. Patients undergoing esophageal or pancreatic procedures sustained a significantly higher complication rate at most albumin levels, whereas colonic surgery resulted in lower complication rates at the same albumin levels. Resource use (eg, length of stay and ICU stay) related to these complication rates; esophageal and pancreatic procedures used the most resources and colon procedures used the fewest at most albumin levels. This lack of appreciation for nutritional risk and operative site can explain discrepancies in outcome noted in several randomized, prospective nutritional studies and must be applied to the design and implementation of new studies. Elective, non-emergent esophageal and pancreatic procedures performed in patients who could have had surgery delayed for preoperative nutrition, but did not, result in higher risk than colon surgery at any given level of serum albumin below 3.25 g/dL. Patient populations in trials should be stratified by operative site and by markers of nutritional status. Degree of hypoalbuminemia and other potential markers of nutritional status may explain many of the discrepancies between trials of nutrition support. Preexisting hypoalbuminemia in patients undergoing elective surgery remains underappreciated, unrecognized, and untreated in many hospitalized patients.

Advising patients who seek complementary and alternative medical therapies for cancer.

Many patients with cancer use complementary and alternative medical (CAM) therapies. Physicians need authoritative information on CAM therapies to responsibly advise patients who seek these interventions. This article summarizes current evidence on the efficacy and safety of selected CAM therapies that are commonly used by patients with cancer. The following major categories of interventions are covered: dietary modification and supplementation, herbal products and other biological agents, acupuncture, massage, exercise, and psychological and mind-body therapies. Two categories of evidence on efficacy are considered: possible effects on disease progression and survival and possible palliative effects. In evaluating evidence on safety, two types of risk are considered: the risk for direct adverse effects and the risk for interactions with conventional treatments. For each therapy, the current balance of evidence on efficacy and safety points to whether the therapy may be reasonably recommended, accepted (for example, dietary fat reduction in well-nourished patients with breast or prostate cancer), or discouraged (for example, high-dose vitamin A supplementation). This strategy allows the development of an approach for providing responsible, evidence-based, patient-centered advice to persons with cancer who seek CAM therapies.

Undernutrition and risk of mortality in elderly patients within 1 year of hospital discharge.

The importance of undernutrition as a determinant of postdischarge mortality among hospitalized elderly people remains controversial. The purpose of this study was to investigate this issue. The study included 660 elderly patients (85% white, 98% men, average age 73 +/- 6 years) discharged from a university-affiliated Department of Veterans Affairs Hospital, who were followed for 1 year. Associations between patient characteristics at hospital discharge and mortality were identified utilizing Cox Proportional Hazards Regression analysis. In the year following hospital discharge, 85 subjects (13%) died. After adjusting for illness severity (Acute Physiology and Chronic Health Evaluation II score) and functional status (Katz Index of Activities of Daily Living score), a body mass index (BMI) </=20 kg/m(2) was strongly associated with mortality (adjusted relative risk, [95% confidence interval] 1.83 [1.17-2.85]), as was more than 10% weight loss in the prior year (2.31 [1.35-3.94]), and weight as percent of usual weight (WPU) </=85% (1.78 [1.14-2.77]). Albumin </=30 g/l was only weakly associated with mortality (1.10 [0.67-1.81]). When all of the putative nutrition variables were included in a multivariable analysis with the two control variables, only BMI followed by WPU </=85% entered the model. Utilizing this model, the predicted probabilities of death at 1 year were calculated for the study subjects and for a hypothetical group of patients who were identical to the study subjects except they were assigned a BMI of 28 kg/m(2) and their WPU was 100%. Compared to 24% of the actual subjects, only 7% of the hypothetical well-nourished patients would have been classified as being at high risk for mortality (a 71% relative reduction). Older patients who have evidence of chronic body mass depletion are at significantly increased risk of mortality within the year following hospital discharge.

Plasma sulfur amino acids in relation to cardiovascular disease, nutritional status, and diabetes mellitus in patients with chronic renal failure at start of dialysis therapy

Sulfur amino acids (sAAs) are potential candidates as risk factors for cardiovascular disease (CVD). However, we recently reported that chronic hemodialysis patients with CVD had a greater prevalence of malnutrition, hypoalbuminemia, and lower plasma total homocysteine (tHcy) levels than those without CVD. In this cross-sectional study, we examined the relationship of plasma sAAs to CVD and nutritional status in 151 patients with chronic renal failure (CRF) close to the start of regular dialysis treatment (33 ± 7 days before the first dialysis treatment). Clinical signs of CVD were present in 32% of patients with CRF, 41% had malnutrition assessed by subjective global nutritional assessment (SGNA) score, and 26% had diabetes mellitus (DM). Plasma tHcy levels were high in 91% of patients, as were plasma total cysteine (tCys) levels, whereas plasma methionine (Met) and taurine (Tau) levels were normal. Patients with CRF who had CVD were older, more often malnourished, and had lower tHcy and serum albumin (s-albumin) levels and a greater frequency of DM than those without CVD. Plasma tCys, Met, and Tau levels did not differ between patients with CRF with and without CVD. The tCys-tHcy ratio was higher in patients with CVD and related to SGNA score and DM. Moreover, this ratio, but not tHcy or tCys level, correlated with age and triglyceride, total cholesterol, and apolipoprotein B levels. Malnutrition and hypoalbuminemia were associated with low plasma sAA levels (tHcy, Met, and Tau); tCys was related to s-albumin level, but not SGNA score. Among patients with diabetes, sAA levels did not differ between patients with and without CVD or between malnourished and well-nourished patients. In conclusion, patients with CRF at the start of dialysis treatment with CVD were more often diabetic, malnourished, and had lower s-albumin and tHcy levels and a higher tCys-tHcy ratio than patients with no CVD. tCys-tHcy ratio, but not tHcy or tCys levels per se, was related to cardiovascular risk factors, suggesting that cysteine may have a role in the development of CVD. Malnutrition, hypoalbuminemia, and DM in patients with CRF influence sAA levels, mainly plasma tHcy, which should be considered when evaluating hyperhomocysteinemia as a cardiovascular risk factor. © 2002 by the National Kidney Foundation, Inc.