Muscle matters: Prognostic implications of malnutrition and muscle health parameters in patients with cancer. A secondary analysis of a randomised trial.

BACKGROUND: Low muscle mass and malnutrition are independently associated with an increased risk of adverse outcomes in patients with cancer. However, it is not yet clear which parameter is most indicative of these risks. This study investigates the prognostic significance of different parameters reflecting malnutrition and muscle health in a well-characterised oncology population at nutritional risk. METHODS: This preplanned secondary analysis included patients with cancer from a Swiss-wide, randomised-controlled nutritional trial. We investigated associations among malnutrition markers (i.e., malnutrition diagnosis based on modified Global Leadership Initiative on Malnutrition (GLIM) criteria, albumin concentration) and muscle health markers (i.e., hand grip strength, computed tomography (CT)-based muscle mass and radiodensity) with 180-day all-cause mortality (primary outcome). RESULTS: We included 269 patients with a main admission diagnosis of cancer and available CT scans. In a mutually adjusted model, four parameters contributed to risk assessment including modified malnutrition diagnosis (GLIM) (HR 1.78 (95%CI 1.17 to 2.69), p = 0.007, AUC 0.58), low albumin concentration (HR 1.58 (95%CI 1.08 to 2.31), p = 0.019, AUC 0.62), low handgrip strength (HR 2.05 (95%CI 1.43 to 2.93), p = 0.001, AUC 0.62) and low muscle radiodensity (HR 1.39 (95%CI 0.90 to 2.16), p = 0.139, AUC 0.63). Combining these parameters resulted in a model with high prognostic power regarding 180-day mortality (overall AUC 0.71). CONCLUSIONS: In this study of inpatients with cancer at nutritional risk, several malnutrition and muscle health parameters emerged as independent prognostic indicators for mortality. The use of these parameters may improve risk stratification and guide nutritional interventions in this vulnerable population. TRIAL REGISTRATION: ClinicalTrials.gov, number NCT02517476.

Illness tracking in SARS-CoV-2 tested persons using a smartphone app: a non-interventional, prospective, cohort study.

There are few data on the range and severity of symptoms of SARS-CoV-2 infection or the impact on life quality in infected, previously healthy, young adults such as Swiss Armed Forces personnel. It is also unclear if an app can be used to remotely monitor symptoms in persons who test positive. Using a smartphone app called ITITP (Illness Tracking in Tested Persons) and weekly pop-up questionnaires, we aimed to evaluate the spectrum, duration, and impact of symptoms reported after a positive SARS-CoV-2 test according to sex, age, location, and comorbidities, and to compare these to responses from persons who tested negative. We followed up 502 participants (57% active participation), including 68 (13.5%) positive tested persons. Hospitalisation was reported by 6% of the positive tested participants. We found that positives reported significantly more symptoms that are typical of COVID-19 compared to negatives. These symptoms with odds ratio (OR > 1) were having difficulty breathing (OR 3.35; 95% CI: 1.16, 9.65; p = 0.03), having a reduced sense of taste (OR 5.45; 95% CI: 1.22, 24.34; p = 0.03) and a reduced sense of smell (OR 18.24; 95% CI: 4.23, 78.69; p < 0.001). Using a random forest model, we showed that tiredness was the single symptom that was rated as having a significant impact on daily activities, whereas the other symptoms, although frequent, had less impact. The study showed that the use of an app was feasible to remotely monitor symptoms in persons infected with SARS-CoV-2 and could be adapted for other settings and new pandemic phases such as the current Omicron wave.

Nutritional support during the hospital stay reduces mortality in patients with different types of cancers: secondary analysis of a prospective randomized trial.

BACKGROUND: Nutritional support in patients with cancer aims at improving quality of life. Whether use of nutritional support is also effective in improving clinical outcomes requires further study. PATIENTS AND METHODS: In this preplanned secondary analysis of patients with cancer included in a prospective, randomized-controlled, Swiss, multicenter trial (EFFORT), we compared protocol-guided individualized nutritional support (intervention group) to standard hospital food (control group) regarding mortality at 30-day (primary endpoint) and other clinical outcomes. RESULTS: We analyzed 506 patients with a main admission diagnosis of cancer, including lung cancer (n = 113), gastrointestinal tumors (n = 84), hematological malignancies (n = 108) and other types of cancer (n = 201). Nutritional risk based on Nutritional Risk Screening (NRS 2002) was an independent predictor for mortality over 180 days with an (age-, sex-, center-, type of cancer-, tumor activity- and treatment-) adjusted hazard ratio of 1.29 (95% CI 1.09-1.54; P = 0.004) per point increase in NRS. In the 30-day follow-up period, 50 patients (19.9%) died in the control group compared to 36 (14.1%) in the intervention group resulting in an adjusted odds ratio of 0.57 (95% CI 0.35-0.94; P = 0.027). Interaction tests did not show significant differences in mortality across the cancer type subgroups. Nutritional support also significantly improved functional outcomes and quality of life measures. CONCLUSIONS: Compared to usual hospital nutrition without nutrition support, individualized nutritional support reduced the risk of mortality and improved functional and quality of life outcomes in cancer patients with increased nutritional risk. These data further support the inclusion of nutritional care in cancer management guidelines.

Does nutrition for cancer patients feed the tumour? A clinical perspective.

This review aims to answer to two basic questions: a) Which substrates does a tumour utilize and is there a regimen that might potentially favour the host over the tumour? and b) Does nutritional intervention disproportionally affect tumour growth? Literature to date focuses on humans; although some references to molecular mechanisms regulating cancer cells metabolism derive from studies on experimental tumours and cell biology. Literature shows that some tumours, especially those of the brain and head/neck and lung, are glucose-dependent, and patients with these tumours could benefit from a normocaloric ketogenic diet provided these tumours exhibit high fluorodeoxyglucose (18F-FDG) captation. A high fat-protein, low carbohydrate diet appears to better fulfil the nutritional requirements of the cancer patient. Current evidence shows no improvement in tumoral response after restricting patients' caloric intake; whereas malnutrition is acknowledged as an important negative predictive and prognostic factor in all cancer patients.

Revisiting nutritional support for allogeneic hematologic stem cell transplantation-a systematic review.

In 2009, the American Society of Parenteral and Enteral Nutrition and its European counterpart (Euopean Society for Parenteral and Enteral Nutrition) published guidelines regarding nutritional support of patients with hematologic stem cell transplantation. Our aim was to do an up-to-date literature review regarding benefit of nutritional interventions and treatment recommendations. We searched MEDLINE, EMBASE and Cochrane Library for interventional and observational clinical studies. We extracted data based on a predefined case report form and assessed bias. Out of 459 potential abstracts, 13 studies of mostly moderate quality with a total of 18 167 patients were included. Two very large trials reported negative associations of malnutrition and survival, transplant-related mortality and relapse risk. Some trials found enteral nutrition (EN) to be as effective as parenteral nutrition (PN) with lower complication rates. In addition, EN was associated with better survival, less acute GvHD and faster neutrophil recovery. A neutropenic diet was not superior regarding overall survival, but in contrast resulted in higher infection risk. Current moderate quality studies show negative associations of malnutrition and clinical outcomes, with EN being superior to PN. There was no benefit of neutropenic diets. Large, randomized controlled studies are needed to better understand optimal nutritional support in this patient population.

Physicochemical stability and compatibility testing of levetiracetam in all-in-one parenteral nutrition admixtures in daily practice.

BACKGROUND: Parenteral antiepileptic drugs are frequently used in critically ill patients for seizure control therapy or prevention. Many of these patients require additional parenteral nutrition (PN). Therefore, a parallel infusion of the frequently used antiepileptic drug levetiracetam (LEV) is interesting in terms of the restricted i.v. lines (e.g., neonates). The potential interactions of the complex PN admixture with the drug product and the appropriate admixing of a drug at effective dosages require physicochemical lab assessments to obtain specific and reliable pharmaceutical documentation for the intended admixing. AIM: To assess the of compatibility and stability of LEV, a neutral and hydrophilic drug, in commercial all-in-one (AiO) PN admixtures using simple validated tests to provide necessary data in a timely manner and to allow convenient, documented and safe treatment with PN as the drug vehicle. METHODS: Different concentrations of LEV were injected into two different AiO PN admixtures with no further additives. Stability and compatibility tests for the drug and the PN admixtures were performed over seven days at +4°C, +23±1°C and +37°C without light protection. Stability and sample characteristics were observed by visual inspection and the validated light microscope method. Moreover, the pH level of the admixture was checked, as were the concentrations of LEV over time in the PN admixtures, using an established LC-MS/MS method. RESULTS: The stability controls of LEV at different temperatures were within absolute ±20% of the theoretical value in a concentration range of 98.91-117.84% of the initial value. No changes in pH occurred (5.55±0.04) and no microscopic out of specification data or visual changes were observed. The mean value of the largest lipid droplet in each visual field over seven days was 2.4±0.08µm, comparable to that of the drug-free AiO admixture. Samples stored at +37°C showed yellowish discolorations after 96h of storage. CONCLUSION: LEV showed compatibility and stability over seven days in the selected PN admixtures, and the described methods represented a valuable and timely approach to determine the stability and compatibility of the highly hydrophilic, not dissociated LEV in AiO admixtures under conditions of use. Further studies with clinically relevant and representative examples of physicochemically different drug classes are needed.

Home parenteral nutrition is beneficial in systemic sclerosis patients with gastrointestinal dysfunction.

OBJECTIVES: To assess 12-month changes in nutritional status and quality of life (QoL) in systemic sclerosis (SSc) patients requiring home parenteral nutrition (HPN). METHOD: We conducted a retrospective, single-centre database analysis of SSc patients regarding a 12-month period of HPN at an interdisciplinary University Unit/team for nutrition and rheumatic diseases. Nutritional status was analysed by nutritional risk screening (NRS) and body mass index (BMI). QoL was evaluated using Short-Form Health Survey (SF-36) questionnaires. RESULTS: Between 2008 and 2013, daily nocturnal HPN was initiated in five consecutive SSc patients (four females and one male, mean age 62.2 years) suffering severe malnutrition due to gastrointestinal tract (GIT) involvement. After 12 months of HPN, the mean NRS score decreased from 4.4 (range 4-5) to 1.4 (range 1-2), the mean BMI increased from 19.1 (range 17.4-20.3) to 21.0 kg/m2 (range 18.3-23.4). QoL improved in all patients, reflected by the summary of physical components with 33.92 points before vs. 67.72 points after 12 months of HPN, and the summary of mental components with 49.66 points before vs. 89.27 points after 12 months of HPN. Two patients suffered one catheter-related infection each with subsequent surgical removal and reinsertion. CONCLUSIONS: HPN is a feasible method for improving anthropometric parameters and QoL in SSc patients severely affected by GIT dysfunction. We recommend HPN in malnourished, catabolic SSc patients unable to otherwise maintain or improve their nutritional status.

Management of patients during hunger strike and refeeding phase.

OBJECTIVE: Hunger strikers resuming nutritional intake may develop a life-threatening refeeding syndrome (RFS). Consequently, hunger strikers represent a core challenge for the medical staff. The objective of the study was to test the effectiveness and safety of evidence-based recommendations for prevention and management of RFS during the refeeding phase. METHODS: This was a retrospective, observational data analysis of 37 consecutive, unselected cases of prisoners on a hunger strike during a 5-y period. The sample consisted of 37 cases representing 33 individual patients. RESULTS: In seven cases (18.9%), the hunger strike was continued during the hospital stay, in 16 episodes (43.2%) cessation of the hunger strike occurred immediately after admission to the security ward, and in 14 episodes (37.9%) during hospital stay. In the refeed cases (n = 30), nutritional replenishment occurred orally, and in 25 (83.3%) micronutrients substitutions were made based on the recommendations. The gradual refeeding with fluid restriction occurred over 10 d. Uncomplicated dyselectrolytemia was documented in 12 cases (40%) within the refeeding phase. One case (3.3%) presented bilateral ankle edemas as a clinical manifestation of moderate RFS. Intensive medical treatment was not necessary and none of the patients died. Seven episodes of continued hunger strike were observed during the entire hospital stay without medical complications. CONCLUSIONS: Our data suggested that seriousness and rate of medical complications during the refeeding phase can be kept at a minimum in a hunger strike population. This study supported use of recommendations to optimize risk management and to improve treatment quality and patient safety in this vulnerable population.

[Characteristics of patients with severe eating disorders from a university hospital and therapeutic guidelines]. / Charakteristika schwer essgestörter Patientinnen in einer universitären Einrichtung und therapeutische Richtlinien.

Patients with a severe eating disorder (anorexia, bulimia, other) are rarely subject of systematic studies. However, many of these patients are in need of in-patient treatment on specialized wards applying interdisciplinary treatment modalities. Updated criteria based on which hospitalisation should occur are provided by the recently issued S3-guideline for the treatment of eating disorders. We retrospectively assessed 26 consecutive patients with a severe eating disorder who were admitted to a psychosomatic/internal medicine university hospital in terms of their somatic, psychological, and social characteristics. Based on the S3-guideline, we conclude that hospitalization of these patients, within a multidisciplinary treatment setting, complies with evidenced-based criteria.

[How to assess the nutritional status of my patient]. / Wie Beurteile ich den Ernährungszustand Meines Patienten?

Protein-energy-malnutrition is a growing problem in industrialised countries. Many studies have found malnourishment in 20-60% of hospitalized medical or surgical patients, as well as out-patients. Malnutrition negatively influences patients' prognosis, immune system, muscle strength, and quality of life. As it is a largely treatable co-morbidity, systematic screening for malnutrition and effective management will improve patient outcomes and reduce healthcare costs. Early diagnosis and assessment depends on a simple and standardised screening tool that identifies at-risk patients, allowing the medical team in charge to solve patients' nutritional problems with an interdisciplinary approach.

[Body-packer & body-stuffer - a medical challenge]. / Body-Packer & Body-Stuffer - eine medizinische Herausforderung.

Since the seventies, the practice of drug smuggling in the form of body packing has increased in the Western world. The goal of our study was to present an algorithm for the safe management of intracorporal drug transport based on clinical experience and current evidence. The retrospective study, conducted over the past four years in our hospital prison, analyzes and discusses the diagnostic and therapeutic concepts. Thirty-four patients hospitalized 37 times in a 48-month period were included. In 28 patients drug packages were identified. Only two patients suffered from serious complications. The study demonstrates that following a specifically designed management algorithm based on clinical experience and principles of evidence-based medicine can optimize risk management, improve quality assurance and patient safety.

Nutritional risk is a clinical predictor of postoperative mortality and morbidity in surgery for colorectal cancer.

BACKGROUND: This study investigated whether nutritional risk scores applied at hospital admission predict mortality and complications after colorectal cancer surgery. METHODS: Some 186 patients were studied prospectively. Clinical details, Reilly's Nutrition Risk Score (NRS) and Nutritional Risk Screening 2002 (NRS-2002) score, tumour stage and surgical procedure were recorded. RESULTS: The prevalence of patients at nutritional risk was 31.7 per cent according to Reilly's NRS and 39.3 per cent based on the NRS-2002. Such patients had a higher mortality rate than those not at risk according to Reilly's NRS (8 versus 1.6 per cent; P = 0.033), but not the NRS-2002 (7 versus 1.8 per cent; P = 0.085). Based on the NRS-2002, there was a significant difference in postoperative complication rate between patients at nutritional risk and those not at risk (62 versus 39.8 per cent; P = 0.004) but not if Reilly's NRS was used (58 versus 44.1 per cent; P = 0.086). Nutritional risk was identified as an independent predictor of postoperative complications (odds ratio 2.79; P = 0.002). CONCLUSION: Nutritional risk screening may be able to predict mortality and morbidity after surgery for colorectal cancer. However, the diverse results reflect either the imprecision of the tests or the small sample size.

ESPEN Guidelines on Parenteral Nutrition: geriatrics.

Older subjects are at increased risk of partial or complete loss of independence due to acute and/or chronic disease and often of concomitant protein caloric malnutrition. Nutritional care and support should be an indispensable part of their management. Enteral nutrition is always the first choice for nutrition support. However, when patients cannot meet their nutritional requirements adequately via the enteral route, parenteral nutrition (PN) is indicated. PN is a safe and effective therapeutic procedure and age per se is not a reason to exclude patients from this treatment. The use of PN should always be balanced against a realistic chance of improvement in the general condition of the patient. Lower glucose tolerance, electrolyte and micronutrient deficiencies and lower fluid tolerance should be assumed in older patients treated by PN. Parenteral nutrition can be administered either via peripheral or central veins. Subcutaneous administration is also a possible solution for basic hydration of moderately dehydrated subjects. In the terminal, demented or dying patient the use of PN or hydration should only be given in accordance with other palliative treatments.

Combination of daptomycin plus ceftriaxone is more active than vancomycin plus ceftriaxone in experimental meningitis after addition of dexamethasone.

We examined the cerebrospinal fluid penetration of daptomycin after the addition of dexamethasone and its bactericidal efficacy with and without ceftriaxone in an experimental rabbit model of pneumococcal meningitis. The combination of daptomycin with ceftriaxone was the most efficacious regimen for pneumococcal meningitis. The previous addition of dexamethasone affected the antibacterial activity of daptomycin only marginally, either as monotherapy or combined with ceftriaxone, although the penetration of daptomycin into inflamed meninges was significantly reduced from 6 to 2%. Daptomycin with ceftriaxone might be a potential candidate for the empirical therapy of bacterial meningitis, although the activity of this regimen against Listeria monocytogenes remains to be demonstrated.

[Hermaphroditos in Greek mythology--DSD in moderne medicine]. / Von Hermaphroditos der griechischen Mythologie bis zu DSD der Moderne.

We report a case of 34 year old woman how has been hospitalized at the age of 6 month with persistent vomitus. The vomitus was found to be caused by adrenal insufficiency with lack of all hormones of steroidobiosynthesis. The phenotypical femal child was diagnosed to have congenital lipoid adrenal hyperplasia with 46,XY DSD. 24 years later a homozygote mutation in the StAR-gene (L260P), which was first described in Switzerland, has been identified.

Practical handling of AIO admixtures - Guidelines on Parenteral Nutrition, Chapter 10.

All-in-one admixtures (AIO-admixtures) provide safe, effective and low-risk PN (parenteral nutrition) for practically all indications and applications. Water, energy (carbohydrates and lipids), amino acids, vitamins and trace elements are infused together with PN either as industrially-manufactured AIO admixtures provided as two- or three-chamber bags (shelf life usually more than 12 months) completed with electrolytes and micronutrients where appropriate or as individually compounded ready-to-use AIO admixtures (compounding, usually prepared by a pharmacy on either a daily or weekly basis and stored at 2-8 degrees C). Physico-chemical and microbial stability of an AIO admixture is essential for the safety and effectiveness of patient-specific PN, and its assurance requires specialist pharmaceutical knowledge. The stability should be documented for an application period of 24 (-48) hours. It is advisable to offer a limited selection of different PN regimes in each hospital. For reasons of drug and medication safety, PN admixtures prepared for individual patients must be correctly labelled and specifications for storage conditions must also be followed during transport. Monitoring is required where applicable. Micronutrients are usually administered separately to AIO admixtures. In case compatibility and stability have been well documented trace elements and/or combination preparations including water-soluble or water-soluble/fat soluble vitamin supplements can be added to PN admixtures under strict aseptic conditions. AIO admixtures are usually not used as vehicles for drugs (incompatibilities).