Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients.

BACKGROUND: A trial in selected men suggested that antibiotic therapy could be an alternative to appendicectomy in appendicitis. This study aimed to evaluate antibiotic therapy in unselected men and women with acute appendicitis. METHODS: Consecutive patients were allocated to study (antibiotics) or control (surgery) groups according to date of birth. Study patients received intravenous antibiotics for 24 h and continued at home with oral antibiotics for 10 days. Control patients had a standard appendicectomy. Follow-up at 1 and 12 months was carried out according to intention and per protocol. RESULTS: Study and control patients were comparable at inclusion; 106 (52.5 per cent) of 202 patients allocated to antibiotics completed the treatment and 154 (92.2 per cent) of 167 patients allocated to appendicectomy had surgery. Treatment efficacy was 90.8 per cent for antibiotic therapy and 89.2 per cent for surgery. Recurrent appendicitis occurred in 15 patients (13.9 per cent) after a median of 1 year. A third of recurrences appeared within 10 days and two-thirds between 3 and 16 months after hospital discharge. Minor complications were similar between the groups. Major complications were threefold higher in patients who had an appendicectomy (P < 0.050). CONCLUSION: Antibiotic treatment appears to be a safe first-line therapy in unselected patients with acute appendicitis. REGISTRATION NUMBER: NCT00469430 (http://www.clinicaltrials.gov).

Collagen degradation products modulate matrix metalloproteinase expression in cultured articular chondrocytes.

Destruction of collagen within osteoarthritic cartilage depends in part on collagen-degrading matrix metalloproteases (MMP). Degradative fragments of type II collagen (Col II) occur in normal and in osteoarthritic cartilage, and may contribute to regulation of matrix turnover by interfering with normal cell-matrix communication pathways. Therefore, the effects of different types of collagen fragments on mRNA and protein levels of MMP-2, MMP-3, MMP-9, and MMP-13 in cultured bovine articular knee chondrocytes and explants were examined. Primary chondrocytes and explants were incubated with fragments from whole cartilage collagen matrix (Colf) and from purified type II collagen (Col2f), or with a synthetic 29-mer peptide representing the amino-terminal domain of type II collagen (Ntelo). Gelatin zymography revealed increases of proMMP-2, a shift towards active MMP-2 and increases in proMMP-9, depending on the type of fragment. In situ hybridization of cartilage sections displayed MMP-3 mRNA in virtually all cells. Moderate to strong increases in MMP-2, MMP-3, MMP-9, and MMP-13 mRNA levels were detected by quantitative PCR. The results demonstrate stimulating effects of collagen fragments on both mRNA and/or protein from MMP -2, -3, -9, and -13, and suggest a novel mechanism of MMP induction and activation that includes a particular role for N-telo in controlling catabolic pathways of matrix turnover.

Ethical and legal aspects of enteral nutrition.

European ethical and legal positions with regard to EN vary slightly from country to country but are based on a common tradition derived from Graeco Roman ideas, religious thought and events of the 20th century. The Hippocratic tradition is based on 'beneficience' (do good) and 'non-maleficience' (do no harm). Religious thinking is based upon the presumption of providing food and drink by whatever means unless burden outweighs benefit. The concept of 'autonomy' (the patients right to decide) arose following in the decades after the Second World War and is enshrined in Human Rights law. The competent patient has the right to participate in decision making and to refuse treatment although the doctor is not obliged to give treatment which he or she considers futile or against the patient's interests. The incompetent patient is protected by law. The fourth principle is that of 'justice' i.e. equal access to healthcare for all. The law regards withholding and withdrawing treatment as the same. It also defines the provision of food and drink by mouth as basic care and feeding by artificial means as a medical treatment. It requires doctors to act in the best interests of the patient.

Anti-inflammatory treatment may prolong survival in undernourished patients with metastatic solid tumors.

Eicosanoids may be important factors for tumor cell proliferation, metastatic formation, and development of cancer cachexia. The present study has evaluated the effect of anti-inflammatory treatment on tumor progression in clinical cancer. Patients (n = 135) with insidious or overt malnutrition due to generalized malignancy (various kinds of solid tumors) and an expected survival of more than 6 months were randomized by a computer-based algorithm to receive placebo, prednisolone (10 mg twice daily), or indomethacin (50 mg twice daily) p.o. until death. Patient groups were stratified in the randomization procedure for sex, tumor type, stage, nutritional state, and previous tumor treatment, and biochemical, physiological, and some functional variables (Karnowsky index, fatigue and pain score). A majority of these variables was then registered during the follow-up. Indomethacin and prednisolone treatment maintained Karnowsky index, while placebo-treated patients experienced a decreased index. Indomethacin-treated patients suffered less pain and consumed less additional analgetics compared to the other patient groups. Indomethacin prolonged mean survival compared to placebo-treated patients from 250 +/- 28 days to 510 +/- 28 days (P < 0.05). Survival analysis on observations from all patients treated with either indomethacin or prednisolone demonstrated a significantly prolonged survival by anti-inflammatory treatment compared to placebo treatment (log rank, P < 0.03). The results suggest that not only may prostaglandin synthesis inhibition offer palliative support to patients with solid advanced cancer, but it may also impact on pathways that ultimately determine outcome.

Protection of metabolic and exercise capacity in unselected weight-losing cancer patients following treatment with recombinant erythropoietin: a randomized prospective study.

This study was aimed at evaluating whether anemia could be prevented in unselected weight-losing cancer patients on anti-inflammatory treatment by early and prophylactic treatment with recombinant human erythropoietin (rhEPO) and whether such a benefit could be translated into improved physical function and metabolic efficiency. One hundred eight cancer patients who experienced progressive cachexia due to solid, mainly gastrointestinal tumors were randomized to receive twice daily a cyclo-oxygenase inhibitor (controls; indomethacin, 50 mg twice a day) or indomethacin and erythropoietin, provided on individual basis to prevent development of progressive anemia (study patients; indomethacin, 50 mg twice a day plus rhEPO; range, 12,000-30,000 units per week). All patients were treated and followed up until death or to preterminal stage. Biochemical tests (blood, liver, kidney, and thyroid), nutritional state assessment (food intake and body composition), and exercise testing with simultaneous measurements of respiratory gas exchanges before and during exercise were performed before institution of treatments and then at regular intervals during the treatment period (2-30 months after start). Study and control patients did not differ in survival. rhEPO prevented development of anemia during the entire observation period. This was associated with a significantly more preserved maximum exercise capacity in study patients compared to control patients during the follow-up period (101 +/- 10 versus 66 +/- 6 W; P < 0.0001), based on more effective ventilation and whole-body respiratory gas exchanges. These improvements were also evident when exercise performance was normalized to lean body mass, an indirect measure of the skeletal muscle mass. The metabolic efficiency, expressed as oxygen uptake per watt produced, was also significantly preserved in rhEPO-treated patients compared to controls (14.1 +/- 1.1 versus 16.3 +/- 0.9 ml O2/W, P < 0.05). Our results demonstrate that institution of early and prophylactic rhEPO treatment to patients with progressive cancer prevents development of tumor-induced anemia. This achievement was associated with a better preserved exercise capacity, which is explained in part by improved whole-body metabolic and energy efficiency during work load.

Beta-adrenoceptor activity and resting energy metabolism in weight losing cancer patients.

This study was aimed at comparing the blocking of beta-adrenoceptor activity to changes in the resting energy metabolism of 10 cancer patients with progressive weight loss due to solid malignant tumours. Resting energy expenditure (REE) as well as whole body carbohydrate and fat oxidation were investigated and related to plasma substrate levels (glucose, glycerol, free fatty acids (FFA)) before and after 5 days of oral administration of specific beta1 receptor blocker (atenolol, 50 mg/day) and non-specific beta1,beta2-adrenoceptor (propranolol, 80 mg/day) blockade. The administration order of the drugs was random, and a 3-day washout period was used in all individuals between the provision of the first and the second drug in order to minimise the risk of carry-over effects. Resting measurements in the morning after an overnight fast were performed by indirect calorimetry. Atenolol treatment reduced REE by 77+/-14 kcal/day and propranolol by 48+/-13 kcal/day, respectively (P<0.05 versus pretreatment values). Whole body oxygen uptake and carbon dioxide production were decreased similarly by both atenolol and propranolol treatment (P<0.05). Carbohydrate oxidation was increased by atenolol and decreased by propranolol, whilst fat oxidation was decreased by atenolol and unchanged by propranolol. The decrease in REE, accounting for the decline in heart rate, was significantly more pronounced following treatment with propranolol compared with atenolol (P<0.05). Atenolol and propranolol had no effect on blood glucose, plasma glycerol and FFA. We conclude that wastage in cancer patients is in part explained by increased beta(1) and beta(2)-adrenoceptor activity, in part secondary to elevated cardiovascular activity as a result of anaemia, loss of cardiac contractile capacity and altered host metabolism.

Elevated energy expenditure in cancer patients with solid tumours.

Cancer patients (n = 106) and non-cancer subjects (n = 96) were classified as weight stable (n = 70) or weight-losing (n = 132). Cancer patients had elevated resting energy expenditure (REE) compared with either weight-losing (23.6 [0.4] vs. 20.5 [0.5] kcal/kg per day, P less than 0.001) or weight-stable controls (22.0 [0.6] vs. 17.9 [0.4], P less than 0.001). Cancer patients had increased fat oxidation irrespective of weight loss (1.24 [0.07] vs. 0.87 [0.04] mg/kg per min; 1.07 [0.04] vs. 0.78 [0.04], P less than 0.001). Elevated energy expenditure was counter-regulated by a decrease in thyroid hormones. Abnormal liver function had no impact on REE in either group. Heart rate was the most powerful factor for prediction of high energy expenditure in both patients and controls. Elevated energy expenditure was related to the increased heart rate in cancer patients in a significantly higher proportion than that in controls. Increased metabolic rate is a significant component behind weight loss in cancer disease, independent of malnutrition and an elevated adrenergic state may be a likely explanation.

Structured triglycerides to postoperative patients: a safety and tolerance study.

Long-chain triglycerides are still the standard in fat emulsions, although medium-chain triglycerides have been suggested to have metabolic advantages even though pure medium-chain triglycerides are toxic in large doses. The next generation of fat emulsions may be structured triglycerides, which are assumed to provide a higher oxidation rate, faster clearance from blood, improved nitrogen sparing, and less of a tendency to accumulate in the reticuloendothelial system compared with long-chain triglyceride emulsions. This study was designed to evaluate the safety and tolerance of structured triglyceride fat emulsion 73403 (Kabi Pharmacia Parenterals, Stockholm, Sweden) compared with that of a standard long-chain triglyceride emulsion (Intralipid 20%) in postoperative patients requiring total parenteral nutrition after major surgery. The study was randomized and of the double-blind, parallel group type. Twenty patients were included and treated for 5 to 7 days. Safety and tolerance variables demonstrated no major differences between the study and control groups. Physiologic and biochemical variables suggested that structured lipids were rapidly cleared and metabolized. This study represents the first report of administration of structured triglycerides to postoperative patients. The structured triglyceride emulsion (73403) demonstrated no difference in safety and tolerance compared with Intralipid 20%. Therefore, it will now be possible to follow up with studies on metabolic efficiencies of structured triglycerides in postoperative patients.

The effect on energy and nitrogen metabolism by continuous, bolus, or sequential infusion of a defined total parenteral nutrition formulation in patients after major surgical procedures.

BACKGROUND: The role of IV infusion kinetics to explain nutrition efficiency was investigated in patients after major surgical procedures. METHODS: IV nutrition was provided as three different infusion kinetic regimens in a randomized fashion. All patients received nonprotein calories (100% of predicted preoperative REE, 60% D-glucose, 40% fat) and amino acid nitrogen (0.2 g N/d). Group A: Nutrition was provided by sequential infusion with combined fat and amino acids during daytime and glucose alone during nighttime ("sequential infusion"). Group B: Patients received 24-hour combined infusion with fat, amino acids, and glucose (all in one mixture) ("continuous infusion"). Group C: Nutrition was provided by bolus infusions during 1 hour followed by 2 hours without any infusion ("bolus infusion"). RESULTS: The daily energy balance was negative in all groups (-318 +/- 25 kcal/d, sequential infusion; -368 +/- 25 kcal/d continuous infusion; -292 +/- 20 kcal/d, bolus infusion). Significantly different excretion patterns of nitrogen in urine occurred among the groups despite an almost identical provision of nitrogen. Continuously infused patients retained nitrogen significantly better (-0.2 +/- 0.6 g/d) compared with sequentially (-3.4 +/- 1.0 g/d) and bolus-infused patients (-2.8 +/- 0.3 g/d) (p < .01), whereas their cumulative urinary glucose excretion was significantly larger. Continuously infused patients were in cumulative nitrogen balance during the entire postoperative period, whereas the other groups were in a significantly negative nitrogen balance. Urinary 3-methylhistidine excretion was similar in all groups. CONCLUSIONS: The breakdown of muscle proteins was not sensitive to alterations in nutrient and substrate supply. Thus improved nitrogen retention reflected entirely improved synthesis. "All-in-one" IV nutrition with prolonged infusion periods is at present the most favorable regimen considering both the nutritional efficiency and its metabolic load on the organism after major surgery.

Structured triglycerides were well tolerated and induced increased whole body fat oxidation compared with long-chain triglycerides in postoperative patients.

BACKGROUND: It has been proposed, on the basis of animal experiments, that medium-chain triglycerides (MCT) may exert more favorable effects on whole body metabolism of injured animals than long-chain triglycerides (LCT). Therefore, the present study was designed to evaluate whether structured triglycerides are associated with increased whole body fat oxidation without promotion of ketogenesis in postoperative patients. METHODS: A structured lipid emulsion (73403 Pharmacia, Sweden) containing medium- and long-chain fatty acids, esterified randomly to glycerol in a triglyceride structure, was used. Whole body fat oxidation was determined by indirect calorimetry in the postoperative period. Patients were randomized to receive structured lipids 1 day followed by LCT (Intralipid, Pharmacia) the next day or vice versa during 6 postoperative days. In part 1 of the study patients received fat at 1.0 g/kg per day in the presence of 80% of the basal requirement of nonprotein calories. In part 2 patients received fat at 1.5 g/kg per day in the presence of 120% of the nonprotein caloric requirement. Amino acids were always provided at 0.15 g N/kg per day. RESULTS: Structured lipids were not associated with any side effects, were rapidly cleared from the plasma compartment, and were rapidly oxidized without any significant hyperlipidemia or ketosis. Provision of structured lipids in the presence of excess of nonprotein calories (part 2) caused a significantly higher whole body fat oxidation (2.4 +/- 0.05 g/kg per day) compared with LCT provision (1.9 +/- 0.06 g/kg per day) (p < .0001) examined in the same patients. CONCLUSIONS: The results demonstrated for the first time in man that provision of structured triglycerides were associated with increased whole body fat oxidation in stressed postoperative patients, which is in line with the original metabolic and biochemical concept for structured triglycerides. The study provided evidence to support that structured lipids may represent a next generation of IV fat emulsions that may be clinically advantageous compared with conventional LCT emulsions in certain clinical conditions.

Metabolic rate and nitrogen balance in patients receiving bolus intermittent total parenteral nutrition infusion.

The present study investigated whether infusion principles are significant factors that influence the nutritional efficiency of complete intravenous nutrition. For this purpose, three infusion modalities were evaluated in patients who underwent elective and uncomplicated cholecystectomy. The nutrition regimens were as follow: group 1, sequential infusion of fat plus amino acids at a constant rate over 12 hours during daytime followed by glucose infusion at a constant rate for 12 hours during nighttime; group 2, simultaneous infusion of all substrates at a constant rate over 24 hours; and group 3, simultaneous infusion of all substrates with bolus-based intermittent infusions during 60 minutes six times per day (24 hours). Nonprotein calories corresponded to 160% of the individually measured resting need and were provided as 60% carbohydrate and 40% fat. Nitrogen was provided as crystalline amino acids in solution at 0.2 g of nitrogen per kilogram per day. All patients were randomized into three comparable groups. Intermittent nutrition (group 3) was associated with a significantly higher thermic effect, which led to a significantly lower although still positive energy balance than either sequential nutrition (group 1) or constant nutrition (group 2). The mean daily nitrogen balance was, however, significantly improved in patients receiving intermittent nutrition, and this was accompanied by much higher plasma insulin levels as well as higher plasma amino acid concentrations. This study demonstrates that all substrates should be given simultaneously and that supplementation of intravenous nutrition in boluses, similar to meal feeding, gave the most pronounced protein accretion when compared with either sequential administration of total parenteral nutrition or administration of all admixtures with constant infusion over 24 hours.(ABSTRACT TRUNCATED AT 250 WORDS)

Registered Replication Report: Schooler and Engstler-Schooler (1990).

Trying to remember something now typically improves your ability to remember it later. However, after watching a video of a simulated bank robbery, participants who verbally described the robber were 25% worse at identifying the robber in a lineup than were participants who instead listed U.S. states and capitals-this has been termed the "verbal overshadowing" effect (Schooler & Engstler-Schooler, 1990). More recent studies suggested that this effect might be substantially smaller than first reported. Given uncertainty about the effect size, the influence of this finding in the memory literature, and its practical importance for police procedures, we conducted two collections of preregistered direct replications (RRR1 and RRR2) that differed only in the order of the description task and a filler task. In RRR1, when the description task immediately followed the robbery, participants who provided a description were 4% less likely to select the robber than were those in the control condition. In RRR2, when the description was delayed by 20 min, they were 16% less likely to select the robber. These findings reveal a robust verbal overshadowing effect that is strongly influenced by the relative timing of the tasks. The discussion considers further implications of these replications for our understanding of verbal overshadowing.

Bioelectric impedance spectroscopy underestimates fat-free mass compared to dual energy X-ray absorptiometry in incurable cancer patients.

BACKGROUND/OBJECTIVES: Weight loss is frequently seen in advanced cancer. Bioelectrical impedance spectroscopy (BIS) is a convenient method for estimating body composition. We examined in a prospective, comparative study if BIS could accurately estimate fat-free mass (FFM) in cancer patients compared to dual-energy X-ray absorptiometry (DXA). SUBJECTS/METHODS: The study was based on 132 consecutive incurable cancer patients with solid tumours in a University hospital outpatient clinic. Comparison of FFM from DXA and BIS with standard and revised equations. Bland-Altman plots, t-tests and linear regression analysis were used to evaluate agreement and differences between methods. RESULTS: BIS significantly underestimated mean FFM with 7.6+/-4.7 kg compared to DXA (P<0.001). Bias was significantly correlated to % weight loss (r=0.32), systemic inflammation as measured by C-reactive protein (r=0.29), malnutrition as assessed by low insulin-like growth factor-1 (r=-0.23) and inversely to the per cent body fat estimated by DXA (P=-0.61) and body mass index (BMI; r=-0.30). Revised BIS equations taking BMI into account reduced bias significantly but still with great individual variation. CONCLUSIONS: BIS by standard equations grossly underestimates FFM compared to DXA in cancer patients. This bias is related to weight loss, malnutrition and systemic inflammation. Revised equations improved FFM estimates, but with large individual variation. Thus, BIS with standard equations is not suitable to estimate FFM in patients with cachexia, inflammation and malnutrition.

[Defining the role of in vitro fertilization and embryo transfer in humans]. / Positionsbestimmung zur In-vitro-Fertilisierung und zum Embryotransfer beim Menschen.

Based on socialist moral and law recommendations about clinical use of in vitro fertilization and application of human oocytes and early embryonal stages in the German Democratic Republic have been formulated as a result of interdisciplinary discussion.

[Ethical questions and marginal problems in assisted reproduction]. / Ethische Fragen und Randprobleme der assistierten Reproduktion.

Assisted reproduction is subject of ethical controversies as it depends very much on our understanding of both the human being and of individual dignity. The ethical and technical boundaries have changed very much over the last decades. The main focus of the debate until the eighties was to avert manipulation and hazards to human health (surrogate mothers, chimeras). Speculations which exceeded the real possibilities of biomedicine were common. Finally the technology was restrained by an ethical and legal framework: in Germany the parliament passed the "Embryo protection act" (Embryonenschutzgesetz). Since the beginning of the nineties the focus of ethical problems has shifted towards the legal overregulation, which is in fact hampering the application of helpful and humane technology, like for instance preimplantation diagnosis. Ethical discussion and analysis should be directed at regulations that promote the dignity of the individual as well as the search of consensus positions, which can live up to the realities of a pluralistic society.

[Sarcoidosis of the optic nerve]. / Sarkoidose des Nervus opticus.

BACKGROUND: Rarely an affection of the optic nerve is seen as the initial or only manifestation of sarcoidosis. Therefore the disease is often diagnosed late. The aim of systemic corticosteroid therapy is to prevent progression though it cannot yield a cure. PATIENT AND METHOD: Despite a high-dose corticosteroid therapy in suspected optic neuritis a 25-year-old woman developed unilateral amaurosis. When visual acuity continuously decreased in the second eye a computerized tomography was performed, which suggested a tumor of the optic nerve. A biopsy of this lesion lead to the diagnosis of Boeck's disease. A long-term corticosteroid therapy was initiated. Over the following 9-year period corticosteroids were dosed according to the results of regular clinical and perimetrical examinations (200 examinations with Octopus-Perimeter 201, program G1). In case of deterioration of the visual field higher oral doses were applied. When no improvement was achieved by this, corticosteroids were given intrathecally. Under this therapeutic regime no systemic side effects were seen. CONCLUSION: In unilateral visual loss Boeck's disease should be considered as a rare etiology. In case of clear optical media frequent computerized perimetry allows the neurologist to adjust the dosage of cortisone and minimize its side effects.

Tetracycline residues in meat and bone meals. Part 1: methodology and examination of field samples.

The incidence of tetracycline residues in commercially available samples of meat meals and meat and bone meals was investigated. Four different methods were used on each of the 87 samples from nine different rendering plants in Germany: examination using a screening fluorescence test; examination by high performance liquid chromatography analysis using three different extraction procedures (succinate buffer, hydrochloric acid, hydrochloric acid after sedimentation of bone particles). Tetracyclines were found in 100% of the samples by one or more of the extraction procedures. The highest concentrations found in meat meals were 2048 microgkg(-1), 1393 microgkg(-1) and 608 microgkg(-1) for oxytetracycline, tetracycline and chlortetracycline, respectively. In meat and bone meals the highest concentrations were 2295 microg oxytetracycline kg(-1) 848 microg tetracycline kg(-1) and 1274 microg chlortetracycline kg(-1). The extraction after sedimentation was the most effective of the applied extraction procedures and exposed the highest total tetracycline concentrations. The results of this investigation showed that considerable amounts of tetracyclines have to be expected in field samples. Further research has to be done on the heat stability of bound tetracycline residues.

Tetracycline residues in meat and bone meals. Part 2: the effect of heat treatments on bound tetracycline residues.

The stability of bound tetracycline residues during heat treatments at 133 degrees C and 100 degrees C for up to 45 min was investigated. An intermediate product from a rendering plant was mixed with bone splinters that contained bound tetracycline (TC) and chlortetracycline (CTC) residues. The mixture was heated in an autoclave at 133 degrees C for 20, 30 and 45 min and at 100 degrees C for 20 and 30 min and subsequently dried at 103 degrees C for 4 h. Two different extraction procedures with hydrochloric acid were used, one with and one without the previous sedimentation of bone particles. Tetracycline concentrations were determined by HPLC analysis before and after the heat treatment. A complete destruction of tetracyclines during heat treatment at 133 degrees C could not be demonstrated, but there was a significant decrease of TC by about 50%. CTC was less resistant to the same temperature, which brought about a reduction of 90-100%. Treatment at 100 degrees C did not bring about any reduction, except for CTC after extraction without sedimentation. The possible toxicological relevance of the findings is discussed. Further research has to be done on possible degradation products of the tetracycline derivatives.

Evaluation of mechanisms behind elevated energy expenditure in cancer patients with solid tumours.

The aim of this study was to demonstrate significant factors behind elevated resting energy expenditure in weight-losing cancer patients. Therefore, weight-losing cancer patients (n = 60), with normal liver and kidney function tests, were randomized to receive one of four drug treatments for 5 days: (a) Propranolol 80 mg x 2 (beta-adrenoceptor blockade); (b) Indomethacin 50 mg x 2 (prostaglandin synthesis inhibition); (c) Morphine 5 mg x 3 (pain relief) or (d) Placebo x 2. A reference group of healthy well-nourished individuals were examined outside the formal randomization protocol and they received Propranolol 80 mg x 2. The cancer patients were randomized by a computer based algorithm stratifying for measured resting energy expenditure (REE), body composition, biochemical tests, previous therapy, tumour type and tumour stage. Resting energy expenditure was measured by indirect calorimetry in the morning after an overnight fast before and after drug treatment. beta-blockade reduced REE significantly in cancer patients from 1416 +/- 95 kcal day-1 to 1160 +/- 63 kcal day-1 (P < 0.02) and from 1472 +/- 69 vs, 1398 +/- 63 kcal day-1 (P < 0.01) in the well-nourished reference individuals. The reduction found in cancer patients (10%) was significantly larger than that in the group of reference patients (5%), (P < 0.01). Indomethacin, morphine or placebo did not induce any significant alteration in energy expenditure in our cancer patients. Propranolol treatment was associated with a significant reduction in plasma concentrations of free fatty acids (FFA), but not in plasma glycerol.(ABSTRACT TRUNCATED AT 250 WORDS)