New horizons in appetite and the anorexia of ageing.

Appetite drives essential oral nutritional intake. Its regulation is complex, influenced by physiology, hedonism (the reward of eating) and learning from external cues within a person's society and culture. Appetite loss is common in the older population and not always attributable to medical conditions or treatment. Although the physiological basis of the anorexia of ageing (loss of appetite due to the ageing process) has been established, the effect of ageing on hedonism and external cues, which may be equally important, is less well understood. The anorexia of ageing is associated with reductions in dietary diversity and oral intake, and increased risk of malnutrition, sarcopenia and frailty. Early identification of poor appetite could allow timely intervention before weight loss occurs. There is no standardised tool for assessing appetite in clinical settings at present but the 4-item Simplified Nutritional Appetite Questionnaire (SNAQ) has the potential to be used in this way. This review, designed for clinicians, will discuss the regulation of appetite and the pathogenesis of the anorexia of ageing. It will describe the current evidence for interventions to manage the anorexia of ageing, which is limited, with little benefit reported from individual studies of education, physical activity and medication. There is some positive evidence for flavour enhancement, fortified food and oral nutritional supplements but mainly within single studies. Looking ahead, the aim is to develop multicomponent approaches to the treatment of the anorexia of ageing based on growing understanding of the role of physiological signalling, hedonism and external cues.

Phase I dose-finding study for melatonin in pediatric oncology patients with relapsed solid tumors.

BACKGROUND: Melatonin is a natural health product used for sleep disturbances. In preliminary studies of adults with advanced cancer, 20 mg of melatonin daily was associated with reduction in anorexia and weight loss-symptoms that also impact pediatric oncology patients. High doses of melatonin have not been studied in pediatrics. METHODS: This was a multicenter single-arm phase I dose-escalation study utilizing a 3 + 3 design to determine the safety and tolerability of escalating doses of melatonin in pediatric oncology patients with relapsed solid tumors. Melatonin was given for 8 weeks at three dose levels-0.075 mg/kg (maximum 5 mg), 0.15 mg/kg (maximum 10 mg), and 0.3 mg/kg (maximum 20 mg). RESULTS: Melatonin was well tolerated at all three dose levels with no significant adverse events or dose-limiting toxicities. The only grade 3/4 toxicities were myelosuppression, which was attributed to the concomitant chemotherapy and occurred at all dose levels. Weight gain occurred in seven of nine patients, with a median increase of 1.1 kg (range -3.3 to 4.5) or 3.4% (range -10.2 to 8.7), with two patients losing weight (one in dose level 1 and one level 3). CONCLUSIONS: Melatonin is well tolerated at a dose of 0.3 mg/kg (maximum 20 mg), in the pediatric population. This study provides the background for further study of high-dose melatonin in pediatric oncology patients.

Assessing pathophysiology of cancer anorexia.

PURPOSE OF REVIEW: Cancer anorexia is a negative prognostic factor and is broadly defined as the loss of the interest in food. However, multiple clinical domains contribute to the phenotype of cancer anorexia. The characterization of the clinical and molecular pathophysiology of cancer anorexia may enhance the efficacy of preventive and therapeutic strategies. RECENT FINDINGS: Clinical trials showed that cancer anorexia should be considered as an umbrella encompassing different signs and symptoms contributing to appetite disruption in cancer patients. Loss of appetite, early satiety, changes in taste and smell are determinants of cancer anorexia, whose presence should be assessed in cancer patients. Interestingly, neuronal correlates of cancer anorexia-related symptoms have been revealed by brain imaging techniques. SUMMARY: The pathophysiology of cancer anorexia is complex and involves different domains influencing eating behavior. Limiting the assessment of cancer anorexia to questions investigating changes in appetite may impede correct identification of the targets to address.

An innovative solid oral nutritional supplement to fight weight loss and anorexia: open, randomised controlled trial of efficacy in institutionalised, malnourished older adults.

BACKGROUND AND OBJECTIVE: To evaluate the impact of a solid nutritional supplement on the weight gain of institutionalised older adults>70 years with protein-energy malnutrition. The innovation of these high-protein and high-energy cookies was the texture adapted to edentulous patients (Protibis®, Solidages, France). DESIGN: An open, multicentre, randomised controlled trial. SETTING: Seven nursing homes. PARTICIPANTS: One hundred and seventy-five malnourished older adults, aged 86±8 years. INTERVENTION: All participants received the standard institutional diet. In addition, Intervention group participants received eight cookies daily (11.5 g protein; 244 kcal) for 6 weeks (w0-w6). MEASUREMENTS: Five visits (w-4, w0, w6, w10 and w18). MAIN OUTCOME: Percentage of weight gain from w0 to w6 (body mass in kg). SECONDARY OUTCOMES: Appetite, rated using a numerical scale (0: no appetite to 10: extremely good appetite); current episodes of pressure ulcers and diarrhea. RESULTS: Average weight increased in Intervention group (n=88) compared with Control group (n=87) without cookies supplementation (+1.6 versus -0.7%, P=0.038). Weight gain persisted 1 month (+3.0 versus -0.2%, P=0.025) and 3 months after the end of cookies consumption (+3.9 versus -0.9%, P=0.003), with diarrhea reduction (P=0.027). There was a synergistic effect with liquid/creamy dietary supplements. Subgroup analysis confirmed the positive impact of cookies supplementation alone on weight increase (P=0.024), appetite increase (P=0.009) and pressure ulcers reduction (P=0.031). CONCLUSION: The trial suggested that, to fight against anorexia, the stimulation of touch (finger food; chewing, even on edentulous gums) and hearing (intra-oral sounds) could be valuable alternatives to sight, smell and taste alterations.

Severe and prolonged hypophosphatemia after intravenous iron administration in a malnourished patient.

Malnutrition may result in a phosphate-deficient state owing to a chronically insufficient phosphate intake. Concomitant iron deficiency is common and often supplemented by the intravenous route. It is not widely recognized that some parenteral iron formulations can induce hypophosphatemia. Herein we report a case of a severe and symptomatic hypophosphatemia (0.18 mM, normal range 0.8-1.4 mM) associated with an inappropriately reduced tubular reabsorption of phosphate (33%, norm >95%) in a malnourished patient with anorexia/bulimia who received 2 × 500 mg iron carboxymaltose (FCM) intravenously. Despite intravenous and oral phosphate supplements, it required 2 months to achieve a normal serum phosphate level. Our case demonstrates that in a chronically malnourished and phosphate-deficient state intravenous FCM could potentially be dangerous. If this form of iron application cannot be avoided, phosphate supplementation before and after iron infusion as well as close monitoring of phosphate levels are needed.

Aquaporin-4 autoantibody: a neurogenic cause of anorexia and weight loss.

Neuromyelitis optica (NMO) is a severe inflammatory demyelinating disease often associated with a highly specific autoantibody, aquaporin-4 antibody. Although the classic syndrome involves the optic nerves and spinal cord, aquaporin-4 antibody has been important in defining the true spectrum of NMO, which now includes brain lesions in areas of high aquaporin-4 expression. Brainstem involvement, specifically area postrema involvement in the medulla, has been associated with intractable vomiting in some patients with NMO. We describe a 14-year-old female with positive aquaporin-4 antibody whose clinical course was dominated by severe anorexia with associated weight loss (from 68-41kg; body mass index 25.2-15.6). Magnetic resonance imaging showed lesions in the medulla, pons, and thalami. Although she had asymptomatic radiological longitudinally extensive transverse myelitis, she never had symptoms or signs referable to the spinal cord or the optic nerves. We propose that anorexia and weight loss should be considered part of the NMO spectrum, probably related to area postrema involvement.

Derrame pericárdico neoplásico infectado por Salmonella enteritidis / Pericardial overflow infected by Salmonell enteritidis

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Medical use of cannabis in the Netherlands.

The authors investigated the indications for cannabis prescription in the Netherlands and assessed its efficacy and side effects. A majority (64.1%) of patients reported a good or excellent effect on their symptoms. Of these patients, approximately 44% used cannabis for >/=5 months. Indications were neurologic disorders, pain, musculoskeletal disorders, and cancer anorexia/cachexia. Inhaled cannabis was perceived as more effective than oral administration. Reported side effects were generally mild.

Amenorrea, anorexia y deporte en adolescencia / Amenorrhea, anorexia and sport in the adolescence

La amenorrea es una patología que produce gran ansiedad tanto en la adolescente como en la mujer adulta. El objetivo del presente artículo es la revisión de la etiología, diagnóstico y tratamiento de la amenorrea en la adolescente, así como su relación con el deporte y la anorexia

Amenorrhea produces big anxiety in adolescence and women of all ages. The aim of this article is the study of aetiology, diagnosis and treatment of amenorrhea in adolescence and its relation with sports and anorexia

[Dronabinol (delta9-tetrahydrocannabinol) in long-term treatment. Symptom control in patients with multiple sclerosis and spasticity, neuropathic pain, loss of appetite and cachexia]. / Dronabinol (deltag-tetrahydrocannabinol) in der Langzeittherapie. Symptomkontrolle bei multipler Sklerose mit Spastik, neuropathischen Schmerzen, Appetitlosigkeit und Kachexie.

Cannabinoid drugs have been used increasingly in the treatment of neuropathic pain and spasticity. Even though the evidence still is scarce, patients with multiple sclerosis seem to benefit substiantially from cannabinoid therapy. In a case report dose finding and long-term therapie with delta9-tetrahydrocannabinol are described. Dronabinol proved effective and was well tolerated in long-term treatment. Pain was reduced significantly and opioid requirements decreased. At the same time spasticity was reduced and appetite and weight increased. It still needs to bei discussed whether or not part of the positive effect on symptoms was probably mediated by psychomimetic effects. This case report shows, that dronabinol offers an additional therapeutic option in a palliative treatment concept for patiens with high symptom load.

Tiflitis aguda: a propósito de un caso / Acute typhlitis: a case report

Se presenta un caso clínico de un paciente varón de 51 años que ingresó en nuestro hospital por presentar rectorragia. En el enema opaco se apreció una imagen de defecto de repleción en el ciego y en la colonoscopia una masa cecal necrosada que posteriormente expulsó con la defecación, siendo el resultado histopatológico de necrosis. Se decidió realizar una laparotomía exploradora encontrando como hallazgos significativos la inflamación de todo el ciego y del apéndice, así como la escara de implantación del pólipo expulsado y una masa submucosa paraapendicular, por lo cual se continuó la intervención con una hemicolectomía derecha. El diagnóstico de anatomía patológica fue de tiflitis aguda, una rara enfermedad cecal de la cual comentaremos algunos aspectos (AU)

Intoxicaciòn por inhibidores de la enzima acetilcolinesterasa / Intexication by inhibitos of the acetil cholinesterase enzyme

Con el objeto de determinar la incidencia de las intoxicaciones por inhibidores de la enzima acetil colimerasa, su distribuciòn de acuerdo a la edad y sexo, las causas, los sìntomas màs frecuentes, el tiempo promedio en que estos pacientes llegaron al Hospital a partir del momento de la ingestiòn y determinar el grado de gravedad de acuerdo a los sintomas presentados, es que se revisaron retrospectivamente los expedientes clìnicos de pacientes internados con este diagnòstico en el Hospital del niño "Dr. Ovidio Aliaga Uria" de la ciudad de La Paz desde enero de 1993 a diciembre de 1994. Se encontro que la intoxicacion por inhibidores de la enzima acetil colinesterasa representò el 0,68 porciento de los ingresos al Hospital; 62,5 porciento de ellos fueron varones, las edades fluctuaron entre 11 dìas y 13 años (promedio de 6.75 años), el 50 porciento de ellos llegaron al Hospital dentro de las primeras dos horas de haber ingerido el veneno 20 porciento de ellos recibieron remedios caseros antes de su ingreso; el 50 porciento fue manejado en el servicio de terapia intensiva; 6 pacientes se complicaron con broncoaspiraciòn y un paciente fallecio. El nùmero promedio de dosis de atropina utilizada como antidoto de la intoxicaciòn fue de 10,7 con una desviaciòn estàndar en 6,66. Se consideraron intoxicaciòn graves a 13 (32,5 porciento), moderados a 25 (62, 5 porciento) y leves a 2 (5 porciento). El tiempo de hospitalizaciòn promedio fue de 4.28 dìas

Anorexia infantil / Infant anorexia

En esta publicación se desarrolla específicamente el gran tema de la anorexia infantil. Se establecen en él las causas más comunes que pueden determinar su aparición, así como la sintomatología con la que habitualmente se expresa. Concluye el artículo con la lista de medicamentos más comúnmente utilizados dentro de nuestro arsenal terapéutico para tratarla con éxito (AU)

Anorexia infantil / Infant anorexia

En esta publicación se desarrolla específicamente el gran tema de la anorexia infantil. Se establecen en él las causas más comunes que pueden determinar su aparición, así como la sintomatología con la que habitualmente se expresa. Concluye el artículo con la lista de medicamentos más comúnmente utilizados dentro de nuestro arsenal terapéutico para tratarla con éxito