Nutritional support for patients with intellectual disability and nutrition/dysphagia disorders in community care.

Patients with intellectual disability and neurological handicaps associated with swallowing difficulties are vulnerable to dehydration and undernutrition. Some patients are severely undernourished, a condition which is usually associated with recurrent food aspiration and respiratory infections. Underweight patients are usually provided with adequate dietary protein by carers: their low energy intakes reflect inadequate intakes of fat and carbohydrate. Many patients gain weight following the provision of easily assimilated energy-dense fat- and sugar-containing foods. Where these measures fail, the provision of a percutaneous endoscopic gastrostomy (PEG) tube may be life-saving. Optimal supervision of patients with severe nutrition/dysphagia problems requires a support network linking carers at home or in community care facilities with the primary health care team and the local district general hospital.

Plasma oxalate in patients with chronic renal failure receiving continuous ambulatory peritoneal dialysis or hemodialysis.

Plasma oxalate was measured in 20 patients receiving continuous ambulatory peritoneal dialysis (CAPD) and 20 patients receiving hemodialysis (HD). All patients had levels well above the reference range of less than 2.0 to 5.0 mumol/L (less than 0.18 to 0.44 mg/L), the medians being 34 mumol/L (2.99 mg/L) and 42 mumol/L (3.70 mg/L) for the two groups, respectively. Plasma oxalate did not differ significantly in the two groups. Plasma oxalate was not influenced by the number of months patients had received dialysis treatment, but a significant correlation was found between oxalate and creatinine in the 40 patients studied (P less than 0.02, r = 0.38). Predialysis oxalate levels were reduced by approximately 60% following HD, but returned to 80% of the predialysis levels within 24 hours and 95% within 48 hours. Oxalate levels did not differ significantly in samples taken before, during, and after exchanges of CAPD fluid. That the patients treated with CAPD did not have higher oxalate levels than the HD group suggests that the continuous nature of the former treatment compensates for the lower oxalate clearance by the peritoneum. The reported higher risk of oxalosis associated with intermittent peritoneal dialysis has led to a similar risk being postulated for CAPD; however, the present study indicates that if such a risk exists, it cannot be explained by higher levels of oxalate or ionized calcium in these patients.

Hypernatraemic dehydration in patients in a large hospital for the mentally handicapped.

OBJECTIVE: To determine the prevalence of hypernatraemic dehydration and to assess the hydration and nutritional state of patients in a large hospital for the mentally and physically handicapped; also to assess the efficacy of an intervention programme to reduce the prevalence of hypernatraemic dehydration in the hospital. DESIGN: Prospective study of patients admitted with hypernatraemic dehydration from a large hospital for mentally and physically handicapped patients (hospital A) to a district general hospital between 1986 and 1988. In 1986 the hydration and nutritional state of a random sample of patients from hospital A was compared with a random sample of patients from a small hospital for the physically and mentally handicapped (hospital B) and with control groups from the community. The hydration of the patients from hospital A examined in 1986 was reassessed in 1988. PATIENTS: 12 Patients were admitted from hospital A to the district general hospital during 1986-8 (seven women, five men; age range 29-82). In 1986, 72 patients were randomly selected for the assessment of hydration and nutritional state from hospital A, 33 who required help with feeding and 39 who could feed independently. Fifty patients were similarly selected from hospital B, half of them requiring help with feeding. In 1988 the hydration state of 60 of the 72 patients from hospital was reassessed. Control values were taken from two published studies. INTERVENTIONS: In 1987 nursing staff in hospital A were asked to provide between 2.5 and 3.0 litres of fluid daily for all patients. The use of hypertonic enemas was discontinued, and the ratio of staff to patients was increased. MAIN OUTCOME MEASURES: Serum concentrations of urea and electrolytes (hydration) and body mass index (nutritional state). RESULTS: Of the 10 patients admitted with hypernatraemic dehydration from hospital A to the district general hospital in 1986, four died of intercurrent infection. No patients were admitted from hospital B with hypernatraemic dehydration during the same time. In 1986 the hydration and nutritional state of patients in hospital A were inferior to those in patients from hospital B and control subjects from the community (serum urea concentrations were 6.1 (SD 1.8) mmol/l v 5.5 (1.9) and 5.6 (0.4) mmol/l, respectively) 50% (36/72) of patients in hospital A had a body mass index less than or equal to 20 compared with 34% (17/50) of patients from hospital B and 12% (1141/9434) of control subjects). After the initiation of the preventive programme only one patient was admitted with hypernatraemic dehydration in each of the years 1987 and 1988. The mean serum urea concentration of the 60 patients who were reassessed in 1988 fell significantly between 1986 and 1988 from 6.1 (SD 1.8) mmol/l to 5.7 (2.1) mmol/l, the value in a control group matched for age and sex. CONCLUSIONS: Hypernatraemic dehydration, subclinical underhydration, and undernutrition were common in a large hospital for the mentally and physically handicapped. The problem of hypernatraemic dehydration was successfully dealt with by the hospital management team. Similar problems may be encountered in hospitals for patients who are mentally and physically handicapped and mentally ill, including psychogeriatric units.

A simple, rapid assay for plasma oxalate in uraemic patients using oxalate oxidase, which is free from vitamin C interference.

An enzymatic assay for the determination of oxalate in plasma was developed which is specific, simple, rapid and requires no specialised equipment; interference from vitamin C was removed by incubation of acidified plasma ultrafiltrate with ascorbate oxidase prior to oxalate estimation. Recoveries were 93 +/- 11% and the inter-batch coefficient of variation for 31 determinations at an oxalate level of 24 mumol/l was 10%. The assay is linear up to 300 mumol/l with a detection limit of 2 mumol/l. The reference range, based on results from 25 healthy volunteers, was defined as less than 2-5 mumol/l which is similar to levels established for the in vivo isotope dilution technique. The assay has an added advantage over the latter method, which requires a urine collection, in that it can be applied to plasma from anuric patients. A linear correlation (r = 0.68, p less than 0.001) was found between plasma oxalate and serum creatinine in individuals with varying degrees of renal failure.

Serum and peritoneal dialysate thyroid hormone levels in patients on continuous ambulatory peritoneal dialysis.

Thyroid function tests were performed on 16 clinically euthyroid patients with end-stage renal failure undergoing regular haemodialysis or continuous ambulatory peritoneal dialysis and compared with 8 healthy subjects. The patient groups were carefully matched, especially regarding relative duration of dialysis (mean of 24 months). Total serum thyroxine, total triiodothyronine, free thyroxine, free triiodothyronine and reverse triiodothyronine were significantly lower in both patient groups than control. The thyrothrophin response to the standard thyrotrophin-releasing hormone test was delayed and blunted. Using a novel concentration technique we measured loss of T4 in peritoneal dialysate effluent and found it to be approximately 10% of daily thyroidal T4 release.

Ploidy and progesterone-receptor distribution in flow-sorted deciduomal nuclei.

Nuclei from rat uterine deciduomata were analysed and sorted into different ploidy classes in a fluorescence-activated cell sorter. The highest proportion of 8 n and 16 n nuclei was observed on days 6-7 after decidualization. At this time the progesterone receptor content per unit DNA of the octaploid nuclei was less than half that of the diploid nuclei.

Nuclear progesterone and estradiol receptors in deciduomata induced in ovariectomised rats.

The levels of nuclear progesterone and estradiol receptors have been followed during the development and decline of deciduomata induced in the uteri of ovariectomised rats. There were broadly 2 phases of deciduomal growth, the first phase being associated with high estrogen nuclear receptor levels per unit DNA. Progesterone nuclear receptor levels did not greatly change (in relation to DNA content) during both phases of full deciduomal development but peak levels were observed on day 5 after decidualization. Alkaline phosphatase activity was maximal by day 3, before peak hormone receptor levels were reached in the nuclei.