Defining the role of dietary intake in determining weight change in patients with cancer cachexia.

BACKGROUND & AIMS: Weight loss is a cardinal feature of cachexia and is frequently associated with reduced food intake and anorexia. It is still unclear how much reduced food intake contributes to cancer-related weight loss and how effective increasing dietary energy and protein is in combating this weight loss. The relationship between weight change and both diet and change in dietary intake, was examined in patients with advanced stage cancer referred to a multidisciplinary clinic for management of cancer cachexia. METHODS: A retrospective study of data for each of the first three clinic visits for patients seen between 2009 and 2015. Data on weight change, dietary intake and change in dietary intake were compared. Regression analysis was used to determine independent explanatory factors for weight change, including the impact of appetite level and a marker of systemic inflammation. RESULTS: Of 405 eligible patients, 320 had data on dietary intake available. Dietary intake varied widely at baseline: 26.9% reported very poor diet and only 17% were consuming recommended levels of energy and protein. A highly significant positive correlation was found between dietary energy or protein intake and weight change, both before and after being seen in the clinic. Anorexia was also significantly correlated with weight loss at each clinic visit. However, there was no similar overall correlation between change in dietary intake and change in weight. CONCLUSIONS: Many patients with advanced cancer and weight loss are consuming diets that would likely be insufficient to maintain weight even in healthy individuals. Higher consumption of protein and energy correlates with greater weight gain, but it is impossible to predict the response to increased nutritional intake when patients are first assessed. There is a pressing need to improve understanding of factors that modulate metabolic responses to dietary intake in patients with cancer cachexia.

A pan-Canadian practice guideline and algorithm: screening, assessment, and supportive care of adults with cancer-related fatigue.

PURPOSE: The purpose of the present systematic review was to develop a practice guideline to inform health care providers about screening, assessment, and effective management of cancer-related fatigue (crf) in adults. METHODS: The internationally endorsed adapte methodology was used to develop a practice guideline for pan-Canadian use. A systematic search of the literature identified a broad range of evidence: clinical practice guidelines, systematic reviews, and other guidance documents on the screening, assessment, and management of crf. The search included medline, embase, cinahl, the Cochrane Library, and other guideline and data sources to December 2009. RESULTS: Two clinical practice guidelines were identified for adaptation. Seven guidance documents and four systematic reviews also provided supplementary evidence to inform guideline recommendations. Health professionals across Canada provided expert feedback on the adapted recommendations in the practice guideline and algorithm through a participatory external review process. CONCLUSIONS: Practice guidelines can facilitate the adoption of evidence-based assessment and interventions for adult cancer patients experiencing fatigue. Development of an algorithm to guide decision-making in practice may also foster the uptake of a guideline into routine care.

Renal revascularization to preserve and restore renal function.

A total of 97 patients underwent 107 renal revascularization procedures for restoration and preservation of renal function. Of the 4 groups of high risk surgical patients that emerged an overall successful outcome was achieved in 83%, with a 6% mortality rate and an 11% morbidity rate. Renal revascularization for restoration and preservation of renal function can be performed safely with good results. The preoperative serum creatinine level was not predictive of the surgical outcome. Alternative bypass procedures are preferred.

Abdominal aortic aneurysms.

Modern surgical techniques permit repair of abdominal aortic aneurysms and prevent eventual rupture, with a mortality rate of only a few percent. Coronary heart disease is the chief cause of death, depriving the patient of an assumed improved life expectancy after successful operation for aneurysm. Therefore, aggressive preoperative cardiac evaluation, including coronary arteriography and perhaps more protective myocardial revascularization procedures, is indicated.

Changing concepts in surgical management of renovascular hypertension.

As newer surgical techniques and concepts have emerged, including revascularization of the totally occluded renal artery and alternatives to aortorenal bypass (hepatic, splenic, or iliac artery to renal artery grafts), our patient population has changed. Patients with diffuse atherosclerotic disease, bilateral renal artery stenosis, totally occluded renal arteries, and azotemia are being referred for renal revascularization, thereby changing the indications for operation and the results that can be anticipated. Although our results in patients operated on solely for uncontrollable hypertension or renal failure have been successful, much work needs to be done to improve the results obtained when patients have a combination of uncontrollable hypertension and renal failure.

Cerebral emboli of paradoxical origin.

A diagnosis of paradoxical cerebral embolus (PCE) was made in five patients aged 31 to 62 years who sustained eight cerebral ischemic events. No patient had evidence of primary carotid system or left heart disease. A probe-patent foramen ovale was the presumed mechanism in four patients, and an unsuspected congenital atrial septal defect was found in the fifth patient. Clinically apparent pulmonary emboli or venous thrombosis preceded the cerebral event in only one instance. Review of the literature reveals a high mortality with PCE. However, careful clinical search for this lesion may be rewarding: four of our five patients survived. One should consider PCE in any patient with cerebral embolus in whom there is no demonstrable left-sided circulatory source. This principle applies particularly if there is concomitant venous thrombosis, pulmonary embolism, or enhanced potential for venous thrombosis due to, for example, morbid obesity, use of hormonal birth control pills, prolonged bed rest (especially postoperatively), or systemic carcinoma.

Predictability of surgical cure of renovascular hypertension.

Seventy-five patients with renal artery stenosis were studied; 50 patients had unilateral lesions and 25 had bilateral lesions. Divided renal vein renins and peripheral renins were collected under strict salt intake, drug intake, and postural conditions. Divided renal vein renin ratios and a scoring system that included peripheral renin and affected and contralateral renal secretion of renin were applied to each patient and compared in each to the patient's ultimate surgical result. Both methods, if positive, are highly predictive of cure in patients with renal artery disease. Both methods are plagued by significant false-negative rates, 20% for renal vein ratio, 33% for the scoring system in patients with unilateral stenosis, and 35% and 48%, respectively, in patients with bilateral renal artery stenosis. For these reasons, surgical selection should be based on evaluation of a combination of the clinical presentation, angiographic findings, and renin data.

Renal artery revascularization. Restoration of renal function.

Fifteen patients with nonfunctioning kidneys and complete main or segmental renal artery occlusion that was discovered on angiographic investigation for hypertension underwent renal artery revascularization. Renal blood flow was restored in all patients. Of these patients, 13 experienced excellent recovery of renal function, one patient had slight return of function, and one patient showed no evidence of improvement. Histologic evidence of intact viable glomeruli, angiographic appearance of collateral circulation, and the presence of proximal occlusion with a patent distal renal artery were necessary for successful results. Revascularization of the ischemic nonfunctioning kidney with restoration of renal function is preferable to nephrectomy when all appropriate criteria are satisfied.

Hypertension and cerebrovascular disease.

Although hypertension is the greatest risk factor for stroke, its control with antihypertensive drugs improves survival and decreases the incidence of stroke. If a stroke should occur, careful antihypertensive therapy has not been harmful. Sodium nitroprusside is the initial drug of choice in acute crises.

Systolic hypertension and cardiac mortality of Takayasu's aortoarteritis.

Long-term observations of a 35-year-old woman who died from refractory congestive heart failure due to Takayasu's aortoarteritis are reported. Severe systolic hypertension was documented in the pre-pulseless phase. After the loss of all limb pulses, but relative sparing of carotid vessels, serial ophthalmodynamometric retinal pressures suggested that central aortic pressure remained high during her terminal cardiac illness. Postmortem pathologic examination showed a narrowed, severely atherosclerotic aorta with variable occlusions of all branch vessels. The loss of capacitance and volume of the aorta appears to be the cause of systolic hypertension and refractory pump failure of the left ventricle.

Hepatorenal artery bypass in the management of renovascular hypertension.

Infrequently, when the aorta cannot be used for a standard renal bypass operation because of a previous aortic operation, severe degenerative atherosclerosis or complete aortic thrombosis, a unilateral (hepatic) or bilateral (hepatic and splenic) visceral bypass should be contemplated. Patients with abdominal aortic aneurysms extending above the renal arteries might benefit from concomitant bilateral visceral bypass procedures followed by aortic replacement during the same operative session. The hepatic circulation with its common anatomic variations, indications, surgical technique and effects of hepatorenal artery bypass on the renal and hepatic circulation are discussed.