Advances in Supportive Care for Late Effects of Head and Neck Cancer.

As the population of head and neck cancer survivors increases, it has become increasingly important for health care providers to understand and manage late complications of therapy. Functional deficits can be categorized as general health deficits resulting in frailty or debility, head and neck-specific functional deficits such as swallowing and speech, and musculoskeletal impairment as a result of tumor and treatment. Of critical importance is the growing data indicating that swallow therapy and physical therapy may prevent or ameliorate long-term functional deficits. Oral health complications of head and neck therapy may manifest months or years after the completion of treatment. Patients with hyposalivation are at high risk for dental caries and thus require aggressive oral hygiene regimens and routine dental surveillance. Swallowing abnormalities, xerostomia, and poor dentition may result in dietary adaptations that may cause nutritional deficiencies. Identification and management of maladaptive dietary strategies are important for long-term health. Follow-up with primary care physicians for management of comorbidities such as diabetes and hyperlipidemia may help to limit late vascular complications caused by radiation therapy. Herein, we review late effects of head and neck cancer therapy, highlighting recent advances.

Weight-based nutritional diagnosis of Mexican children and adolescents with neuromotor disabilities.

BACKGROUND: Nutrition related problems are increasing worldwide but they have scarcely been evaluated in people with neuromotor disabilities, particularly in developing countries. In this study our aim was to describe the weight-based nutritional diagnoses of children and adolescents with neuromotor disabilities who attended a private rehabilitation center in Mexico City. METHODS: Data from the first visit's clinical records of 410 patients who attended the Nutrition department at the Teleton Center for Children Rehabilitation, between 1999 and 2008, were analyzed. Sex, age, weight and height, length or segmental length data were collected and used to obtain the nutritional diagnosis based on international growth charts, as well as disability-specific charts. Weight for height was considered the main indicator. RESULTS: Cerebral palsy was the most frequent diagnosis, followed by spina bifida, muscular dystrophy, and Down's syndrome. Children with cerebral palsy showed a higher risk of presenting low weight/undernutrition (LW/UN) than children with other disabilities, which was three times higher in females. In contrast, children with spina bifida, particularly males, were more likely to be overweight/obese (OW/OB), especially after the age of 6 and even more after 11. Patients with muscular dystrophy showed a significantly lower risk of LW/UN than patients with other disabilities. In patients with Down's syndrome neither LW/UN nor OW/OB were different between age and sex. CONCLUSIONS: This is the first study that provides evidence of the nutritional situation of children and adolescents with neuromotor disabilities in Mexico, based on their weight status. Low weight and obesity affect a large number of these patients due to their disability, age and sex. Early nutritional diagnosis must be considered an essential component in the treatment of these patients to prevent obesity and malnutrition, and improve their quality of life.

Using rapid-cycle quality improvement methodology to reduce feeding tubes in patients with advanced dementia: before and after study.

PROBLEM: Despite lack of evidence that enteral feeding tubes benefit patients with dementia, and often contrary to the wishes of patient and family, patients with dementia who have difficulty swallowing or reduced food intake often receive feeding tubes when hospitalised for an acute illness. DESIGN: We conducted a retrospective chart review of all patients receiving percutaneous endoscopic gastrostomy or jejunostomy tubes between March and September 2002. QI interventions including a palliative care consulting service and educational programmes were instituted. We conducted a second chart review for all patients receiving feeding tubes between March and September 2003. SETTING: 652 bed urban acute care hospital. KEY MEASURES FOR IMPROVEMENT: We measured the number of feeding tubes placed in patients with dementia, the number of feeding tubes placed in patients with dementia capable of taking food by mouth, and the number of feeding tubes placed in patients with dementia with an advance directive stating the wish to forgo artificial nutrition and hydration. STRATEGIES FOR CHANGE: Medical and allied health staff received educational programmes on end of life care and on feeding management of patients with dementia. A palliative care consulting team was established. EFFECTS OF CHANGE: After the interventions, the number of feeding tubes placed in all patients and in patients with dementia was greatly reduced. LESSONS LEARNT: Multidisciplinary involvement, including participation by the administration, was essential to effect change in practice. The intensive focus on a particular issue and rapid change led to "culture shift" within the hospital community. The need to establish unified goals of care for each patient was highlighted. BACKGROUND: A growing body of research over the past decade has questioned the utility of placing feeding tubes (percutaneous endoscopic gastrostomy (PEG) or jejunostomy) in patients with advanced dementia. Studies have found no evidence that feeding tubes in this population prevent aspiration, prolong life, improve overall function, or reduce pressure sores. Additionally, the quality of life of a patient with advanced dementia can be adversely affected when a feeding tube is inserted. The patient may require wrist restraints to prevent pulling on the tube or may develop cellulitis at the gastrostomy site, develop decubitus ulcers, be deprived of the social interaction and pleasure surrounding meals, and require placement in a nursing home. Unfortunately, many doctors are unfamiliar with this literature or face barriers-attitudinal, institutional, or imposed by the healthcare industry-to applying its findings to their practice. Thus feeding tubes are placed in patients who will not benefit from this intervention and whose quality of life in the terminal stage of their illness will be adversely affected. With the expected increase of elderly people with dementia, a great change in doctors' knowledge, attitudes, and practice is necessary to prevent even greater numbers of patients receiving this futile treatment.

Evaluation of the nutritional status during stay in the subacute care nursing home.

Malnutrition represents an underestimated danger in the elderly population. It is found frequently and casually during admissions to our subacute care nursing homes (abbreviated from the Italian name: "Residenza Socio-Assistenziale" = RSA) when patients are treated for other types of disorders. During a period of 24 months, in our RSA, we found that 93% of patients were malnourished or at risk of malnourishment at admission. Specific interventions allowed us to substantially improve the nutritional status of these patients.

[Morphofunctional characteristic of enteral insufficiency and means of nutritional maintenance in casualties with a severe trauma]. / Morfofunktsional'naia kharakteristika énteral'noi nedostatochnosti i sposoby nutritsionnoi podderzhki u postradavshikh s tiazheloi travmoi.

Examinations of 257 casualties were performed at different terms after trauma. The criteria for determination of the degree of enteral insufficiency in patients with traumas were the severity of the injury, the severity of the state, the absorption state in the small intestine and the degree of errosive-ulcerous processes in the upper parts of the gastro-intestinal tract. The clinico-laboratory gradation of the enteral insufficiency was developed according to the severity degree that allows to establish the algorithm of its diagnosing and treatment based on the principle of outstripping therapy of the appearing disorders and to optimize the terms and methods of the nutritional maintenance of the patients with traumas.

Catch-up growth assessment in long-term physically neglected and emotionally abused preschool age male children.

OBJECTIVE: To assess the catch-up growth of long-term physically neglected and emotionally abused preschool male children who have entered foster residential care and remained 1 year after initial placement. METHOD: Longitudinal study over a 7-year period (1994-2001). So that a child was eligible for the study, three selection criteria were included: (1) aged between 24 and 48 months at the time of entry into residential facility, (2) having suffered both long-term (more than 6 months) physically neglected and emotionally abused, and (3) having stayed in foster care for 1 year after initial placement. Weight, height, and head circumference were established upon entry and re-assessed 1 year after initial placement, calculating the annual growth velocity. Results were compared with normal regional longitudinal standards of reference (Z score). Student's t test was used to assess statistically significant differences. RESULTS: During the study period, 87 children aged between 24 and 48 months (54 male/33 female) were admitted to residential facility after having suffered both long-term physical neglect and emotional abuse. Nevertheless, only 20 children (23% of the total admissions) met the third selection criteria (having remained 1 year after initial placement). Of these children, all were males and at placement they were between the ages of 30 and 42 months, with an average age of 36 months (1.9 SD). At placement, the analyzed parameters were below the normal standards, showing a statistically significant difference for height (Z score = -1.29; p = .008) and weight (Z score = -.75; p = .038). The annual growth velocity for all parameters was above the normal standards showing a statistically significant difference for height (Z score = +1.43; p = .009). One year after initial placement, the significant differences for height (Z score = -.68; p = .102) and weight (Z score = -.31; p = .435) with respect to the normal standards disappeared, though still remained below, showing a significant catch-up growth for height (improvement height Z = +.61 SD). CONCLUSIONS: At placement, the both long-term physically neglected and emotionally abused preschool age male children showed a mild form of chronic malnutrition with growth failure. Growth failure was reversible after the first year of stay, which demonstrates that this delay in growth was secondary to nutritional and psychosocial factors. Placement in foster residential care was beneficial for the catch-up growth of these patients.

[Nutrition mixes in the complex rehabilitation of young men with constitutional deficit of body weight]. / Pishchevye smesi v kompleksnoé reabilitatsii molodykh muzhchin s konstitutsional'no obuslovlennym defitsitom massy tela.

It was investigated peculiarities of the constitutional malnutrition in 94 young men. The influence of oral supplementation by enteral nutrition on recovering 54 young men with constitutional malnutrition was examined. The results of investigation indicated a high efficacy of using oral supplementation in the complex treatment of malnourished young men. It results in improvement of patient's rehabilitation and reduce the time of hospitalization.

Behavioral effects of protein deprivation and rehabilitation in adult rats: relevance to morphological alterations in the hippocampal formation.

In the present study we have analyzed the behavioral and neuroanatomical effects of protein deprivation in adult rats. Starting at 2 months of age, animals were maintained on 8%-casein diet either for 8 months (malnourished group), or for 6 months followed by a 2-month period of nutritional rehabilitation (17%-protein diet, rehabilitated group). Malnourished rats exhibited reduced emotional reactivity and impaired habituation in the open field. In a water maze, these animals did not differ from controls during training, but showed retention deficits on the probe trial. However, working memory, sensorimotor abilities and passive avoidance behavior were not significantly impaired in malnourished rats. The performance of rehabilitated group was similar to that of the control group throughout behavioral testing. Postmortem morphological analysis revealed that the total number of neurons in the granular layer of the dentate gyrus, and in CA3 and CA1 hippocampal fields was reduced in protein-deprived and rehabilitated rats relative to controls. In addition, it was found that protein deprivation caused a 30% loss of synapses established between mossy fibers and dendrites of CA3 pyramidal cells, whereas nutritional rehabilitation resulted in a reversal of this effect. These results show that prolonged malnutrition in adult rats produces marked loss of hippocampal neurons and synapses accompanied by substantial impairments of hippocampal-dependent behaviors. The fact that nutritional rehabilitation results in restoration of the total number of hippocampal synapses and parallel amelioration of the behavioral impairments suggests that the mature CNS possesses a remarkable potential for structural and functional recovery from the damage induced by this type of dietary insult.

Metabolic handling of different fatty acids during rehabilitation from childhood malnutrition

The gastrointestinal handling and post absorptive metabolism of [1, 1, 1-13 C] triolein (TO) and [1, 1, 13 C] tripalmitin (TP) were studied in two groups of eight severely malnourished children (5-0 months): on admission (Phase 1), during rapid-catch up growth (Phase 2) and when weight for height had reached 90 percent of the reference (Phase 3). Total excretion of 13 C label in stool (over 3 days) and breath as 13 CO 2 (over 24 hours) were analysed by isotope radio mass spectrometry. Stool 13 C excretion at admission was approximately 10 percent of the administered dose for both trials but varied markedly between subjects, was significantly reduced during rehabilitation in the TO trial (Phase 2:0.5 +or- 1.0; Phase 3: 1.3 +or- 0.9; p<0.05) and tended to decline on the P trial. ANOVA analysis of the magnitude and time course of 13 C excretion in breath (from area under the curve), excretion tended to decrease during rehabilitation in the TO trial but remained unchanged on the TP trial. These results suggest that the efficiency with which dietary triacylglycerol is handled within the gastrointestinal tract is generally impaired in severely malnourished children at admission but improves during rehabilitation.(Au)

Disability is associated with malnutrition in institutionalized elderly people. The I.R.A. Study. Istituto di Riposo per Anziani.

Several factors, such as disability, malnutrition, weight loss, and the interactive effect of diseases and aging have been associated with morbidity and mortality in the elderly population. Nevertheless, the relationship between disability and biological parameters has not been extensively investigated as a primary focus. In a cross sectional survey, 344 institutionalized elderly subjects were evaluated. Disability was measured according to the Katz index, and patients were divided into three groups: low (0-1 lost ADL), mild (2-4 lost ADL), and severe (5-6 lost ADL). Anthropometric, metabolic, and nutritional parameters were assessed; age, gender, number of pathologies, and number of drugs were also recorded. Data were analyzed by multiple comparison of means according to Scheffé, and by multivariate logistic regression analysis. An impairment in functional status was associated with several modifications in biological parameters. Logistic regression analysis showed that severe disability (5-6 lost ADL) was associated with low waist/hip ratio (< 0.9 vs > 0.9, OR: 1.56, CI 95%: 1.08-2.25), high body resistance (> 625 vs < 575 omega, OR: 1.39, CI 95%: 1.38-1.39), low plasma albumin levels (< 3.5 vs > 4.0 g/dL, OR: 6.02, CI 95%: 5.18-6.85), and low plasma transferrin levels (< 200 vs > 250 mg/dL, OR: 5.47, CI 95%: 4.56-4.58) independently of age, gender, comorbidity, and other confounding factors. Our results indicate that severe disability in ADL is strongly associated with anthropometric and biohumoral parameters suggesting the presence of malnutrition. A careful evaluation of the nutritional state appears to be of primary importance, and efforts to improve nutritional status are needed in approaching disabled elderly patients.

[Evaluation of a project for nutritional rehabilitation at home in Benin]. / Evaluation d'un projet de réhabilitation nutritionnelle à domicile au Bénin.

Childhood malnutrition is a public health problem in most developing countries and the rehabilitation of malnourished children is a real challenge for health services. The main aim of this study was to evaluate the implementation of a community-based strategy for nutritional rehabilitation at home (NRH). This strategy was assessed in two districts of Benin. We also evaluated its effects on the nutrition status of the children involved in the study. Screening and rehabilitation protocols were developed for the project and were defined before the study began. The implementation process was evaluated by checking whether the children registered for NRH had received adequate treatment from the health agencies. Intervention was judged to be adequate if it was consistent with that previously set out in the rehabilitation protocol. The variables studied concerned whether the health workers had adequately implemented NRH and had applied UNICEF's three. "A" (Assessment, Analysis and Action). The results of the rehabilitation process were recorded. The weight and age of the children were determined to evaluate changes in their nutrition status. The study population was a group of 452 children aged 0 to 35 months old. The frequency of NRH sessions was adequate in 259 cases (57.9%), the quality of observations and advice was adequate in 284 cases (63.1%) and the protocol was followed properly in 151 cases (34.1%). At inclusion, 191 children (42.3%) were suffering from mild malnutrition and 146 (32.3%) were suffering from severe malnutrition. Seventy children (15.5%) were rehabilitated as defined in the protocol standards. One hundred and fifty nine children (35.2%) were lost to follow-up, 83 (18.4%) stopped the treatment and 83 (18.4%) were declared rehabilitated when they were not. The nutrition status of 69 of the 70 children who completed NRH had improved. Thus, there are flaws in the implementation process, with the three "A" not being reliably applied by health workers, particularly in terms of analysis and action. However, NRH does seem to be effective for the rehabilitation of children suffering from malnutrition, improving their nutrition status at least.

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.

Energy and protein metabolism during recovery from malnutrition due to nonneoplastic gastrointestinal disease.

The magnitude of metabolic adaptation to malnutrition is still debated and few studies have investigated the phase of recovery from malnutrition. The aim of the present work was to determine whether refeeding was associated with adaptive changes in 1) energy expenditure, 2) maximal capacity for oxidizing lipids, and 3) whole-body protein turnover. Eleven malnourished patients with nonneoplastic gastrointestinal diseases were studied by using indirect calorimetry and L-[1-13C]leucine infusion while being infused with lipid-rich total parenteral nutrition (TPN). The same study was performed before initiation of TPN and after a mean gain of 6.5 kg body wt. In absolute values, resting energy expenditure (REE) increased after refeeding (4.05 +/- 0.85 compared with 4.60 +/- 1.05 MJ/d). Change in REE adjusted for fat-free mass (FFM) correlated significantly with change in body weight (r = 0.850, P = 0.01) and change in body fat (r = 0.798, P = 0.01) but not with change in FFM (r = -0.06, NS). Lipid oxidation decreased significantly after body weight gain (0.93 +/- 0.28 compared with 0.50 +/- 0.37 mg.kg-1.min-1). When expressed per kg FFM, protein turnover and breakdown increased significantly during body weight gain. Moreover, the change in protein turnover correlated with the rate of change in FFM, suggesting that FFM accretion requires increased interorgan exchange of amino acids. Our data suggest that in patients similar to those studied here and during recovery from malnutrition, the degree of change in adjusted REE during refeeding is correlated with change in fat mass and not with change in FFM, and that there is a decrease in oxidation of infused lipids. These mechanisms may contribute to body fat repletion and regulation during weight gain.

Management of artificial nutrition in East Anglia: a community study.

In the Cambridge health district the growth of artificial nutritional support was prospectively assessed over a five-year period (1988-93). The aim of this study was to investigate the variation in the prevalence of enteral tube feeding (ETF) and parenteral nutrition (PN) in hospital and at home and to assess the organisation. There was a fourfold variability in the prevalence of artificial nutritional support in the eight districts. The prevalence of home artificial nutrition doubled between 1988 and 1993, whilst that in hospital increased to a smaller extent (31%). Overall standards of care are not keeping pace with the demand for artificial nutritional support. Only half the districts had nutrition teams, and only one had a specialist nutrition sister. Policies about ETF and PN in hospital and at home were judged to be variable in quality. About one in five patients (or carers) at home experienced problems related to organisation of nutrition support services. General practitioners were also frequently uncertain about their role in managing patients on artificial nutrition at home. Home ETF is a rapidly growing form of home care therapy in East Anglia; in 1992-93 it was quantitatively as important as ETF in hospital. Improvements in organisation are recommended.

Rehabilitation of grade III protein energy malnutrition on out patients basis.

Malnutrition is an important yet preventable and curable cause of morbidity and mortality. One hundred and thirty-five children suffering from grade III Protein Energy Malnutrition (PEM) from a poor urban population of Karachi city were enrolled for rehabilitation by health education and growth monitoring as out patient. Of these, 89% showed satisfactory recovery during a mean follow-up period of 3.2 months. Mainstay of this study was simple health messages adapted according to local cultural practices in native language. This simple strategy can go a long way in prevention and treatment of PEM in all the developing countries.

Randomized clinical trial comparing hospital to ambulatory rehabilitation of malnourished children in Niger.

This study compared hospital to ambulatory nutritional rehabilitation outcomes and costs. Following a hospital stay to resolve initial acute medical conditions, 100 malnourished children (54 per cent male, ages 5 to 28 months) in Niger were randomly assigned to either hospital or ambulatory nutritional rehabilitation. Anthropometric measures were assessed at 15, 30, 60, 90 and 180 days post-randomization. Following randomization, the hospital group received a mean of 12.9 days of hospital rehabilitation and 5.6 days of ambulatory rehabilitation, while the ambulatory group received 2.2 days of hospital rehabilitation and 11.9 days of ambulatory rehabilitation. No significant differences between the two study groups in mortality rates or weight gain were found. The mean cost for hospital rehabilitation was 120 per cent higher (P < 0.001) than ambulatory rehabilitation. This study was the first randomized clinical trial directly comparing hospital to ambulatory nutritional rehabilitation and suggests that ambulatory rehabilitation is more cost-effective.