1997 AuSPEN ABSTRACTS OF PROFFERED ORAL and POSTER PRESENTATIONS

CONTENTS

1: PARENTERAL GLUTAMINE FAILS TO ENHANCE ADAPTATION AFTER SMALL BOWEL RESECTION

2: INSULIN-LIKE GROWTH FACTOR ONE (IGF1) TO MONITOR NUTRITIONAL THERAPY IN ADOLESCENTS WITH ANOREXIA NERVOSA

3: NUTRITIONAL STATUS OF THE ADULT VICTORIAN CYSTIC FIBROSIS POPULATION

4: DEVELOPMENT OF A LARGE ANIMAL MODEL FOR INTESTINAL ADAPTATION FOLLOWING SMALL INTESTINAL RESECTION

5: THE INFLUENCE OF PARENTERAL GLUTAMINE ON THE RESPONSE OF THE SMALL INTESTINE TO 5-FLUOROURACIL

6: AN AUDIT OF TRAUMA PATIENTS RECEIVING ENTERAL NUTRITION

7: SHORT CHAIN FATTY ACID (SCFA) AND GAS PRODUCTION OF A NEW FIBRE MIX USING AN IN VITRO TECHNIQUE

8: LONG-TERM NUTRITIONAL STATUS OF PATIENTS UNDERGOING OESOPHAGECTOMY FOR OESOPHAGEAL CANCER

9: A PILOT PROJECT IN NUTRITION ASSESSMENT AND SCREENING

10: BARRIERS TO OPTIMAL NUTRITION IN CANCER PATIENTS RECEIVING CHEMOTHERAPY

11: FIBRONECTIN LEVELS IN BURN PATIENTS: WHAT ROLE IN MANAGEMENT ?

12: STRATEGIES FOR THE RATIONALIZATION AND IMPROVEMENT OF PARENTERAL NUTRITION ADMINISTRATION

13: VITAL STATISTICS IN TOTAL PARENTERAL NUTRITION

14: TASTE SENSITIVITY IN PATIENTS WITH RENAL FAILURE ON CONTINUOUS AMBULATORY PERITONEAL DIALYSIS

15: THE CALCULATION OF ENERGY REQUIREMENTS IN A CRITICALLY ILL CHILD: A DIETITIANS SURVEY


1: PARENTERAL GLUTAMINE FAILS TO ENHANCE ADAPTATION

AFTER SMALL BOWEL RESECTION

Kathryn Heel, Sung-Eun Kong*, Wendy Erber#, Rosalie McCauley, John Hall

University Department of Surgery and Department of Haematology#

Royal Perth Hospital, GPO Box X2213, Perth WA 6001, Australia

 

 

Parenteral nutrition inhibits adaptation in the remaining bowel after intestinal resection. It has been suggested that this is due to an inability of conventional solutions of parenteral nutrients to adequately nourish the epithelium o f the small intestine. The aim of this study was to evaluate the effect of parenteral nutrients supplemented with glutamine on the residual intestine after a 25% mid-small bowel resection.

 

Wistar rats were randomised after standardised surgical procedure (neck dissection, insertion of central lines, and removal of 25% of mid-small bowel) to receive 6 days of either conventional parenteral nutrition or 2.5% glutamine-enhan ced parenteral nutrition.

 

The results for standardised segments of jejunum (mean + SD):

 

 

Conventional

Glutamine-Enhanced

Parenteral Nutrition

Parenteral Nutrition

 

(n= = 5)

(n = 4)

         
 

Pre-

Post-

Pre-

Pre-

 

Resection

Resection

Resection

Resection

Mucosal Weight (mg/cm)

37 + 17

29 + 16

32 + 10

28 + 15

Mucosal Protein (mg/cm)

2.2 + 0.5

1.6 + 1.0

2.3 + 0.6

1.6 + 0.7

Mucosal DNA (m g/cm)

159 + 98

96 + 114

112 + 32

78 + 49

Glutaminase Activity

24+ 15

29 + 16

19 + 14

26 + 6

(nmol/hr/cm)

       
         
         

In this study parenteral supplements of glutamine failed to promote intestinal adaptation in rats after 25% mid-small bowel resection. This may indicate a need for greater emphasis on enteral, rather than parenteral, nutrition for shor t bowel syndrome.


2: INSULIN-LIKE GROWTH FACTOR ONE (IGF1) TO MONITOR

NUTRITIONAL THERAPY IN ADOLESCENTS WITH ANOREXIA NERVOSA

J. Turner*, P.O’Leary, K. Pasco, D. Forbes

Eating Disorders Team, Princess Margaret Hospital, & Department of Paediatrics

University of Western Australia, & Biochemistry Department,

Royal Perth Hospital, Western Australia

 

 

Introduction: IGF1 is a peptide hormone with important anabolic actions, especially for growth. Serum IGF1 levels are regulated by nutrition and levels decrease in malnutrition and increase with nutritional therapy. In adolesc ence IGF1 levels normally peak with growth and so monitoring IGF1 levels to assess malnutrition in this age group may be particularly useful. IGF1 levels were studied during a short-term intensive refeeding programme for adolescent girls with anorexia ne rvosa (AN) and compared to changes in anthropometric measurements and clinical status.

 

Method: Twelve adolescent girls with AN were enrolled following admission to hospital for refeeding and compared to eleven healthy controls. IGF1 levels were measured in the morning within 72 hours of admission and weekly leadi ng up to discharge. Temperature, lying and standing pulse and blood pressure were measured prior to blood sampling. Weight and height were measured and body mass index (BMI) calculated. Percentage body fat (%BF) was calculated for subjects from three s kinfolds, measured by the same examiner, using two methods.

 

Results: Mean age and pubertal status did not differ between subjects and controls (15yrs; tanner stage 4). Mean length of admission for subjects was 14 days. Mean BMI for subjects at admission was 14.8, and at discharged was 16.3, both significantly different from each other (p=0.001) and from the control value of 20.8 (p-=0.002). Mean IGF1 level at admission was 110.8ug/L and at discharge was 188.3ug/L, again both significantly different from each other (p=0.01) and from th e control mean of 380.9ug/L (p<0.000). Mean %BF at admission was 13% and at discharge 14%, not significantly different. IGF1 levels correlated well with BMI (p<0.000) but not with %BF. IGF1 correlated with pulse rate and postural change in pulse rate (p=0.007) but not with temperature or blood pressure. Neither BMI or %BF correlated with clinical status and BMI correlated poorly with %BF. The best predictor of IGF1 level at discharge was length of stay and not weight or BMI.

 

Conclusion: Levels of IGF1 are extremely low in malnourished adolescent girls with AN and increase during short term refeeding in proportion to the length of time spent refeeding. In comparison to BMI, increase in IGF1 levels i s associated with improved cardiovascular status but not with weight gain, that may possibly be attributed to body water. These results suggest that monitoring of IGF1 levels is useful during nutritional therapy for adolescents.

 

 


3: NUTRITIONAL STATUS OF THE

ADULT VICTORIAN CYSTIC FIBROSIS POPULATION

*I.E. Richardson1, I. Nyulasi2, S. King2, M. Ball1, J. Wilson2

1Deakin University, Public Health & Nutrition, Burwood, VIC 3125

2Alfred Hospital, Commercial Road, Prahran, VIC 3181

 

 

Dietary recommendations for cystic fibrosis (CF) patients have changed considerably over the past 10-15 years. Fat intake is no longer restricted and energy intake is recommended to be 120% of the Recommended Daily Intake (RDI) for nor mal health Australians [1]. The nutritional status of adult CF patients at the Alfred Hospital was assessed prior to the changes in nutritional management. The aim of the present study was to determine if the altered nutritional management had resulted in an improvement in the nutritional status of the adult CF population since the previous study (15 years ago). Body composition was determined by body mass index (BMI), triceps skinfold (TSF), mid-arm muscle circumference (MAMC) and % body fat.

 

A random sample of 36 adult CF patients (21 males, 15 females) was selected from the Alfred Hospital CF Unit database. Subjects’ height and weight were measured, anthropometric measurements taken and skinfold data collected. The table shows the data that has been collected to date compared with the results of the previous study.

 

 

Males1

P-Value1

Females1

P-value2

 

Pres. (n=21)

Past (n=25)

 

Pres. (n=21)

Past (n=25)

 

Age (years)

28.5 (5.9)

26.3 (8.67)

0.344

27.5 (6.5)

24.6 (3.3)

0.137

Weight (kg)

66.6 (11.1)

55.8 (11.4)

0.0023

58.5 (8.1)

46.7 (9.2)

0.0006

Height (cm)

174.7 (6.7)

168.2 (8.3)

0.006

161.8 (7.6)

157.3 (6.6)

0.078

BMI

21.8 (2.8)

19.3 (3.0)

0.006

22.3 (2.6)

18.6 (3.1)

0.001

TSF (mm)

6.76 (2.89)

4.11 (1.5)

0.0003

14.22 (5.09)

8.10 (3.0)

0.0003

%BF skfold

13.96 (5.2)

11.74 (3.3)

0.097

27.91 (4.8)

19.64 (5.9)

0.0002

MAMC

27.8 (4.0)

22.3 (4.3)

0.0001

26.1 (2.9)

18.3 (2.0)

<0.0001

1mean (standard deviation) 2P=value determined by unpaired T-test

 

Analysis of preliminary data revealed that weight, height, BMI, TSF and MAMC measurements of both males and females has increased significantly in the current study. Percentage body fat in the current study, as determined by the sum of the four skinfold thicknesses [2], was also significantly greater in females, however not significantly different in males compared with the previous study. This could be explained by an increase in body weight and an increase in total body fat, with th e percentage of body fat not increased significantly. These findings suggest that the nutritional status of CF patients has improved since the previous study was undertaken 15 years ago.

 

1. Hodson M.E. and Geddes D.M. Cystic Fibrosis. 1st Ed. London: Chapman & Hall 1995:384-5.

  1. Durnin J.V.G. and Wormsley J. "Body fat assessed from total body density and its elimination from skinfold thickness measurement on 481 men and women aged 16 to 72 years". Brit .J. Nutr 1974; 32:77-97.


4: DEVELOPMENT OF A LARGE ANIMAL MODEL FOR INTESTINAL

ADAPTATION FOLLOWING SMALL INTESTINAL RESECTION

J. Bines*, F. Justice*, P.J. Fuller^, M. Sourial#, M. Wolvekamp^ and R. Taylor#

Department of Gastroenterology and Clinical Nutrition, and Department of Surgery#,

Royal Children’s Hospital and Prince Henry’s Institute of Medical Research^,

Melbourne VIC 3052

 

 

Knowledge of the mechanisms involved in intestinal adaptation following massive small intestinal (SI) resection is fundamental in the clinical approach to short bowel syndrome. This study aimed to develop a preclinical model of SI adap tation using massive SI resection in the pig. The pig has a smaller intestine to the human.

 

Methods: Four week old weaned piglets underwent 75% proximal SI resection (R) or transection (T) with reanastomosis. Pigs received either ad lib pig chow (4), limited pig chow (4), elemental formula (NeocateR; 7) or a polymeric formula (Polymeric NeonateR;2). Weight gain, food intake and stool were monitored. Histology, molecular biology and disaccharidases were performed at baseline (ileum), terminal ileum and colon. Intestinal function was asses sed pre-op and at 6, 8 and 11 weeks (d-xylose, lactulose/rhamnose absorption, faecal fat and microscopy).

 

Results: 14 of 17 pigs undergoing surgery survived to sacrifice. At sacrifice 6 of 8 R pigs had macroscopic and histological features of intestinal adaptation. Adaptation only occurred if normal weight was maintained. Pigs (T &R) fed elemental formula gained weight at a slower rate than other groups, probably due to the reduced voluntary intake (<80% estimated requirements).

 

Villus height of ileum (um)

 

Pig Group

Baseline

Sacrifice (Wk 12)

Mean Diff

       

R-poor wt gain

252 (42)

345 (27)c

94d

R-normal wt gain

263 (75)a

666 (103)a,c

417d

T

212 (27)b

481 (129)b,c

156d

a,b,c,d = p <.05

     

Conclusion:

1. A large animal model of intestinal adaptation following massive SI bowel resection has been established.

2. SI adaptation is dependent on the type of diet, intake and weight gain achieved.

 


5: THE INFLUENCE OF PARENTERAL GLUTAMINE ON THE RESPONSE

OF THE SMALL INTESTINE TO 5-FLUOROURACIL

Kathryn Heel, James Trotter#, Sung-Eun Kong*, Rosalie McCauler, John Hall

University Department of Surgery and Department of Medical Oncology#

Royal Perth Hospital, GPO Box X2213, Perth WA 6001, Australia

 

 

Chemotherapeutic agents damage the rapidly proliferating epithelium of the gastrointestinal tract resulting in stomatitis and enterocolitis. Glutamine is a conditionally-essential amino acid that plays a key role in maintaining the cellularity of the mucosa of the small intestine. It has been suggested that glutamine-supplemented nutritional support can diminish the extent of 5-fluorouracil damage to the small intestine. The aim of this study was to evaluate the ability of a short course of parenteral glutamine to ameliorate the adverse effects of 5-fluorouracil on the small intestine.

 

Wistar rats (250-300g) underwent standardised surgical procedure (neck dissection and insertion of a central line) prior to two-day nutritional support period of 2,5% parenteral glutamine.

 

The results for standardised segments of jejunum (mean + SD):

 

     
 

Conventional Parenteral

Glutamine-Enhanced

 

Nutrition

Parenteral Nutrition

 

(n = 10)

(n = 10)

     

Gut Weight (mg/cm)

50 + 10

49 + 6

Mucosal Weight (mg/cm)

15 + 5

15 + 4

Mucosal Protein (mg/cm)

2.0 + 0.4

1.8 + 0.5

Mucosal DNA (m g/cm)

16 + 14

22 + 25

Glutaminase Activity

17.1 + 3.8

16.3 + 5.0

(mmol/hr/cm)

   
     

 

In this study a two-day course of 2.5% parenteral glutamine failed to ameliorate the adverse effects of 5-fluourouracil (100mg, intraperitoneal) on the small intestine. This suggests that glutamine-supplemented parenteral nutrition may not protect the gut against 5-fluorouracil-induced enterocolitis.

 


6: AN AUDIT OF TRAUMA PATIENTS RECEIVING ENTERAL NUTRITION

Kathryn Marshall*, Ibolya Nyulasi, Susannah King, Jennifer Keogh

Nutrition Department, Alfred Hospital, Prahran, VIC, Australia

 

 

Introduction: The benefits of early enteral nutrition in the critically ill are well recognised. The majority of trauma patients are healthy and well nourished before their accident. However the hypermetabolic response to such se vere injuries places these patients at risk of becoming malnourished and delays recovery.

 

Objective: To review the current practices related to enteral feeding of trauma patients.

 

Methodology: A retrospective audit was conducted of trauma patients who received enteral nutrition for four or more days, during a 12 month period. Data collected included age, diagnosis, route of feeding, time before feeding was comm enced, the length of time feeds continued and the adequacy of nutrition provided. If patients were still receiving enteral nutrition at the time of discharge from the Alfred Hospital, the route of feeding was also recorded.

 

Results: 99 trauma patients were recorded to have commenced enteral nutrition during their admission. 47 patients received enteral nutrition for greater than or equal to 4 days. 61% of these patients sustained severe closed he ad injuries. The majority of patients were male (70%).

 

Enteral nutrition was commenced within 48 hours of admission for 65% of patients. 79% of patients were fed via a naso-gastric tube. 3 patients received naso-jejunal feeds. 3 patients received TPN for a short period. A standard polym eric formula (Osmolite HN) was used for 69% of patients. Most patients reached their set target rate within 2 days of commencing enteral nutrition. Yet most received only 70-80% of the estimated energy requirements during the time they were fed. Interr uptions to feeding included fasting for theatre or procedures, high gastric aspirates and removal of tubes.

 

All patients were discharged to rehabilitation facilities. 51% were still receiving enteral nutrition at this time. A Percutaneous Endoscopic Gastrostomy (PEG) was placed in 13 patients. Patients who continued to receive enteral feed ing at day 14 were most likely to be discharged requiring enteral nutrition as their sole source of nutrition. Insertion of a PEG was often delayed until after day 20 and may contribute to an increased length of stay.

 

Conclusion: These results indicate that despite the early commencement of enteral nutrition the nutritional requirements of these patients are not being met adequately. There appears to be a role for wider use of jejunal feedin g in this population. Indicators for earlier insertion of longer term feeding tubes (PEGs) can be developed from information collected.

 


7: SHORT CHAIN FATTY ACID (SCFA) AND GAS PRODUCTION OF A NEW

FIBRE MIX USING AN IN VITRO TECHNIQUE

K.A. van Hoeij, C.J. Green*

Nutrica Corporate Research, PO Box 1,2700 MA Zoetermeer, The Netherlands

 

 

 

Fibre-containing enteral formulae typically contain a single fibre source. Formulae containing a mix of fibre types, as consumed in normal health diets, may be more beneficial for bowel structure and function. The SCFA and gas product ion of six single fibre sources and a mixture of them in amounts proportional to those present in a Western diet were measured using an in vitro system. Before fermentation the fibres were predigested with salivary, gastric, pancreatic and mucosal enzymes to release mono and disaccharides. Released glucose, fructose and sucrose were removed by transforming to ethanol by incubation with Saccharomyces cerevisiae in the presence of glucose-isomerase, followed by boiling to remove the ethanol. Rema ining monosaccharides were transformed to lactic acid by incubation with Lactobacillus rhamnosus. The predigested fibre solutions were subjected to fermentation by a suspension of fresh human faeces mixed with a carbonate-buffer complex, supplemen ted with trace elements in a static in vitro colon model with an automated time-related gas production test system. SCFA production was determined periodically. The results are presented in the table.

 

       

Sample

[SCFA] mmol/g

Gas production

SCFA/gas

 

Residual fibre

ml/g fibre

Ratio

               

4hr

24hr

48hr

4hr

24hr

48hr

48hr

               

Blank

0.9

3.4

3.0

122

220

220

13.8

Oligofructose

3.1

4.4

4.2

406

524

540

7.8

Soy polysaccharide

3.4

4.3

5.8

412

534

536

10.8

Cellulose

1.7

1.9

2

125

153

154

13.0

Resistant starch

1.8

2.8

3.1

240

428

430

7.2

Arabic gum

2.4

3.8

4

204

471

486

8.2

Fibre mix

2.4

3.7

5.2

260

386

386

13.5

               

 

Of the single fibres, only inulin continued to produce SCFA after 24 hours, whereas the fibre mix resulted in continuous SCFA production throughout 48 hours. Gas production did not rise after 24 hours in any of the fibres studied, but was higher for all single sources (except for cellulose) than for the mix. This is reflected in the high SCFA/gas ratio of the mix. These preliminary results suggest that a mix of fibres reflective of those in the normal diet has a more prolonged SCFA p roduction than most of its components fermented singly. The favourable SCFA/gas ratio indicates that the mix would be well-tolerated.

 

 


8: LONG-TERM NUTRITIONAL STATUS OF PATIENTS

UNDERGOING OESOPHAGECTOMY FOR OESOPHAGEAL CANCER

Anita Comacchio*

Department of Nutrition and Food Service, Royal Adelaide Hospital,

North Terrace, Adelaide, South Australia 5000

 

 

An oesophagectomy has the potential to significantly impact on nutritional status. However, as five year survival is less than 5% (1) there are no published studies which evaluate nutritional status in these patients. Anthropometric and nutrient intake data (3-way weighed food record) were collected for 19 patients (14 males) who underwent an oesophagectomy for oesophageal cancer. Four patients died within the first 12 months. A questionnaire to assess appetite and gastrointestinal symptoms was also administered. Data were collected pre-operatively and at 1, 6 and 12 months post-surgery. Jejunostomy feeding was instigated immediately post-operatively and followed by a high energy protein, soft, small frequent dietary regimen. Me an (+sd) age was 61.7+10.5 years. Although 53% of patients reported weight loss, pre-operative Body Mass Index (BMI) was 24.2+2.8kg/m2 and albumin was 37.9+3.3g/L (n=13) prior to surgery. Weights at one month (BMI 23.1+2.9kg/m2; n=14) and six months (BMI 22.0+2.9kg/m2; n=11) were lower than pre-operatively (p<0.001) but there was no net change over 12 months (n=9). Energy intake at one month was 80+26% of requirements and this increased to 119+30% at six months (n=9, p=0.040).

 

Before surgery 68% (13) of patients had dysphagia compared with 29% (4) and 50% (6) at one and twelve months respectively. 58% (11) of patients reported good appetite pre-operatively compared with 36% (5) and 50% (6) at one and twelve months. 71% (10) and 73% (8) of patients found it helpful to separate food and fluids at one and twelve months but this was only useful for 16% (3) patients before surgery. The results show that patients in this study, who presented for an oesohagectomy were in a well-nourished state, despite significant weight loss prior to surgery. Despite some weight loss, enteral feeding was able to support BMI within normal range and there was no net change in weight status in twelve months. In addition, jejunos tomy feeding has many clinical cost advantages over total parenteral nutrition. Whilst energy requirements were met at six months and BMI was within normal range, there was still significant gastrointestinal symptomatology with 50-75% of patients reporti ng problems of dysphagia, poor appetite and the need to separate food and fluids.

 

References

(1) Earlam R, Cunha-Melo JR Oesophageal squamous cell carcinoma 1. A critical review of surgery.

Br J Surg 1980; 67: 381.

 


9: A PILOT PROJECT IN NUTRITION ASSESSMENT AND SCREENING

Annette Byron1, Anita Comacchio1, Catherine Leu2

1Clinical Dietetics, Royal Adelaide Hospital, North Terrace, Adelaide SA 5000

2Cugy, Switzerland

 

 

Introduction: Casemix funding has provided an incentive for clinicians to diagnose, document and treat malnutrition in hospital patients. This paper describes a pilot project in nutrition assessment and screening where the obj ectives were to identify the prevalence of malnutrition, to investigate the use of the malnutrition screening tool (MST), and to determine whether malnutrition was coded for Casemix funding.

 

Method: Nutrition screening was conducted for one month on patients admitted to gastrointestinal surgical units within 72 hours of admission using the MST. The tool involved scoring answers to questions relating to changes in w eight and intake. If patients were found to be at risk of malnutrition then Subjective Global Assessment (SGA) was administered to determine whether patients were severely malnourished, moderately malnourished or well nourished.

 

Results: Seventy-five percent of patients (216/290) were screened. Sixty-seven patients (31% of those screened) were found to be at risk of malnutrition and consequently were assessed using SGA. Seven patients (3.2%) were foun d to be severely malnourished, and thirty-nine patients (18.1%) were found to be moderately malnourished. Hospital information services were asked whether patients identified as malnourished were coded as such. If patients were not coded as malnourished , a request was made to determine whether the diagnosis related group (DRG) would have changed if malnutrition had been coded. None of the patients diagnosed as malnourished were coded as such. Thirteen patients (28.3% of the 46 patients diagnosed as ma lnourished) would have been assigned to a different DRG if malnutrition was coded. This would have resulted in an additional average reimbursement of $2 631 per patient to the hospital. The MST took approximately one minute to apply and the SGA took bet ween 5 and 15 minutes to apply. Both tests were considered easy to use and non-invasive.

 

Conclusion: This project showed that malnutrition is poorly diagnosed and documented. We can recommend the use of the MST and SGA to ensure that malnourished patients are identified at admission for improved patient care and cod ed for appropriate financial reimbursement.

 


10: BARRIERS TO OPTIMAL NUTRITION IN

CANCER PATIENTS RECEIVING CHEMOTHERAPY

Nazafarin Zarshenas, Lesley McSharry and Margaret Allman-Farinelli*

Human Nutrition Unit, G08, University of Sydney, NSW 2006

and Department of Nutrition, Concord Hospital, Concord, 2137

 

 

Introduction: Cancer and its treatments are known to cause severe weight loss and malnutrition in many patients. However, as many patients are overweight at time of diagnosis nutritional problems may be overlooked. The early d etection and treatment of malnutrition prior to, or in conjunction with therapy, is associated with reduced mortality. As chemotherapy is increasingly conducted on an outpatient basis there is a need for outpatient nutrition screening. The aim of this s tudy was to examine the nutritional status and factors affecting nutrient intake in patients attending the Oncology Day Care Centre at a large teaching hospital in central Sydney.

 

Method: Sixty cancer patients (27 male, 33 female) receiving chemotherapy treatment in the Oncology Day Care Centre participated. The weight and height of the patients was measured and body mass index (BMI) calculated. Mid upp er arm circumference (MUAC) and triceps skinfolds (TSF) were also measured and mid upper arm muscle circumference (MUAMC) calculated. A single interview was conducted with each patient to examine factors which would affect their nutrient intake. Diet hi story was taken and analysed qualitatively with a cross check using the five food groups. The primary site of cancer, presence of metastases and other treatment were recorded from the medical notes.

 

Results: The patients exhibited a mean weight loss of 13% since diagnosis (about 60% losing weight). Only three patients had a BMI <20 but seven patients had a TSF <5th percentile and 11 had a MUAMC <5t h percentile. Almost 90% of patients reported at least one symptom which could compromise nutrient intake. Nausea (52%), taste changes (48%) reduced appetite (43%), early satiety (42%) and food aversions (42%) were the most common symptoms followe d by constipation (33%), diarrhoea (23%), vomiting (22%), mouth ulcers (10%) and swallowing difficulties (10%). The food most commonly avoided was meat (44%).

 

Conclusion: Weight loss continues to be common in cancer patients with the main barriers to intake nausea, taste change and food aversion and anorexia. This is despite the use of pharmacological agents to reduce some of these s ymptoms. It may be that dietary manipulation and other non-pharmacological treatments may be beneficial in improving symptoms and quality of life.

 


11: FIBRONECTIN LEVELS IN BURN PATIENTS:

WHAT ROLE IN MANAGEMENT?

Christine Kiddelln*, Alan Claguep, Sandra Klinbergp,

Karin Kaisers, and Michael Mullers

Burns/Trauma Research Unit

Departments of Nutrition and Dieteticsn, Pathologyp Surgerys

Royal Brisbane Hospital, Herston Road, Herston, QLD 4029

 

 

Introduction: Plasma Fibronectin (pFNC) levels correlate with reticuloendothelial function and are reduced in burns, trauma and sepsis. No adequate marker exists for nutritional depletion or repletion, pFNC may fill this role.< /P>

 

Method: 50 adults (15 females, 35 males aged 20-85 years) who had sustained burn injuries of 1-87% Total Body Surface Area were studied. pFNC concentrations were determined twice weekly by immunonephelometry. Nitrogen balance was calculated when enteral feeds were the sole means of nutritional support (n=18). pFNC was also determined in 103 volunteers and blood donors (42 females, 61 males aged 22-55 years) to establish a reference range.

 

Results: 5 patients died and 45 survived. pFNC levels showed an upward trend with increasing days post burn (p=0.15). In those that died pFNC levels remained low whilst of the survivors some had normal levels in the first week post burn whereas others took up to 5 weeks to normalise. pFNC was significantly lower during episodes of sepsis (p=0.001). Operative procedures did not appear to affect pFNC levels. pFNC levels were a significant predictor of nitrogen balance (p=0.00 6) and correlated well with prealbumin (p=0.8) and total protein (p=0.6).

 

Conclusion: Results confirm that pFNC is significantly reduced during episodes of sepsis and may have a role as a predictor of survival in major burns. pFNC may be a useful indicator of nitrogen balance.

 


12: STRATEGIES FOR THE RATIONALIZATION AND IMPROVEMENT OF

PARENTERAL NUTRITION ADMINISTRATION

Julie Bines*, Deborah Jessen*, Thirza Titchen^

Nutrition Support Service, Department of Gastroenterology and Clinical Nutrition, and

Department of Pharmacy, Royal Children’s Hospital, Parkville, Victoria 3052

 

 

In September 1993 a consultative Nutrition Support Service (NSS) was established to rationalize the use of parenteral nutrition (PN) and improve the quality of nutrition support provided. After a critical review of the existing PN pres cribing and administration practices, the following areas were targeted for action: education, standard PN solutions, monitoring and establishing outcome date.

 

Methods:

 

1. Education

 

Patient/parent/carer

Medical/Allied Health Staff

Written information

 

PN information pamphlet

Paediatric PN Manual

Short bowel syndrome book

 

Home PN Manual

 

Individual contact

 

NSS Co-ordinator daily

NSS Co-ordinator daily

NSS Team Round twice weekly

NSS Team Round twice weekly

 

Lecture and tutorial programme

 

2. Standard PN solutions (4 neonatal, 3 paediatric) were introduced in June 1997 with a new order form, manual and education sessions.

 

3. Monitoring: Compliance to prescribing and monitoring protocols are reviewed daily and trends defined. Complications are documented and reviewed.

 

4. Outcome data: An in-depth audit is conducted over one month each year.

 

Results: Since NSS has been established the one month audit has shown a 24% reduction in the number of patients prescribed PN for the month (46pt vs 35pt). Mean duration of therapy was shorter 19.5d vs 9d with a trend away from therapy for >3 weeks (18pt vs 3pt; p=0.002). This has been associated with a 43% reduction in the annual cost of PN solution alone $341,237 vs $194,624). Compliance to the monitoring protocol has significantly improved (16% to 77%; p<.001). Impr oved clinical outcome was reflected in a reduction in average ventilation time (423hrs to 199hrs) and mean hospital length of stay for PN patients (59d vs 29d). Since the standards were introduced in June 1997, compliance with their use has risen from 50 % initially to almost 100%.

 

Summary: Strategies aimed to improve education, monitoring and data collection have been successful in improving the quality of PN provision and rationalizing the use of PN.

 

 


13: VITAL STATISTICS IN TOTAL PARENTERAL NUTRITION

Tom Hartley, Cate Law and Bill Flukes: TPN Team: Royal Hobart Hospital

 

The assessments of ideal body weight and the muscle mass of TPN patients is a recurrent problem for the nutrition support team. We have evaluated (a) an anthropometric measurement – the total arm length and wrist circumference to predi ct a patient’s ideal body weight – and (b) a biochemical measurement – the 24 hour total urinary creatinine excretion – to classify their muscle mass status and compared these assessments with the corresponding non-parametric parameters in the Subjective Global Assessment (SGA) protocol.

 

METHOD A The patient’s ideal body weight, in Kg., was predicted from their Total Arm Length and Wrist Circumference using the equation in Reference (1):

2 * Wrist Circumference in cms + 1.25 *Total Arm Length in cms – 40.9

Measurements were made using a good quality tape measure on the patient’s non-dominant arm while bent at the elbow to an angle of 45 degrees and recorded to the nearest millimetre. Patients were also weighed to obtain their actual body weight.

 

METHOD B Urinary creatinine is derived from the irreversible conversion of creatine phosphate and is proportional to an individual’s muscle mass. We derived two sex dependent significant linear regression equations from data in Reference (1). These were used to calculate ideal creatinine excretions, mmol/day, and compare them to actual creatinine excretions.

Ideal Creatinine Excretion in Men = 22.1 – 0.1878* Age

Ideal Creatinine Excretion in Women = 14.3 – 0.1175* Age

Urine creatinines were measured on the Johnson and Johnson Vitros 250 Analyser.

 

RESULTS A 36 data sets were collected. Analysis showed that there were 25 patients in which the SGA categorisation of their actual body weight agreed with both the measurements of their actual body weight and their predicted ide al weight. Chi Squared statistic was 5.44 and significant at the p < 0.05 level. We concluded that the SGA and the equation based technique agreed. We can recommend the equation as a reliable technique.

RESULTS B 18 data sets were collected and assessed versus four models involving SGA assessments of muscle mass and the comparison of the measured creatinine to the ideal creatinine excretion. 15 patients had combinations of data consistent with these models. Chi Squared statistic of 4.00 was significant at the p < 0.05 level. We concluded that the SGA assessments of muscle masses were consistent with the patterns of ideal and observed 24 hour creatinine excretions.

 

Reference: Creatinine Arm Index as an Alternative for Creatinine Height Index, R J Van Hoeyweghen, I H De Leeuw, M F J Vandewoude, Am J Clin Nutrit (1992), v56, 611-615.

 


14: TASTE SENSITIVITY IN PATIENTS WITH RENAL FAILURE ON

CONTINUOUS AMBULATORY PERITONEAL DIALYSIS

Robyn Middleton and Margaret Allman-Farinelli

Human Nutrition Unit G08, University of Sydney, NSW 2006

 

Introduction: Patients with chronic renal failure have been shown to have altered taste sensitivity. Decreased taste sensitivity (or increased taste detection threshold) may be one of the factors influencing the poor nutritiona l status seen in many of these patients. Several studies have examined taste sensitivity in haemodialysis patients but patients on continuous ambulatory peritoneal dialysis (CAPD) warrant investigation.

 

The aim of this study was to determine if the taste detection threshold for each of the four tastes, sweet, salty, sour and bitter differs between CAPD patients and controls with normal renal function.

 

Method: Taste detection thresholds were assessed in 18 CAPD patients and 18 controls, matched for age and sex. The thresholds were determined by a forced-choice sample presentation using the two right one wrong method, based on Cornsweet's staircase method.

 

Result: The taste detection threshold for all the CAPD patients was significantly higher for the taste salty (p=0.04) and for females the taste bitter (p=0.04).

 

Conclusion: This study revealed that CAPD patients do have decreased taste sensitivity. This information may be useful when designing dietary supplements and devising meal plans to assist patients to consume nutritionally adequ ate diets.

 


15: THE CALCULATION OF ENERGY REQUIREMENTS IN A

CRITICALLY ILL CHILD: A DIETITIANS SURVEY

M.S. White, R.W. Shepherd, J. McEniery

Children's Nutrition Research Centre, Department of Paediatrics and Child Health,

University of Queensland, Royal Children's Hospital, Herston, Brisbane, Qld, 4029

 

 

Introduction: Optimal nutritional support is essential to the recovery of critically ill children. To supply optimal nutritional support, knowledge of the energy requirements is needed. The aim of this survey was to determine the methods by which dietitians in Australian hospitals calculated the energy requirements of critically ill children.

 

Methods: A questionnaire was sent to the Nutrition and Dietetic departments of 79 Australian hospitals. The questionnaire contained a case study of a critically ill child and the respondents were requested to calculate the chil d's energy requirements. In addition, four questions followed the case study pertaining to the use of predictive equations in estimating energy requirements in critically ill children.

 

Results: Sixty-two percent of the questionnaires were returned and 41% completed. A large variation was found in the predicted energy requirements of the child in the case study, they ranged from 11 560kJ/day to 2 550 kJ/day. The mean calculated energy requirement was 6 198+1 972 kJ/day. Sixty-six percent of the respondents calculations used the recommended energy intakes (FAO/WHO/UNU, 1985). The total injury factors used in the calculations ranged from 2.18 to 1. Th e mean total injury factor was 1.35+0.29. The child in the case study was underweight for age and 50% of the respondents used ideal weight and 50% used current weight in their calculations. There was no significant difference in calculated energy requirements by dietitians who saw more than 40 critically ill children per year (6 296 kJ/day) and those who saw less than 40 critically ill children per year (5 489 kJ/day). The respondents rated the accuracy of predictive equation on a scale of 1 to 7 as 3 and rated the importance of knowing the exact value of the energy requirement for treatment of critically ill children as 6. Fifty-seven percent of the respondents were unsure if current predictive equations over or underestimated true energy expe nditure and 33% stated the equations overestimated true energy expenditure in critically ill children.

 

Conclusion: The survey demonstrates the variability in calculation of energy requirements in critically ill children. The recommended energy intakes is inappropriate to determine energy expenditure in critically ill children as it is derived from food intake data of healthy active children. These results indicate a need for guidelines on the use of predictive equations and injury factors.

 


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