Carrie Cheney

Effects of resistive exercise on skeletal muscle in marrow transplant recipients receiving total parenteral nutrition

Skeletal muscle protein loss occurs during marrow transplantation despite total parenteral nutrition. To determine if muscle atrophy could be minimized with exercise therapy, 30 patients undergoing marrow transplantation for acute leukemia completed a prospective randomized trial to receive: (1) no therapy (controls), (2) physical therapy thrice weekly (PT3), or (3) physical therapy five times weekly (PT5). Patients were studied through 35 days posttransplant. Muscle protein status and turnover was assessed by weekly nitrogen balance, and creatinine and 3-methylhistidine excretion. Results favored a muscle protein-sparing effect of exercise, as a significant decrease in creatinine excretion in controls only suggested muscle protein loss associated with inactivity. Changes in arm muscle area correlated with energy, but not protein intake. Large individual variation, inadequate nutritional support and differences in admission arm muscle area may have clouded these results.

Fluid intake and the incidence of bladder cancer among middle-aged men and women in a three-county area of western Washington.

This population-based case-control study reports on the relationship between fluid intake and the incidence of bladder cancer among 262 bladder cancer cases from Western Washington and 405 controls identified through random-digit dialing Cases were identified from the Surveillance. Epidemiology, and End Results (SEER) registry and were diagnosed between January 1987 and June 1990. All eligible subjects were Caucasian 45- to 65-year-old residents of King, Pierce, or Snohomish counties and completed a structured telephone interview. Analyses were conducted by logistic regression with adjustment for age, county, and smoking (current, former, never). Among women there was a positive association between total fluid intake and the incidence of bladder cancer [p (trend = 0.02] and a moderate positive association between the use of decaffeinated coffee and the incidence of bladder cancer [p (trend) = 0.08]. Among men there was an inverse association between the consumption of regular soft drinks and the incidence of bladder cancer [p (trend) = 0.03]. No association was found between the incidence of bladder cancer and the intake of water, coffee, tea, diet soft drinks, alcohol, or liquids from tap for men or women. This study suggests that the intake of water and specific beverages is overall not associated with risks of bladder cancer. This study provides limited evidence of a positive association between total fluid intake and bladder cancer among women.

The Use of Sterile and Low Microbial Diets in Ultraisolation Environments

The evidence for the use of sterile and low microbial diets in ultraisolation environments is reviewed. Studies have suggested that sterile food is not required for gut sterilization when oral nonabsorbable antibiotics are used, but if a low microbial food contains an antibiotic-resistant organism, colonization can occur. There may be a beneficial effect on the incidence of infection by serving pathogen-free foods, either sterile or low microbial, to the immunosuppressed patient regardless of type of environment, yet the comparative effectiveness of sterile and low microbial diets in preventing introduction of new pathogens accessing the host via the mouth, oropharynx, and esophagus has not been systematically evaluated.

Intravenous Branched Chain Amino Acid Trial in Marrow Transplant Recipients

Branched chain amino acids (BCAA) improve nitrogen balance and end-organ function in surgical patients, but are untested in marrow transplant recipients. We compared nitrogen balance, urinary 3-methylhistidine-to-creatinine ratio, upper arm anthropometry, serum prealbumin, and day to peripheral engraftment in a randomized, double-blinded trial between 45% (high-leucine) and 23% BCAA intravenous solutions in 40 adult leukemia patients for 1 month following allogeneic marrow transplantation. Nutritional support, provided at approximately 30 nonprotein calories/kg and 0.21 g nitrogen/kg ideal weight, did not differ between groups. Despite greater nitrogen loss and muscle breakdown evidenced by increased 3-methylhistidine-to-creatinine ratio and loss of arm muscle area by study end in the 45% BCAA, no statistical differences were observed when nitrogen balance was compared by week and within stress level as defined by organ and infectious complications. It is likely the patients in the 45% BCAA experienced greater metabolic stress by study end. Serum prealbumin and day posttransplant to peripheral engraftment also did not differ between groups. The chances (power) of this study exceeded 85% in detecting a difference in nitrogen balance of 2.5 g during study week 1 and 4.0 g during week 2. The power during week 3 was 77% for detecting a difference of 4.0 g, and it is unlikely that the true difference exceeds this magnitude. Thus, we did not find any evidence that intravenous BCAA-enriched solutions improved nitrogen balance during the first month after marrow transplantation.

Plasma Fatty Acid Patterns of Bone Marrow Transplant Patients Primarily Supported by Fat-Free Parenteral Nutrition

Oral food tolerance is compromised by drug and radiation therapy administered to patients undergoing bone marrow transplantation for hematological malignancy or aplastic anemia. Resultant decreases in oral fat intake coincident with fat-free parenteral nutrition may predispose patients to essential fatty acid (EFA) deficiency. Determinations were made of the fatty acid composition of plasma total lipid from 20 bone marrow transplant patients on admission, at the time of bone marrow transplant, and on days 7, 14, 30, and 60 post-bone marrow transplant. Patients ate ad libitum but with little appetite and received fat-free parenteral nutrition interrupted for numerous blood product and drug infusions. Abnormal EFA status was manifest (20:3 omega 9/20:4 ratio greater than 0.2) in 12 of 20 patients during the course of treatment. Plasma EFA status was consistently correlated with oral fat intake but not with sex, age, percentage of ideal body weight, or amount of plasma infused. This suggests that dietary fat was absorbed limiting the severity of EFA deficiency. Interruptions of glucose infusion averaging only about 2 hours/day, also may have helped moderate the deficiency.

The association between vitamin C and vitamin E supplement use before hematopoietic stem cell transplant and outcomes to two years

OBJECTIVE To examine the prevalence of supplement use in persons before receiving hematopoietic stem cell transplant (HSCT) and the association of select supplements with outcomes. DESIGN This observational cohort study included a questionnaire on supplement use before HSCT. Nonrelapse mortality, recurrence/relapse, and mortality or relapse (the inverse of disease-free survival) were followed to two years. Subjects/Setting Persons receiving HSCT at the Fred Hutchinson Cancer Research Center between September 1994 and December 1997 were eligible (N=1,182). Statistical Analyses Performed Descriptive statistics and univariate and Cox regression analyses were conducted. RESULTS Sixty-six percent of patients used supplements (31% vitamin C, 19% vitamin E, and 20% herbs or others preparations). Vitamin C at > or =500 mg/day was inversely associated with recurrence among persons with breast cancer (RR=0.11; 95% CI, 0.02-0.89; P=.03). However, among persons with acute leukemia, vitamin C at > or =500 mg/day was positively associated with nonrelapse mortality (RR=2.25; 95% CI, 1.33-3.83; P=.01) and mortality or relapse (RR=1.63; 95% CI, 1.09-2.44; P=.01), respectively. Vitamin E at > or =400 IU/day was positively associated with mortality or relapse (RR=1.77; 95% CI, 1.06 -2.96; P=.02). Applications/Conclusions Though this work was observational, the results suggest supplemental vitamin C before therapy may be beneficial in persons with breast cancer but both vitamin C and vitamin E may increase risk in persons with acute leukemia receiving HSCT. Practitioners should document supplement use in subjects receiving therapy for cancer.

Comparison of 1983 and 1992 renal dietitian staffing levels with patient morbidity and mortality

Abstract •■ Objective: To compare 1992 and 1983 renal dietitian staffing patterns in relation to changes in patient age, morbidity, and mortality. •■ Design: Data were obtained by survey research. The original questionnaire used in 1983 was maintained and mailed for data collection in 1992. Existing records provided age, morbidity, and mortality data. •■ Setting: Research was coordinated through the Nutrition Services department at the Northwest Kidney Centers, Seattle, Washington. Data were collected from dialysis centers in the Northwest Renal Network No. 16 (WA, OR, AK, ID and MT). •■ Subjects: Characteristics of Network No. 16s dialysis patient population and the nutritional service provided by renal dietitians were examined in 19 of the 29 kidney dialysis centers existing in 1983 and all 57 centers existing in 1992. •■ Main outcome measures: Renal dietitian hours per patient per month, patient characteristics (number of patients served, age, morbidity, mortality ratio, and cause of death), and dialysis center characteristics (size and profit status). •■ Statistical analysis performed: Examination of the original 19 centers over time was analyzed either by a paired t-test or a sign test. A t-test was used to compare means from all centers in 1983 and 1992. Correlation coefficients were calculated to measure relationships between reported variables. •■ Results: Between 1983 and 1992, the number of kidney centers and dialysis patients doubled, with the greatest increases observed in the numbers of patients with diabetes and diseases of connective tissue. People with diabetes accounted for 50% of all new patients. The patient population was approximately 5 years older, with crude mortality increasing significantly from 17% to 28%. Cardiac-related deaths increased significantly from 34% to 54%. Average dietitian hours per patient per month increased from 0.8 hours in 1983 to 1.1 hours in 1992. More dietitian staffing was provided in larger centers and in nonprofit centers. A significant increase in dietitian staffing was observed in patients dialyzing in-center rather than at home. •■ Conclusions: Between 1983 and 1992, renal dietitian staffing increased by 18 minutes per patient per month. Considering that the patient population became older and sicker (primarily because of diabetes), had a higher mortality, and comprised a larger proportion dialyzing in-center rather than at home, the increase in 18 minutes per patient per month may be inadequate.

Prevalence of low albumin, suboptimal energy, and muscle stores in Asian dialysis patients

OBJECTIVE Investigate the prevalence of low serum albumin levels (<3.2 g/L) and decreased arm muscle area percentiles and arm fat area percentiles in Asian patients compared with non-Asian patients treated with dialysis. DESIGN Cross-sectional study in which serum albumin and anthropometric measurements were averaged over 6 months, and compared between patients of Asian ethnicity and patients of non-Asian ethnicity. SETTING Eight outpatient dialysis facilities. SUBJECTS Ninety-seven Asian and 513 non-Asian patients treated with hemodialysis or peritoneal dialysis. RESULTS Height, weight, and body mass index were significantly lower in Asians compared with non-Asians (P <.001). Protein catabolic rate was significantly greater in Asian (1.17 +/- 0.29 g/kg) compared with non-Asian (0.97 +/- 0.28 g/kg) women (P <.001). Asian men (3.30 g/dL) and women (3. 26 g/dL) had lower serum albumin compared with non-Asian men (3.35 g/dL; P =.057) and women (3.34 g/dL; P =.040). The proportion of patients with serum albumin <3.2 g/dL was greater for both Asian women (35%) (P <.040) and men (30%) than non-Asian women (25%) and men (20%). After adjusting for important covariates, serum albumin remained significantly different between Asian and non-Asian patients (P <.05). The proportion below the fifth percentile for arm muscle area was significantly greater for both Asian men (54%) and women (19%) compared with non-Asian men (24%) and women (8%). Proportions of Asian and non-Asian women below the 10th and 5th percentile for arm fat area were similar. However, Asian men (54%) had a significantly greater fat depletion than non-Asian men (26%). CONCLUSION Mean serum albumin was significantly lower in Asian patients on dialysis than in non-Asians. Muscle stores were depleted in Asian men and women compared with non-Asians, and fat stores were depleted in Asian men. Based on this study, Asian dialysis patients would seem to be at higher nutritional risk than non-Asians, particularly Asian men. Further research is needed to assess factors that affect serum albumin and mortality in Asian dialysis patients, and standards need to be developed to further assess anthropometric measurements in this population.

Computer integration and time spent on direct patient nutritional care activities in an outpatient dialysis setting

OBJECTIVE To compare time spent in patient and administrative activities by nutrition professionals in a group of dialysis facilities, and relate differences to the degree of computer integration at the sites and between 2 time periods. DESIGN Survey design, self-administered activity form, completed in 1992 and 1997. SETTING Three of the largest outpatient dialysis centers in western Washington state. SUBJECTS Ten nutrition professionals completed the activity forms. INTERVENTION Activity form (recording time), questionnaire (results not reported here). MAIN OUTCOME MEASURES Amount of time spent on administrative activities in 1997 and the number of patients and number of hours per nutrition professional per month spent with patients in 1997, compared with 1992. RESULTS Time spent on administrative activities decreased in all facilities since 1992, with the largest decrease at the unit having the most computer integration. CONCLUSION Extensive computer integration seems to allow for a decrease in the amount of time spent on administrative activities by nutrition professionals.

GROWTH IN INFANTS WITH BRONCHOPULMONARY DYSPLASIA AFTER INITIAL HOSPITAL DISCHARGE. 1595

Bronchopulmonary Dysplasia (BPD) is often associated with long term growth problems. This study was designed to examine current rates of growth failure in infants with BPD and to prospectively determine risk factors associated with growth failure. After initial hospital discharge, the growth of 40 infants with mean gestational age of 27 ± 2 weeks, was followed with 7 monthly home visits. Potential risk factors included, low energy intake, feeding problems, difficult temperament, low socioeconomic status (SES), post discharge illness/hospitalization, and compromised caregiver-infant feeding relationship. Z score differences were calculated between the first visit and the last visit. Twenty nine infants (73%) experienced a drop in weight for age Z score, and 8 infants (20%) experienced a drop in height for age Z score. Risk of growth failure, defined as weight or length less than the 5th percentile at the last visit and experienced by 18 (45%) infants, was increased by low socioeconomic status (RR 2.13, 95% CI 1.04,4.33), significant feeding difficulties (RR 2.33, 95% CI 1.24,4.38), and difficult temperament(RR 2.08, 95% CI 1.04,4.19). Problems associated with feeding were common and included choking, coughing, cyanosis, crying, and fatigue. Infants with growth failure were more likely to have a “suspect” finding on the Denver II (Chi square 6.05, p=0.014). Growth failure and feeding problems continue to be a problem for infants with BPD. We found that growth was adversely affected by low socioeconomic status, feeding difficulties, and difficult temperament. High risk infants may benefit from frequent nutrition assessment and intervention for feeding problems.