Impact of a multidisciplinary nutritional support team on quality improvement for patients receiving home parenteral nutrition

Introduction

Home parenteral nutrition (HPN) is essential for patients with intestinal failure requiring long-term nutritional support. The Amerita Quality Improvement Project for HPN Patients (QIP-PN) explored the effect of a physician nutrition expert (PNE)-led multidisciplinary nutritional support team (MNST) on HPN care for patients under its service.

Objective

To determine an MNST effect on adherence to protocols, outcomes and quality of life (QOL) in HPN.

Methods

The study was divided into three phases: data review (phases 1a and 1b), observation (phase 2) and intervention (phase 3). Seven Amerita locations were selected as 'study branches' (population), from which all study patients and controls were drawn. The quality improvement project employed a quasi-experimental case-matched control group (control) design. Data were collected on demographics, treating physicians PNE status, HPN care variables, recommended interventions, quality-of-life assessment, adverse outcomes and hospitalisations. Paired t-test compared continuous data between phases 2 and 3. Comparisons between study and control groups used a negative binomial regression model.

Results

Thirty-four patients were reviewed in phase 1a and 197 in phase 1b. Forty study patients completed phase 2 and progressed into phase 3, of whom 30 completed ≥60 therapy days. Patients were lost to follow-up if they discontinued HPN for any reason. Improvements in weight, body mass index and QOL were seen in the study patients during intervention. Recommendations made and accepted by treating physicians differed based on PNE status. Study patients had fewer adverse outcomes and related hospitalisations than controls.

Conclusion

MNST recommendations improved clinical, biochemical parameters and patients' self-reported overall health. MNST input reduced adverse outcomes, hospitalisation and the length of stay at the hospital. This study highlights the potential for MNST to have a significant impact on the quality and overall cost of HPN management.

Severe Asymptomatic Essential Fatty Acid Deficiency (EFAD) in a Patient Enrolled in a Quality Improvement Project for HPN Patients (QIP-PN)

Objectives

Introduction. A 97-year-old, 47 kg female with a history of dysphasia, and failed enteral feeding was on HPN for 35 months. PN provided 150 grams dextrose, 75 grams amino acids, electrolytes, MVI and trace elements. Intravenous lipid emulsion (ILE) was held because liver dysfunction and line infections.

Methods

The patient enrolled in Amerita QIP-PN program. Essential fatty acid and trace element levels were obtained.

Results

Severe deficiencies of linoleic (c18:2w6; 524.3; (nl) 2653.4–6130.3 umol/L) and ἀ-linolenic acids (c18:3w3; 4.12; nl 26.1–150.1) were detected. Eicosatrienoic (Mead) acid (c20:3w9) was markedly elevated at 135.33 (nl 10.3–41.3). The eicosatrienoic to arachidonic acid (triene to tetraene) ratio was markedly elevated (0.27; nl 0.02–0.05). Stearic (267.2; nl 590.2 – 1377.2) and arachidic (8.86; nl 16.8 – 38.5) acids were low. Total polyunsaturated (1.6; nl 3.57 – 8.11) and total n-6 fatty acids (1.3; nl 3.3 – 7.1) were low. Seven fatty acid levels were elevated, apparently from de novo lipogenesis in the presence of insulin: myristic = 299.15 (nl 39.4 – 258.2), hexadecanoic = 300.41(nl 19.82 – 59.93), palmetoleic = 1197.60 (nl 68.5 – 570.2), vaccenic = 458.11 (nl 84.82 – 260.8), docosapentanoic = 32.8 (nl 9.2–32.1), docosenoic = 20.88 (nl 5.73 – 11.92). Interventions. Four-oil ILE was added as 20 grams once weekly, providing ∼4 grams of linoleic and ∼0.5 grams of ἀ-linolenic acids. Follow up free fatty acids showed normalization of ἀ-linolenic (27.07) and improvement in linoleic (889.74) and mead (60.34) acids. The triene to tetraene ratio improved to 0.17.

Conclusions

An elevated Mead acid level and elevated triene to tetraene ratio confirmed severe EFAD. Mead acid is produced from the elongation of oleic acid (n-9). The n-3, n-6, and n-9 fatty acids all compete for the same desaturases. But the desaturase enzymes have a preference for the fatty acids based on their n-terminal structure. The sequence is n-3 > n-6 > n-9. Therefore, increased Mead acid (20:3n-9) synthesis occurs only with very low availability of n-3 and n-6 fatty acids. In severe EFAD, Mead acid serves as a precursor to specific prostaglandins and leukotrienes via the cycloxygenase and lipoxygenase pathways. This case highlights the value of the QIP-PN in identifying EFAD in long-term HPN patients.

Funding Sources

None.

Metabolic Reversal of Low Cardiac Output Syndrome (LCOS) After Coronary Artery Bypass Grafting (CABG)

Objectives

Severe nutritional deficiencies may play a causative role in LCOS after CABG. Older cardiac patients have an increased incidence of micronutrient depletions, including thiamine (B1) and zinc (Zn). Both of these deficiencies have been reported to cause reversible cardiomyopathy (CM). We present herein a case of B1 and Zn deficient-LCOS after CABG which resolved with micronutrient repletion (MR).

Methods

Case Report: A 72-year-old female with a 70–80% midsegment left anterior descending artery (LAD) lesion and left ventricular ejection fraction (LVEF) of 50% underwent elective CABG, mitral valve annuloplasty, Maze procedure, and left atrial appendage clipping. She developed LCOS immediately postoperatively with diffuse hypokinesis, LVEF of 25–30% and an elevated serum lactate (5.8 mmol/L; nl < 2.0). Classical perioperative causes for LCOS were ruled out. Her LVEF did not respond to pressor or inotrope therapy. She started MR on postoperative day # 2.

Results

Pressors and inotropes were weaned one day after beginning MR. Her lactate level improved and a repeat echocardiogram showed an LVEF of 45–50%. Pretreatment metabolic labs disclosed an undetectable RBC B1 level (nl 70–180 nmol/L) and severely low RBC Zn (19 mcg/dL; nl 60–130). MR was continued orally. On day 16, an echocardiogram showed LVEF of 55–65% with no regional wall motion abnormality and normal right ventricular movement.

Conclusions

This patient's LCOS post CABG appears to have been due to combined, severe micronutrient deficiencies. Marked clinical improvement occurred after MR administration, with normalization of serum lactate, LVEF and regional wall motion. Aggressive B1 and Zn repletion were given prior to confirmation by laboratory analysis. Clinical suspicion should be raised for B1 and Zn deficiencies when other perioperative LCOS causes are ruled out. This may be particularly important with elevated lactate levels and lack of response to inotrope therapy. MR therapy should be considered for such individuals while awaiting confirmatory laboratory results.

Funding Sources

None.

Metabolic Support for Elderly, Severe COVID-19 Patients With Acute Respiratory Failure: A Case Series

Objectives

Severe COVID-19 (SvC19) is a syndrome of acute lung injury, respiratory failure, cytokine storm, distributive shock, multi-system organ failure and high mortality. SvC19 disproportionately impacts the elderly, who are also at risk for micronutrient deficiency. After observing a beneficial response to micronutrient repletion (MR) in a 69 year-old male with SvC19, we hypothesized that nutritional deficiencies were linked to the pathogenesis and that correcting them could be beneficial. In this report we detail a case series of 18 older patients with SvC19 treated with MR.

Methods

All patients had SvC19 requiring mechanical ventilation, elevated levels of CRP, D-dimer and neutrophil to lymphocyte ratio. MR consisted of daily parenteral ascorbate, thiamine, pyridoxine and multivitamins, as well as daily ergocalciferol, zinc and carnitine via nasogastric tube.

Results

The average age was 63.3 years. Six patients were male, 12 female. Disease severity was comparable based on SOFA score. A partial response was observed in 10 of the 18 patients (55.5%). Six (33.3%) were able to wean off blood pressure support. Five (27.7%) had improvement in gas exchange. Four (22.2) were able to wean off ventilator support. Three patients (37.5%) showed improvement in renal dysfunction.

Conclusions

MR shows potential promise as an adjunctive treatment for severe COVID-19, particularly in older patients or those with chronic illness in whom nutritional deficiencies are more probable.

Funding Sources

None

An Algorithmic Approach for Lipid Metabolism and Management of Patients with Xanthelasma Palpebrarum (XP)

Objectives

XP (flat, yellowish plaques around the eyes) is difficult to treat and often recurs. We describe an algorithmic approach to explore the lipid metabolism and management of XP.

Methods

A 64 yo female with hypothyroidism, obesity, and metabolic syndrome was successful with weight loss and glycemia but noted recurrence of XP after a surgical excision. Her lipid profile (on rosuvastatin) revealed: total cholesterol 150 mg/dL, LDL 54 mg/dL, triglycerides 74 mg/dL, HDL 81 mg/dL. Apolipoprotein (Apo) A1 was 213 mg/dL (nl female > 140). Apo B100 was 63 mg/dL (nl < 130). Lp(a) was 29 mg/dL (nl < 30). LDL particles were 958 nmol/L (nl < 1000). LDL particle size was 20.9 nm (nl > 20.5). Small dense LDL particles were 598 nmol/L (nl < 528). There was presence of serum campesterol (3.7 mg/L; nl 0–7.0) and sitosterol (2.1 mg/L; nl 0–5.0), but not desmosterol or lathosterol. Oral ezetimibe (EZ), 10 mg/day was administered. After 8 months of therapy, campesterol and sitosterol dropped significantly (campesterol: 2.1, - 44%; sitosterol: 1.3, - 39%). XP lesions resolved completely.

Results

We developed an algorithmic approach to XP management. The sequence is as follows: 1) examine standard lipid levels, 2) examine levels of pro-atherogenic particles, 3) explore net cholesterol tissue transport, 4) confirm hepatic cholesterol synthesis suppression, 5) examine plant sterols, 6) treat the abnormalities detected.

In this example case phytosterols were responsible for XP recurrence. Sitosterol and campesterol should be minimally absorbed by the gut through the Nieman Pick C1 Like 1 (NPC1L1) sterol influx transporter and eliminated by the sterol efflux transporters, adenosine triphosphate-binding cassette (ABC) ABCG5/ABCG8. If phytosterols are retained in the body, they may predispose to resistant XP.

An algorithmic approach to XP suggested that hyper-absorption of plant sterols by the NPC1L1 transporter was present. This was clinically confirmed because inhibition of NPC1L1 transport (by EZ) significantly reduced plant sterol levels. Plant sterols were also clinically confirmed as the cause of her XP, since their reduction and led to XP resolution.

Conclusions

We present an algorithmic approach to help detail the metabolic etiology of XP and direct its management. The example case demonstrates its value to reduce XP recurrence and resolve XP in selected cases.

Funding Sources

None.

Selenium (Se) Deficiency After Orthotopic Heart Transplantation (OHT) (P12-056-19)

Objectives

Se and selenoproteins play critical metabolic roles, as in glutathione peroxidase (antioxidant defense) and iodo-thyronine deiodinase 2 (thyroid hormone production). Other Se-dependent pathways can promote apoptosis and decrease oncogene expression. Se deficiency (SeD) is rare in the US, given its abundance in food and soil. SeD is linked to tobacco use, excessive ETOH consumption, birth control pills, and inflammatory bowel disease. SeD can increase the risk of prostate cancer and Burkitt's lymphoma. Severe SeD can cause skeletal muscle dysfunction and endemic cardiomyopathy (Keshan disease). We present herein a case of SeD 7 + years after heart transplantation, in whom prostate cancer and Burkitt's post transplant lymphoproliferative disorder (PTLD) developed.

Methods

A 77-year-old male with hypertension, dyslipidemia, diabetes mellitus and non-ischemic cardiomyopathy underwent OHT in 2011. He developed prostate cancer in 2015, treated with hormonal and radiation therapy. In January, 2019 he had progressive dyspnea, muscle weakness, abdominal pain, weight loss and diarrhea x 1 week. An ascending colonic mass revealed Burkitt's PTLD. A metabolic evaluation uncovered a serum Se of 31 mcg/L (normal range 63–160).

The patient received TPN with additional Se. He underwent chemotherapy and developed tumor lysis syndrome, requiring renal replacement therapy. He remained on single drug immunosuppression with Tacrolimus. Renal function and oral intake returned after 3 weeks.

Results

Our patient presented with a severe SeD without apparent predisposing factors. He has developed 2 SeD-related neoplasms: prostate cancer and Burkitt's PTLD. The congruence of his clinical course and biochemical results support the diagnosis of a true SeD. However, the etiology of the SeD state remains unknown. We hypothesize that his immunosuppression therapy with Tacrolimus may have played a role. If so, it could be a previously unidentified drug effect.

Conclusions

Serum Se monitoring should be considered in post OHT patients who develop prostate cancer or Burkitt's PTLD. Given the increased risk of prostate cancer in OHT patients, routine screening of Se levels and Se supplementation of deficiency states should be considered after OHT.

Funding Sources

none.

Essential Fatty Acid Deficiency (EFAD) in a Patient with Vascular Ehlers Danlos Syndrome (EDS-4) (P12-053-19)

Objectives

EDS-4 comprises ∼4% of all EDS, involving mutations in type III procollagen rather than type V. It causes spontaneous vascular and visceral rupture but not large joint or skin hypermotility. Nutritional deficiencies and malabsorption have been described in classical EDS, but not in EDS-4.

Methods

A 30-year-old female with EDS-4, bowel obstruction, spontaneous colon rupture, spontaneous pneumothorax and cholecystitis had fatigue, diarrhea, abdominal pain, hair loss and dry skin. Stools were malodorous and floating; oily and often orange in color. There was no response to bile acid sequestration.

The patient weighed 40.4 KG (BMI = 16.9) with intact muscle mass and near total absence of subcutaneous adipose tissue. There were sparse hair follicles; hair was easily pluckable and lanugo-like. The skin was thin and translucent; dry with flaking and peeling both tibial regions.

Vitamin levels (A, D, E, K1, C, B1, B6, B9, B12) were normal as were zinc, iron, copper and carnitine. Levels of palmitoleic (C16:1w7), hexadecenoic (C16:1w9), linoleic (C18:2w6), alpha linolenic (C18:3w3), gamma linolenic (C18:3w6), vaccenic (C18:3w7), arachidic (C20:0), arachidonic (C20:4w6), docosenoic (C22:1) and nervoic (C24:1w9) acids were deficient. The triene-tetraene ratio was 0.028 (range = 0.01–0.038).

Results

We diagnosed fat malabsorption (FM) with EFAD and began pancreatic enzyme replacement with a blend of vegetable oils (coconut, corn, soy, safflower, olive and avocado). After 6 months, there was reversal of all deficiencies. GI symptoms, general strength and vitality improved. Her scalp hair increased. The hair shafts were less fragile and normal in color. The skin dryness, flaking and peeling had resolved.

Conclusions

EDS-4 patients may present with FM and develop EFAD. The pathogenensis of FM in EDS-4 may involve disordered collagen type III within the bowel wall, pancreatic matrix or ductal system. Dysbiosis and dysautonomia may also play a role. The combination of pancreatic enzyme replacement and fatty acid supplementation was beneficial in this case and may be appropriate for other patients with EDS-4 and FM.

Funding Sources

none.

Enterocutaneous Fistula (ECF) Resolution with Isonitrogenous Parenteral Nutrition (PN), L-Carnitine (LC) and Ramped Infusion of Octreotide (Oct) (P12-054-19)

Objectives

PN is a mainstay for ECF after pancreatoduodenectomy. LC has been studied for cutaneous wound healing. Oct lacks consistent evidence in ECF but may be beneficial with soft pancreatic texture or small ducts, as in pediatric patients. Prior experience suggests that intravenous Oct is superior for ECF than intermittent forms. This case demonstrates the value of isonitrogenous PN, LC and Oct infusion in ECF management.

Methods

A 59-year-old male with familial adenomatous polyposis underwent pancreaticoduodenectomy. He returned to the OR after 4 weeks for abscess drainage, cholecystojejunostomy with transhepatic stent, and small bowel resection. The patient returned from rehabilitation 6 months later with persistent fistula output from recurrent ECF. We started on PN and subcutaneous Oct (100 mg TID). The PN amino acid content was guided based on nitrogen balance data. Carnitine levels were very low and LC (1000 mg) was added to the PN.

The patient continued to have high volume fistula output and returned to the OR for closure of an anterior ECF, which was followed by development of a right-sided and left-sided ECFs. Continuous infusion of Oct was initiated at 250 mcg/d and gradually ramped-up by 250 mcg/d increments to 1500 mcg/d. ECF fluid output decreased with each step. Complete closure of ECFs was seen after 4 weeks. Oct drip was ramped downward by 250 mcg increments/d and discontinued. The patient advanced his diet and PN was discontinued. He was discharged to rehabilitation without re-emergence of ECF.

Results

This case demonstrates the value of combination isonitrogenous PN, LC and continuous Oct for ECF. Nitrogen balance based amino acid intake ensured PN nutritional adequacy. Car was similarly based on actual patient data rather than empiric therapy. A continuous Oct ramping protocol enabled judgement of the beneficial effect and determine the need for further dosage increases. Continuous infusion was superior to the previous intermittent Oct. It is possible that the continuous infusion induced more significant suppression of gastrointestinal secretions than subcutaneous Oct administration, thereby improving its efficacy.

Conclusions

Combination therapy with PN, Car continuous Oct could be an effective approach for ECF management for patients who have failed surgery and standard medical therapy.

Funding Sources

None.

Long Term Follow up of Cerebellar Ataxia CA) and MRI Lesions Which Responded to Copper (Cu) Supplementation (P12-055-19)

Objectives

Cu deficiency (CuD) produces anemia and leukopenia. CuD neurologic dysfunction can also occur. We follow a patient with CuD with CA and MRI lesions that responded to Cu replacement.

Methods

A 64-year-old male with progressive ataxia and neuropathy was found to have a significant CuD (copper level 38 mmol/L, normal range 70–175) 7 years ago. The etiology of CuD was unknown. There was no previous gastric surgery, malabsorption, ingestion of zinc containing products or medications associated with Cu loss.

He had an ataxic gait with a steppage component. Muscle stretch reflexes were brisk at the knees and absent at the ankles. He had length dependent loss to all modalities. Other etiologies for CA were not found. The blood smear showed anisocytes and poikilocytes, but anemia and leukopenia were absent. He became wheelchair bound after several weeks.

Brain MRI without contrast revealed non-enhancing symmetric T2 signal prolongation of the medial cerebellar white matter extending into left middle cerebral peduncle. Neuroconductive studies showed moderate-to-severe axonal sensorimotor polyneuropathy.

Results

Cu supplementation with using 5 mg cupric oxide daily raised serum Cu to 97 mmol/L. Symptoms improved after 1 month. Brain MRI 3 months later showed no cerebellar lesions with serum Cu of 123 mmol/L. At this point he was able to walk with a cane. His gait disturbance further improved to the extent that he was able to walk without assistance or support. His follow up Cu levels remain in the normal range (last value = 128 mmol/L).

Conclusions

Cu is a component of the neurologic metalloenzymes cytochrome-c oxidase (CcO), Cu-zinc superoxide dismutase, tyrosinase, dopamine β-hydroxylase, peptidylglycine α-amidating monooxygenase and ceruloplasmin. Cu and iron pass electrons through CcO to oxygen, forming water. CuD impacts the electron transport chain, impairing ATP production which injures susceptible tissues.

This case demonstrates the reversibility of neurologic dysfunction and MRI lesions by means of correcting CuD. Our 7-year follow up period confirms the validity of the pathogenesis and management. Further study is needed to identify the specific roles of Cu metabolism in such cases and the individual factors allowing for the dramatic response we observed.

Funding Sources

none.

Phase II study of everolimus (E) with imatinib (IM) in patients with previously-treated renal carcinoma (RCC)

e16075

Background: Inhibitors of mTOR improve progression-free survival (PFS) in advanced RCC. We hypothesized that co-administration of the mTOR inhibitor E with an upstream receptor tyrosine kinase inhibitor could augment activity in advanced RCC. We chose to study IM due to its inhibition of PDGFR, a relevant target for RCC with potential activity at both the tumor cell and the pericyte. Methods: Eligible patients had metastatic or unresectable clear cell renal carcinoma, at least one prior systemic therapy, no prior mTOR inhibitor therapy, performance status 0–2, and measurable disease. Treatment consisted of E 2.5 mg p.o. daily and IM 600 mg p.o. daily, a dose determined from a phase I study in GIST. A two-stage design was employed to test for a 3-month PFS of ≥ 70% vs. ≤ 50%. Results: 19 subjects were evaluable for toxicity and 18 for response. Median age 65; number of prior systemic therapies 1:2:3+ (47%:32%:21%); prior sorafenib and/or sunitinib 89%; MSKCC prognostic categories favorable:intermediate:poor (42%:47%:11%). There were no objective responses. Best response was stable disease (67%) and progressive disease (33%). The 3-month PFS rate was 49% (95% C.I. 23%, 72%). The median PFS was 2.9 months (95% C.I. 1.9, 6.2) and the median overall survival was 14.4 months (95% C.I. 11.3, N.R.). Toxicities and lab abnormalities affecting >50% of subjects were: nausea, elevated creatinine, edema, anemia, hypocalcemia, fatigue, diarrhea, vomiting, and dyspnea, and leucopenia. Most common grade 3+ events were: fatigue (16%), pleural effusion (16%), edema (11%), and renal failure (11%). The study was closed after the first stage as the 3-month PFS did not meet continuation criteria. Conclusions: The combination of E 2.5 mg with IM 600 mg in previously-treated patients with advanced RCC did not meet the study-defined level of activity to warrant further investigation. The natural history assumptions for this pretreated RCC population may have been overly optimistic. While the observed PFS is comparable to that reported with E 10mg monotherapy, there appears to be no advantage to combination IM therapy and the incidence of adverse events is high. Further development of this regimen for RCC is not recommended.

[Table: see text]

Home parenteral lipids in AIDS: a three-month study

Parenteral nutrition is a part of the nutritional support regimen of patients with AIDS-associated wasting syndrome and gastrointestinal dysfunction. The cholesterol (CHOL) level in human immunodeficiency virus (HIV) membrane is very high, and recent lipid formulations with high phospholipid (PL) content have demonstrated the ability to trap CHOL from endogenous sources, modifying the composition of cell membranes. We administered lipid-based home parenteral nutrition for 3 mo to malnourished AIDS patients. The patients were randomly divided into two groups: 23 received the regular 20% fat emulsion formulation, and 27 received a 2% formulation enriched 10-fold with PLs but containing the same amount of triglycerides. All patients gained weight and improved their activity level. Those receiving the high-PL composition showed increased serum CHOL concentrations (from 147 to 241 mg/dL; P < 0.01), but no increase was seen in the number of CD4 cells or improvement in immune function. HIV infectivity was not modified. Patients receiving regular PLs had significantly decreased (P < 0.02) IgA concentrations (from 776 to 300 mg/dL) and improved mitogen response to phytohemagglutinin and to concanavalin A. This formula, too, had no effect on HIV infectivity. We conclude that standard parenteral nutritional influences the nutritional and immune status of malnourished AIDS patients. A PL-enriched parenteral formulation can trap CHOL, but it does not affect the immune profile or HIV infectivity in patients with advanced disease.

Fuel utilization in neoplastic disease: implications for the use of nutritional support in cancer patients

Tumor cell metabolism and the whole-body response to tumor metabolic activity produces a complex derangement, including alterations in carbohydrate oxidation with futile cycling and changes in gluconeogenesis and lipid utilization. An interplay between circulating hormones, lymphocyte-mediated cytokines, and tumor growth factors complicates fuel metabolism in these individuals. Adequate attention to these concepts has not been provided in the studies evaluating the effects of parenteral nutrition in cancer patients that have been performed to date. Therefore, it is impossible to determine the validity of the results. Furthermore, it is possible that some of the detrimental effects of TPN observed in earlier studies were secondary to the inappropriate use of large glucose loads in cancer patients.

Metabolic and ventilatory responses during very low level exercise

1. Nine male and six female healthy subjects were studied during supine bicycle exercise at workloads of 12 and 37 W; pedalling rates varied between 30 and 50 cycles/min at each workload. Measurements were made of oxygen consumption (VO2), carbon dioxide production (VCO2), minute ventilation (VE), tidal volume (VT), respiratory frequency (fR), inspiratory and expiratory time (TI, TE) and mean inspiratory flow (VT/TI) using a non-invasive canopy-computer-spirometer system. 2. At rest, males had greater values of VE, VT, TI, inspiratory duty cycle (TI/TTOT), VCO2 and VO2, and a lower fR, than females. 3. At the lower workload, VO2, VCO2, VE, VT and VT/TI increased linearly with increasing pedalling rate, whereas at the higher workload there was a decrease in VO2 and little or no change in ventilatory parameters from 30 to 50 cycles/min except for an increase in fR in females. 4. While performing supine exercise, there was an effect of pedalling rate on ventilatory and metabolic parameters at the low workload (12 W) which diminished at the higher workload (37 W). An increase in pedalling rate appears to enhance efficiency at these low workloads. 5. Differences between the sexes during exercise generally include: (a) a higher breathing frequency, (b) a greater mechanical efficiency, and (c) lower ventilatory equivalents of O2 and CO2 (VE/VO2 and VE/VCO2) during the higher workload in females than males.

[Tuberculous prostatitis within the scope of urogenital tuberculosis--pathogenetic and diagnostic aspects]

208 males with tuberculosis of the urogenital system showed a participation of prostate in 110 cases (53%), however, in 52 transrectal punch biopsies of the prostate only 25 times a tuberculosis could histologically be proved. An isolated tuberculosis of the prostate was found only in 6 males (5.4%), in most cases accidentally in biopsies of the prostate, after adenomectomy of the prostate or TURP. The way of the infection of the tuberculosis of the male genitals and the question of the primary focus on the genitals remained unclarified.

[Detection of mycobacteria in tissue in urogenital tuberculosis]

121 tissue specimens of the urogenital systems (66 from the kidney, 39 from the epididymis and testis, 8 from the prostate, 4 from the bladder and 4 from the female genital tract) were examined by microscopy, culture and animal experiment on the presence of mycobacteria. In 37 of these specimens (30.6%) mycobacteria were demonstrated, 10 of that only by microscopy and in 27 cases by culture and/or animal experiment. Up to 20 weeks after onset of treatment mycobacteria were demonstrated from the kidney tissue of treated patients by the diagnostic methods mentioned above. After this time mycobacteria never could be demonstrated. There was no correlation between the histological findings and the mycobacteriological investigations. The investigation of tissue specimens on the presence of mycobacteria also from other organs of the urogenital tract is suitable method of the bacteriological proof of tuberculosis, especially in the absence or positive bacteriological findings from the urine or accessory gland secretion for the estimation of species and resistance of these bacteria.

Patterns of fuel utilization during parenteral nutrition

Utilization of fuel in clinical conditions has become an important area of interest to the clinician. Injury and sepsis cause predictable changes in the metabolism of fuel, favoring a shift toward the oxidation of fat. Similar considerations apply to the tumor-bearing host.

[Nonspecific pyelonephritis and the formation of urinary calculi in urogenital tuberculosis]

The course of urogenital tuberculosis is complicated by unspecific bacterial infections of the urinary tract and nephrolithiasis. Among 605 patients with bacteriological or histological verified urogenital tuberculosis, 122 patients (20%) developed unspecific bacterial urinary infection--commonly caused by E. coli, proteus and pseudomonas--and 57 patients (9.4%) showed nephrolithiasis. In 42% of the lithiasis patients an urinary tract infection simultaneously occurred. 22 calculi are analyzed by the combined crystal-optical and x-ray-diffraction method with following results: 9 X struvite/carbonate apatite, 6 X calcium phosphate, 7 X calcium oxalate. The texture of 12 calculi was investigated on thin sections by polarization microscopy and a high concentration of organic material was found in both calcium oxalate and struvite/carbonate apatite calculi.

Lethal atherosclerosis associated with abnormal plasma and tissue sterol composition in sitosterolemia with xanthomatosis

Tissue sterol composition was determined in an 18-year-old male with sitosterolemia with xanthomatosis who died suddenly and whose coronary and aortic vessels showed extensive atherosclerosis and, for comparison, in an 18-year-old male with minimal atherosclerosis who died accidently. Sterols in the control tissues (plasma, erythrocytes, cardiac muscle, lung, liver, aorta, and brain) contained cholesterol with only trace amounts of cholestanol. In contrast, sterols in corresponding tissues of the sitosterolemic subject (except brain) were composed of cholesterol, increased amounts of plant sterols, campesterol and sitosterol, and 5 alpha-saturated stanols, cholestanol, 5 alpha-campestanol, and 5 alpha-sitostanol, that were deposited in approximately the same ratio as present in plasma. However, sitosterolemic brain sterol composition resembled that of the control brain with cholesterol and only trace amounts (less than 1%) of cholestanol and phytosterols. The sitosterolemic aorta was extensively atherosclerotic and contained more than twice the quantity of sterols as the control aorta (5.6 mg/g versus 2.6 mg/g) with increased amounts of cholesterol, plant sterols, and 5 alpha-saturated stanols. These results indicate that cholesterol, plant sterols, and 5 alpha-stanols are deposited prematurely and are associated with accelerated atherosclerosis in subjects with sitosterolemia with xanthomatosis.

Renal and electrolyte effects of total parenteral nutrition

Effects of short-term (4-14 days) total parenteral nutrition on renal handling of water and electrolytes were studied retrospectively in 24 patients and prospectively in eight patients. There was 33% incidence of hyponatremia and significant reductions in serum creatinine (from 1.03 +/- 0.06 to 0.88 +/- 0.06 mg/dl, p less than 0.001), phosphorus (from 3.2 +/- 0.14 to 2.5 +/- 0.17 mg/dl, p less than 0.005) and uric acid (from 6.09 +/- 0.38 to 3.66 +/- 0.24 mg/dl, p less than 0.001) were observed. Hypouricemia correlated with increased fractional excretion of urate (r = 0.81, p less than 0.05). Hypophosphatemia was associated with increased tubular reabsorption of phosphate. Clearance studies in eight patients showed high urine flow rate (1.7 +/- 0.2 ml/min), osmolar clearance (3.2 +/- 0.7 ml/min), urinary nonelectrolyte, nonurea solute excretion (0.23 +/- 0.14 mmol/min), and negative free water clearance (TcH2O = 1.5 +/- 0.6 ml/min). These data suggest presence of compartmental shifts, expanded extracellular fluid volume, and possible direct effects on renal tubular transport functions during total parenteral nutrition.

[Therapy of bladder cancer. Value of transurethral resection--treatment results]

The significance of carcinomas of the bladder is shown on the basis of epidemiological data. A survey is given of the numbers of operations using various methods over the last 24 years; in our institution TuTuR is mainly used. A report is given on the indications, procedure and possibilities of complications, showing the limits of the method. Problems of radical operations, which make supravesical derivation of the urine necessary, are discussed. Our therapeutic results are presented in the form of mortality curves. The unfavourable therapeutic results cause us to pose the question once again whether, in the light of modern intensive medicine, greater radicality might not be recommendable.

[20 years' treatment of urogenital tuberculosis with reference to the epidemiology and the general tuberculosis situation]

After introductory remarks on the historical development of the treatment of patients with UGT, the general tuberculosis situation in the GDR is referred to. With the steady decline in tuberculosis of the respiratory system, a clear reduction in the rate of new cases of UGT was registered from 1972 on, due to the well-known late manifestation of the disease. In 1980, 164 new cases of urological tuberculosis were registered, which represent a rate of less than 1 (0.97) new case per 100,000 head of population for the first time. It has been possible to reduce the total duration of medicinal treatment to 9 months from an original figure of 2 years. Despite the use of highly effective aggressive anti-tuberculosis agents the rate of nephrectomy in our patients is 27%, whereby in the last 6 years as many as 31% of all patients with UGT have undergone nephrectomy in the course of treatment. In 20 of these 54 patients the nephrectomy had already been performed elsewhere and UGT was diagnosed from histological examination of the surgical specimen. Neglected cases have become more common in the last 6 years. UGT has been diagnosed very late, whereby it has been observed that patients with pronounced tubercular changes have been little affected in their general state of health. In one case urotuberculosis appeared after a kidney allotransplantation from a dead donor.

[Quantitative kidney function scintigraphy (FSG) on separate sides in urogenital tuberculosis]

Depending on degree and size of the changes the function of the tuberculous kidney is disturbed with different strength. With the help of the quantitative function scintigraphy by means of 131 J hippuran (sequence scintigraphy, ROI nephrography and side-separated clearance) 33 patients with urotuberculosis were examined and their course of the disease was observed. The greatest value has the function scintigraphy in progressed renal tuberculosis in the differential therapy (nephrectomy, organ-maintaining operation or conservative therapy) and control of the course.

Hemodynamic evaluation of the Carpentier-Edwards bioprosthesis in the aortic position

The Carpentier-Edwards bioprosthesis is a glutaraldehyde-fixed porcine xenograft with a fully flexible thin-walled stent. Cardiac catheterization studies were performed in 17 patients to evaluate use of this valve in the aortic position. Hemodynamic studies established a mean peak gradient across the prosthesis of 19 mm Hg (range 5 to 65). The mean effective orifice area was calculated to be 1.6 cm2 (range 0.8 to 3.3). All patients demonstrated an improvement in functional class after operation. Mean left ventricular ejection fraction increased from 51 +/- 16 to 68 +/- 9 percent (P less than 0.004) in eight patients operated on for aortic stenosis, but was not significantly changed in patients operated on for aortic insufficiency. Hemodynamic comparison of the Carpentier-Edwards bioprosthesis with the standard Hancock xenograft showed similar effective orifice areas for the 23 and 25 mm diameter valves. In two patients studied the 21 mm Carpentier valve demonstrated a greater effective orifice area than that previously reported for the standard Hancock xenograft. The Carpentier-Edwards bioprosthesis affords both clinical and hemodynamic improvement when used in the aortic position and may allow improved effective orifice area when used in the smaller aortic root.

Detection of myocardial infarct extension by CK-B radioimmunoassay

Myocardial infarct extension after the acute event was defined as a second reise in the myocardial isoenzyme of serum creatine kinase (CK-B) after the initial return of CK-B to normal values. In 43 patients with acute myocardial infarcts, CK-B was measured by radioimmunoassay every 12 hours for 14 days. Nineteen patients had anterior transmural myocardial infarcts AMI, 14 had inferior transmural myocardial infarcts (IMI) and 10 had subendocardial myocardial infarcts (SEMI). Infarct extension as detectd by a second rise in serum CK-B occurred in six patients (32%) with AMI, two (14%) with IMI and two (20%) with SEMI; these differences are not statistically significant. Infarct extension for all patients combined was 23%. Four patients with AMI also had infarct extension as determined by recurrent chest pain. ECG alterations and other enzyme changes. In the other six, the infarct extension was undetected clinically. Four patients with AMI and infarct extension died within 3 weeks after hospitalization. We did not note any additional morbidity or mortality in patients with infarct extension who had IMI or SEMI. There was no significant difference in the frequency of previous myocardial infarction, history of hypertension, diabetes mellitus or smoking history in patients with and without infarct extension shown by serum CK-B isoenzyme elevations. The measurement of serum CK-B values with a quantitative and sensitive assay suggests that myocardial infarct extension occurs more commonly than clinically recognized, but the frequency of extension may be less than that reported in patients in whom precordial mapping and total serum CK values were measured to identify this phenomenon.

[Modern therapy and after-care in urogenital tuberculosis]

The present therapy of the urogenital tuberculosis is based on the effective medicaments (rifampizin, isonicotinic acid hydrazid, streptomycin, and ethambutol). It rests on an optimum dosage in connection with a best suited combination, taking into consideration the relations of sensitiveness and side effects as well as consequent long-term treatment. It is referred to the possibility of additional administrations of corticosteroid preparations and it is taken notice to the necessity also to treat unspecific mixed infections. Under the modern chemotherapy with bactericidal effect a stable negativation practically always develops within 3 months. Actual recidivations were not seen during the last 12 years. Apart from a compilation of the indications to nephrectomy references to possibilities of plastic surgical corrections of the urinary system are given. Two tables give information about the patients who were operatively treated during the last 15 years. A close collaboration of the various therapeutic institutions with a consulting urologist -- particularly in problematic and advanced cases of the disease -- nearly always saves the patient with urogenital tuberculosis from invalidism.

[New findings on the efficacy and mode of action of the horse chestnut saponin escin]

In order to complete previous results of the efficacy of the horse chestnut saponin escin, its activity was tested on two further models of inflammation: the rat serous peritonitis provoked by i.p. injection of formalin solution, and the rat serous pleurisy provoked by intrapleural injection of Evans Blue/carrageenan. The results showed escin to be an anti-exudative substance with regard to its exudation inhibitory effect determined by the reduction of exudative fluid. As to peritonitis the diminution of protein permeation into the abdominal cavity was determined: with increasing doses escin tended to prevent more efficiently the diffusion of small molecules than the permeation of large molecules. The hypothesis that escin has an effect on the vascular walls in the sense of a "sealing" effect on the capillaries was tested on the following model: the permeability of the plasma-lymph barrier of the hind leg of the rabbit was enhanced by injection of bradykinin. Escin antagonised the bradykinin effect dose-dependently determined by the depression of the raised lymph-flow by about 70%.