Starvation-induced Liver Enzyme Elevation after Initiation of Feeding

Exacerbation of liver enzymes after the initiation of feeding in malnourished patients is caused by refeeding syndrome or persistent starvation. There are no definite clinical markers for distinguishing between the two conditions. We herein report a 63-year-old woman with starvation-induced liver enzyme elevation. Her body weight was inversely associated with the liver enzyme levels after refeeding, which was a different course from refeeding syndrome. Normalization of liver enzymes ensued as the caloric intake increased and weight gain progressed. Daily changes in body weight can be a useful clinical marker for distinguishing between refeeding syndrome and starvation-induced liver enzyme elevation.

Ketoacidosis due to a Low-carbohydrate Diet in an Elderly Woman with Dementia and Abnormal Eating Behavior

Strict restriction of carbohydrates can induce symptomatic ketoacidosis. We herein report a 76-year-old demented woman who developed ketoacidosis after 1 month of abnormal eating behavior involving selectively eating hamburger steak (estimated carbohydrate =12.7 g/day). Laboratory tests showed high-anion-gap metabolic acidosis with elevated blood ketone levels. She was successfully treated with intravenous fluids followed by oral intake of a regular diet. She remained relapse-free after correcting her eating habits. Healthcare providers should know that abnormal eating behavior in demented people can lead to an extremely-low-carbohydrate diet and cause atypical ketoacidosis unexplained by diabetes, heavy alcohol intake, or starvation conditions.

Influence of nutrition therapy on the intestinal microbiome

PURPOSE OF REVIEW

This review describes the relationship between nutritional therapies and the intestinal microbiome of critically ill patients.

RECENT FINDINGS

The intestinal microbiome of the critically ill displays a near complete loss of health-promoting microbiota with overgrowth of virulent healthcare-associated pathogens. Early enteral nutrition within 24 h of admission to the ICU has been advocated in medical and surgical patients to avoid derangements of the intestinal epithelium and the microbiome associated with starvation. Contrary to previous dogma, permissive enteral underfeeding has recently been shown to have similar outcomes to full feeding in the critically ill, whereas overfeeding has been shown to be deleterious in those patients who are not malnourished at baseline. Randomized clinical trials suggest that peripheral nutrition can be used safely either as the sole or supplemental source of nutrition even during the early phases of critical care. The use of probiotics has been associated with a significant reduction in infectious complications in the critically ill without a notable mortality benefit.

SUMMARY

Focus of research is shifting toward strategies that augment the intestinal environment to facilitate growth of beneficial microorganisms, strengthen colonization resistance, and maintain immune homeostasis.

[Organization of medical support for troops, defending Leningrad and the people of the blockaded city]

The data on the composition of forces of medical services and organization of medical-evacuation support for troops defending the blockaded Leningrad are presented. The information about the health losses among the population of Leningrad as a result of bombing, shelling and disease is given. Extremely high rates of morbidity and mortality in residents were associated with hunger, hypothermia and emotional stress. The clinical picture of some diseases has different peculiarities because of alimentary dystrophy background. The city health service suffered huge losses: 482 medical institutions were destroyed, only about 300 people from 1.5 thousand of medical personnel in 1942 saved working capability. The health care service of the local air defense played an essential role in delivery of medical aid. The contribution of civil and military health workers in saving residents lives in the blockaded Leningrad was appreciated.

Management of patients during hunger strike and refeeding phase

OBJECTIVE

Hunger strikers resuming nutritional intake may develop a life-threatening refeeding syndrome (RFS). Consequently, hunger strikers represent a core challenge for the medical staff. The objective of the study was to test the effectiveness and safety of evidence-based recommendations for prevention and management of RFS during the refeeding phase.

METHODS

This was a retrospective, observational data analysis of 37 consecutive, unselected cases of prisoners on a hunger strike during a 5-y period. The sample consisted of 37 cases representing 33 individual patients.

RESULTS

In seven cases (18.9%), the hunger strike was continued during the hospital stay, in 16 episodes (43.2%) cessation of the hunger strike occurred immediately after admission to the security ward, and in 14 episodes (37.9%) during hospital stay. In the refeed cases (n = 30), nutritional replenishment occurred orally, and in 25 (83.3%) micronutrients substitutions were made based on the recommendations. The gradual refeeding with fluid restriction occurred over 10 d. Uncomplicated dyselectrolytemia was documented in 12 cases (40%) within the refeeding phase. One case (3.3%) presented bilateral ankle edemas as a clinical manifestation of moderate RFS. Intensive medical treatment was not necessary and none of the patients died. Seven episodes of continued hunger strike were observed during the entire hospital stay without medical complications.

CONCLUSIONS

Our data suggested that seriousness and rate of medical complications during the refeeding phase can be kept at a minimum in a hunger strike population. This study supported use of recommendations to optimize risk management and to improve treatment quality and patient safety in this vulnerable population.

Laparoscopy-assisted percutaneous endoscopic gastrostomy enables enteral nutrition even in patients with distorted anatomy

AIM: To analyzed whether laparoscopy-assisted percutaneous endoscopic gastrostomy (PEG) could be a valuable option for patients with complicated anatomy.

METHODS: A retrospective analysis of twelve patients (seven females, five males; six children, six young adults; mean age 19.2 years) with cerebral palsy, spastic quadriparesis, severe kyphoscoliosis and interposed organs and who required enteral nutrition (EN) due to starvation was performed. For all patients, standard PEG placement was impossible due to distorted anatomy. All the patients qualified for the laparoscopy-assisted PEG procedure.

RESULTS: In all twelve patients, the laparoscopy-assisted PEG was successful, and EN was introduced four to six hours after the PEG placement. There were no complications in the perioperative period, either technical or metabolic. All the patients were discharged from the hospital and were then effectively fed using bolus methods.

CONCLUSION: Laparoscopy-assisted PEG should become the method of choice for gastrostomy tube placement and subsequent EN if PEG placement cannot be performed safely.

Refeeding in the ICU: an adult and pediatric problem

PURPOSE OF REVIEW

To describe the etiology and complications of the refeeding syndrome.

RECENT FINDINGS

Complications of the refeeding syndrome can include electrolyte abnormalities, heart failure, respiratory failure, and death. This syndrome is of particular importance to critically ill patients, who can be moved from the starved state to the fed state rapidly via enteral or parenteral nutrition. There are a variety of risk factors for the development of the refeeding syndrome. All of these risk factors are tied together by starvation physiology. Case reports and case series continue to be reported, suggesting that this entity continues to exist in critically ill patients. Initiation of enteral nutrition to patients with starvation physiology should be gradual and careful monitoring of electrolytes and organ function is critical during the early stages of refeeding.

SUMMARY

The refeeding syndrome remains a significant issue in critically ill patients. Knowledge of the risk factors and the clinical signs of the refeeding syndrome is important to optimize outcomes.

Determinants of coverage in community-based therapeutic care programmes: towards a joint quantitative and qualitative analysis

One of the most important elements behind the success of Community-based Therapeutic Care (CTC) programmes for the treatment of severe acute malnutrition has been their ability to achieve high levels of coverage. In CTC, coverage is measured using the Centric System Area Sampling (CSAS) method, which provides accurate and reliable estimates of programme coverage as well as information on the primary reasons for non-attendance. Another important feature of CTC programmes is their use of socio-cultural assessments to determine potential barriers to access and to develop context-specific responses. By analysing data on non-attendance provided by CSAS surveys, in conjunction with data from socio-cultural assessments, it is possible to identify common factors responsible for failures in programme coverage. This paper focuses on an analysis of data from 12 CTC programmes across five African countries. It pinpoints three common factors (distance to sites, community awareness of the programme, and the way in which rejections are handled at the sites) that, together, account for approximately 75 per cent of non-attendance.

Cancer-induced cachexia: a guide for the oncologist

Cancer-induced cachexia (CIC) is a paraneoplastic syndrome that may account for up to 20% of deaths in cancer patients. Cachexia includes distinct metabolic changes that are the result of an acute-phase response (APR) mounted by the host as a reaction to tumor cells. These changes include increased muscle proteolysis, increased fat lipolysis, and increased hepatic production of acute-phase proteins such as C-reactive protein and fibrinogen. This APR pathogenesis is an important consideration in trying to treat cachectic patients as most therapies do not target the APR and its subsequent metabolic effects. Although there is currently no cure for CIC, the oncologist frequently encounters cachectic patients in practice, and evidence-based management is needed. We review the current data for assessment of starvation and cachexia, providing guidelines for management that include serum markers and functional assessment. In addition, a review of current therapies is provided, including hypercaloric feeding and nutritional intervention to address starvation, as well as data on appetite stimulants such as corticosteroids and megestrol acetate. Experimental therapies are also discussed, including nonsteroidal antiinflammatory drugs, tumor necrosis factor alpha antagonists, tetrahydrocannabinol, growth hormone, ghrelin, oxandrolone, and omega-3 fatty acids.

["Junk-food"-intervention in poisoning delusion]

Case report about a 29-year old US-American patient who suddenly flew to Germany due to a schizoaffektive disorder. During a stay in our psychiatric hospital she refused food, liquid and medication because of fear of being poisoned. After four days her general condition had worsened rapidly so that parenteral nutrition was discussed. Surprisingly her poisoning delusion could be overcome by offering American "Junk-Food". From this moment on compliance in taking of medication improved too, so that renormalisation of her condition was achieved.

The metabolic response to stress: a case of complex nutrition support management

The ICU patient with burns, neurotrauma, sepsis, or major surgery typifies the classic hypermetabolic patient. These patients have increased energy and nutrient needs as a result of their injuries and require early nutrition support. Although these patients are likely to benefit from nutritional intervention, the complexity of the stress response to injury and subsequent changes in nutrient metabolism make the design and implementation of nutrition care challenging. This article reviews the pathophysiology of common hypermetabolic conditions and provides strategies to manage the complications associated with nutrition support.

The refeeding syndrome and hypophosphatemia

The refeeding syndrome is an underappreciated entity characterized by acute electrolyte derangements--notably hypophosphatemia--that occur during nutritional repletion of patients with significant suboptimal caloric intake. Adverse effects of hypophosphatemia include cardiac failure, muscle weakness, immune dysfunction, and death. Hypokalemia and hypomagnesemia commonly complicate refeeding syndrome as well; however, this report briefly reviews the clinical manifestations of refeeding-induced hypophosphatemia.

Refeeding syndrome

Refeeding syndrome can occur when nutrition is reinstituted in a starved patient and, if abnormalities are not corrected, can be lethal. This article describes metabolic adaptations to starvation, risk factors for the development of refeeding syndrome, and causes as well as symptoms of refeeding syndrome. Adverse consequences of hypophosphatemia, hypomagnesemia, and hypokalemia are described. Nursing implications to prevent refeeding syndrome are outlined.

Dispersion of the corrected QT interval in the electrocardiogram of the ex-prisoners of war

The study of electrocardiograms (ECGs) was performed in a subgroup of 181 men, ex-prisoners of war with mean age 35.8+/-11.0 years and mean duration of imprisonment 164.5+/-87.1 days, chosen at random from the total sample of released prisoners (N=1458). The control group was pair-matched. The analysis of ECGs was done according to the Minnesota code, and Bazett's formula gave the values of the corrected QT interval (QT(c)). The dispersion of the QT(c) interval is determined by the difference between the longest and the shortest measured QT(c) interval in each ECG lead. The results of descriptive statistics in the group of ex-prisoners showed the range of QT(c) dispersion of 8.0-122.0 ms (mean 52.4+/-21.6 ms), while in the control group the range was 6.0-72.0 ms (mean 30.4+/-13.8 ms) (df=360, t=11.536; P<0.001). The QT(c) interval from 422.0 to 480.0 ms had 60.2% ex-prisoners and 30.4% controls, while a QT(c) interval over 480.0 ms had 19.3% ex-prisoners and 1.10% controls (P<0.0001). In the ex-prisoners group, the QT(c) dispersion over 50 ms was present in 51.4%; of those, a dispersion of 95 ms and more was found in 3.9%, while in the controls a QT(c) dispersion over 50 ms was found in 8.3%, but a dispersion of 95 ms and more was not recorded (P<0.0001). The odds ratio estimated for the prolonged QT(c) interval was 8.467 and for enlarged QT(c) dispersion it was 11.695 in the ex-prisoners versus controls (P<0.001). In conclusion, persons exposed to long-term maltreatment in detention camps have significantly greater QT(c) dispersion, as well as a higher relative risk of prolonged QT(c) interval and greater QT(c) dispersion than a control group.

Percutaneous endoscopic gastrostomy and outcome in dementia

The use of percutaneous endoscopic gastrostomy for the administration of food and medications in patients with dementia has been on an increase. Many studies have failed to demonstrate the positive outcome expected of this feeding modality for the indications that required tube placement. Hence, the concept of feeding through gastrostomy tubes has become the subject of much discussion and controversy in recent times. We have reviewed the literature with regard to outcome in older patients with dementia and percutaneous endoscopic gastrostomy with respect to nutritional parameters, quality of life, and survival. A brief discussion on ethical and legal aspects is included. Much of the data do not suggest that outcome in dementia is favorably improved after percutaneous gastrostomy.

Refeeding procedures after 43 days of total fasting

Refeeding syndrome encompasses fluid and electrolyte imbalances and metabolic, intestinal, and cardiorespiratory derangements associated with appreciable morbidity and mortality. Although refeeding syndrome has been well documented in concentration-camp subjects, and more recently during parenteral therapy of critically ill patients, little is known about the importance of refeeding syndrome during recovery from a hunger strike. Thus, we studied the response to a four-step dietary replenishment routine in eight hunger strikers who refused food for 43 d. In this retrospective, observational study, we assessed the safety and efficacy of the refeeding procedure and analyzed the clinical and nutritional course of the cohort during both starvation and refeeding, mainly on the basis of clinical as well as a few biochemical determinations. During starvation, average weight loss was about 18% and, with the exception of occasional oral vitamins and electrolytes, the subjects consumed only water. Available body-composition and biochemical profiles showed no clinically significant changes during starvation, but one-half of the group displayed spontaneous diarrhea at some time before refeeding. Stepwise nutritional replenishment lasted for 9 d, after which all patients tolerated a full, unrestricted diet. Only one episode of diarrhea occurred during this phase, and both clinical and biochemical indexes confirmed a favorable clinical course, without any manifestation of refeeding syndrome. In conclusion, we observed the following: 1) Hypophosphatemia and other micronutrient imbalances did not occur, nor was macronutrient intolerance detected. 2) Despite some episodes of diarrhea, nutritional replenishment was not associated with significant enteral dysfunction. 3) There was some fluid retention, but this was mild. 4) Acute-phase markers were abnormally elevated during the refeeding phase, without associated sepsis or inflammation.

Protein hydrolysate vs free amino acid-based diets on the nutritional recovery of the starved rat

BACKGROUND AND AIMS

To test the hypothesis that a peptide-based enteral product was equivalent to a low-fat, free amino acid-based formula in the nutritional and functional recovery of the starved rat.

METHODS

Sixteen male Wistar rats were starved for 3 days. Then, rats were randomised to a whey protein hydrolysate-based diet or a free amino acid-based diet and refed for 3 days. The experiment was designed to provide the same energy intake in both groups. The parameters studied included body weight gain, nitrogen retention, plasma free amino acid concentrations, muscle glutamine concentrations and glutathione levels in gut mucosa and liver.

RESULTS

Weight gain was statistically higher on the peptide-based diet than on the elemental diet after the refeeding period. This difference in weight gain was associated with a statistically higher nitrogen retention. Plasma and muscle free glutamine concentrations were higher in rats fed the whey protein hydrolysate-based diet than those in rats refed the free amino acid-based diet, even though the glutamine intake was higher in the latter group. Glutathione concentrations in liver and gut mucosa were similar in the groups.

CONCLUSION

We conclude that enteral diets containing peptides were more effective than a diet containing free amino acids in the nutritional recovery of the starved rat.

Regulation of PepT1 peptide transporter expression in the rat small intestine under malnourished conditions

BACKGROUND AND AIMS

Many investigations suggested that peptide nutrition had a clinical advantage for nitrogen absorption. Recently, the cDNA encoding the H(+)/peptide cotransporter PepT1 was cloned. However, the regulatory mechanism of PepT1 expression under malnourished conditions has not been elucidated. The aim of this study was to clarify regulatory mechanisms of PepT1 expression.

METHODS

Sprague-Dawley rats were starved for 4 days, semistarved (50% amount of control) for 10 days, or given total parenteral nutrition (TPN) for 10 days. Rats with free feeding were used as control. Among those groups, the changes of PepT1 mRNA level in the jejunal mucosa and PepT1 protein density at the brush-border membranes were examined by Northern blot and by Western blot analysis, respectively.

RESULTS

Both starvation and TPN treatment caused a significant decrease in mucosal weight by 41 and 50% respectively. PepT1 mRNA level increased to 179% in the starved group and also to 161 and 164% in the TPN and semistarved groups, respectively. In contrast, sodium-dependent glucose transporter 1 mRNA expression showed no significant change. PepT1 protein density showed similar changes with the mRNA.

CONCLUSIONS

PepT1 gene expression was significantly enhanced under the malnourished conditions in spite of atrophic changes of intestinal mucosa.

Natural hazards: causes and effects. Lesson 7-Drought

Drought has long been recognized as one of the most insidious causes of human misery. Today, it is the natural disaster that annually claims the most victims. Its ability to cause widespread misery is estimated to be increasing. While generally associated with semiarid climates, drought may occur in areas that normally enjoy adequate rainfall and moisture. In the broadest sense, any lack of water for the normal needs of agriculture, livestock, industry, or human population may be termed as a drought. The cause may be lack of supply, contamination of supply, inadequate storage or conveyance facilities, or abnormal demand. Drought is a condition of climatic dryness severe enough to reduce soil moisture and water below the minimums necessary for sustaining plant, animal, and human life. Drought usually is accompanied by hot, dry winds and may be followed by damaging floods. More socially relevant than technically correct is the definition used by Ari Toubo Eibrahim, the minister of agriculture in Niger, who has said that a drought is "Not as much water as the people need."

Infections during severe primary undernutrition and subsequent refeeding: paradoxical findings

BACKGROUND

Our earlier uncontrolled observations during primary famine and subsequent refeeding did not suggest that severe undernutrition inevitably increases vulnerability to infection. Some infections appeared suppressed by famine but reactivated by refeeding.

AIMS

To examine prospectively the occurrence of infections in a large cohort of primary famine victims before and during refeeding.

METHODS

From 1973 to 1993, 4382 famine victims aged 14 or more with an estimated weight loss greater than 25% were weighed and examined for infection before and after one, two, three and four weeks of refeeding. In 137, serum C-reactive protein was measured in an effort to detect latent asymptomatic infections before and after two weeks of refeeding. Refeeding diets included wheat, sorghum, millet, ghee and milk powder.

RESULTS

Mean weight loss +/- SD was 28.7 +/- 2.3%. Before refeeding overt infections were found in 4.9%, an incidence rising to 29.1% at two weeks of refeeding and declining after four. Those developing infections gained more weight at two weeks, 4.6 3 +/- 0.81 kg, than those never infected, 3.94 +/- 0.76 (p = < 0.001 t test). C-reactive protein levels confirmed the presence of latent infections before refeeding.

CONCLUSIONS

Severe undernutrition can suppress certain infections, mostly those due to intracellular pathogens and especially P. falciparum. Refeeding reactivates suppressed infection and can increase vulnerability to certain new infections especially of viral origin. Those gaining weight the most rapidly may be at greatest risk. Refeeding with foods alien to local culture could play a role in reactivating latent infections. Our findings may be limited to severe undernutrition and not apply to lesser forms or secondary undernutrition in hospital patients. These studies were done during charitable provision of medical care to famine victims.

The limit of human adaptation to starvation

During the height of the 1992-93 famine in Somalia, data were collected from 573 inpatients at the Concern Worldwide Adult Therapeutic Centre in Baidoa, the town at the epicentre of the disaster. These data indicate that a body mass index (BMI, body weight in kilograms divided by height in metres squared) of less than 10 kg m-2 can be compatible with life, so long as specialized care is provided. Such low levels of BMI may be explained, in part, by the high ambient temperature, the tall phenotype of the Somalis, the gradual reduction in food intake and previous exposure to chronic energy deficiency. Famine oedema occurred with the same prevalence in male and female patients, but male patients had more severe oedema and a poorer prognosis at any given degree of severity. Survival from these extremes of emaciation has never before been recorded, and many of the BMI values documented here are below the level of 12, previously thought to mark the limit of human adaptation to starvation.

Ethical and medico-legal problems concerning so-called hunger strikers

In the Middle European medico-legal climate, the moral rule 'salus aegroti suprema lex' has been accepted for a long time. In the last few years, under the pressure of fear of accusation of a paternalistic attitude, this postulate has been changed to 'voluntas aegroti suprema lex'. The question stands: Is this valid in each case and in all the situations? For example, it is possible to use compulsory treatment with those who have not given their informed consent. Even the charter of basic human rights and freedom states in its article 6 that everyone has a right of life. The law specifies in which cases an individual can be accepted or can be held in a health care institution without his/her consent. In cases of so-called 'hunger strikers', the strikers refuse food and expose themselves to extreme starvation in order to reach some political goals or to express their views. If, in such situations, the patient endangers his/her life, the physician who is facing this problem is, according to Czech law and similarly to some other Central European laws, and according to the Ethical Code of the Czech Medical Chamber, bound to act to protect and restore the life and the health of that person. The Health Care Act No. 540/1991 of the Czech Republic states the obligation to provide emergency care to anyone whose life or health is threatened. Compulsory treatment is possible, for example, if an individual shows signs of mental disease or if an intoxication threatens him or his neighbourhood.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of early enteral feeding and acute starvation on postburn bacterial translocation and host defense: prospective, randomized trials

OBJECTIVES

To investigate the effect of: a) starvation during the preburn period and b) immediate postburn enteral nutrition on the permeability of the gut to microorganisms and the ability of the host to kill translocated bacteria.

DESIGN

Prospective, randomized, experimental trials.

SETTING

Laboratory.

SUBJECTS

Balb/c mice and Hartley guinea pigs.

INTERVENTIONS

In the first experiment, mice were starved for 0, 6, 12, 18, or 24 hrs before receiving gavage with 10(10) 14C-labeled Escherichia coli and a 20% burn injury. In the second experiment, guinea pigs received a 40% burn injury and were randomized to receive a complete enteral diet (175 kcal/kg/day) or infusion of an equal volume of lactated Ringer's solution via a previously placed gastrostomy for 6, 24, or 48 hrs. After each feeding period, 10(10) 14C Escherichia coli were infused intragastrically. In both experiments, the animals were killed 4 hrs after gavage, and mesenteric lymph nodes, spleen, liver, lungs, peritoneal fluid, and blood were harvested aseptically.

MEASUREMENTS

For each tissue or fluid, the number of viable E. coli and radionuclide counts of the 14C E. coli were measured and the percentage of translocated bacteria that remained alive was calculated.

MAIN RESULTS

In mice, 18 and 24 hrs of preburn starvation increased translocation only to the mesenteric lymph nodes, but it also enhanced bacterial killing in all tested tissues. Guinea pigs that were fed enterally for 6, 24, and 48 hrs postburn had significantly lower bacterial translocation in all tissues compared with animals infused with lactated Ringer's solution. Additionally, enhanced killing of translocating organisms was observed after 24 and 48 hrs of feeding.

CONCLUSIONS

Starvation preburn has different consequences than starvation postburn on translocation and bacterial killing. Postburn enteral nutrition decreases the load of viable bacteria in the tissues via a double mechanism: an initial decreased translocation and a subsequent improved ability to kill bacteria that do translocate.

The behavioral treatment of self-starvation and severe self-injury in a patient with borderline personality disorder

The successful treatment by behavioral methods of self-starvation and self-injury in a 35-year-old psychiatric in-patient, with a diagnosis of borderline personality disorder, is described. An individualized program using positive and negative reinforcers to increase food and fluid intake was used, while a token economy therapeutic milieu with time out was used to decrease acts of self-injury and aggression. Progress in treatment generalized to a non-secure treatment environment, and was maintained at an 8-month follow-up. The study illustrates the differential response of active and passive self injurious behaviors to group-based and individual treatments, respectively.

Chromosomal abnormalities in starved and marginally malnourished rats and in utero upon rehabilitation

The effects of starvation and marginal malnutrition (MN) on the lymphocytes of rats were evaluated by chromosomal analysis before and after rehabilitation. The effect of parental starvation or malnutrition on chromosomal aberrations in the foetus was also studied. Wistar rats, 30-35 days old, were starved for 5 days or fed a minimally restricted or a severely restricted diet for three weeks. At the end of the period of starvation or malnutrition, lymphocytes were isolated and chromosomal analysis was performed. Starved and severely restricted rats showed significantly higher mean chromosomal aberrations than the controls. These aberrations returned to a normal level when the experimental groups were rehabilitated for a month, indicating that the damage was transient. A chromosomal aberration study done on foetal cells from rehabilitated rats which had previously been starved or fed a severely restricted diet showed significantly increased values, indicating that some damage was permanent. A low number of implantations was also recorded in these experimental groups. These observations clearly indicate that young animals exposed to conditions like starvation or chronic malnutrition are prone to permanent damage of the genetic system.

Effect of glutamine-supplemented total parenteral nutrition on recovery of the small intestine after starvation atrophy

Intestinal atrophy was induced in rats by infusion of 5% dextrose for 7 days with only oral water allowed. Compared with control animals fed standard rat chow (Purina Mills, St. Louis), the starved animals lost 30.5% of their initial body weight, 34.7% mucosal wet weight, 68.3% mucosal nitrogen content, 36.7% mucosal thickness, and 38.6% villous height and had variable losses of mucosal disaccharidase activities. Three groups of depleted rats were then refed with different regimens. One group was refed with standard Purina rodent chow (n = 15); a second group with a standard total parenteral nutrition (TPN) solution containing 16% glucose, 2.8% fat, and 4.25% standard amino acids (Travasol 8.5%, Baxter Healthcare Corporation, Deerfield, IL) (n = 15); and the third group with a TPN solution of 16% glucose, 2.8% fat, 2.75% standard amino acids, and 1.5% glutamine (n = 15). After 7 days of refeeding, rats were killed to determine the degree of intestinal recovery. Animals refed with standard TPN solution showed no significant recovery of intestinal mucosal weight, mucosal nitrogen content, villous height, mucosal thickness, or mucosal disaccharidase activities. Animals refed with glutamine-supplemented TPN solution demonstrated significant recovery of all parameters but not back to normal. Oral rodent chow completely restored intestinal anatomy and function. The addition of glutamine to TPN solutions significantly improved recovery of the intestine from starvation atrophy, and additional efforts to make it commercially available are indicated. This study again confirms the preferable use of a regular oral diet when clinically feasible and safe.

Famine-affected, refugee, and displaced populations: recommendations for public health issues

During the past three decades, the most common emergencies affecting the health of large populations in developing countries have involved famine and forced migrations. The public health consequences of mass population displacement have been extensively documented. On some occasions, these migrations have resulted in extremely high rates of mortality, morbidity, and malnutrition. The most severe consequences of population displacement have occurred during the acute emergency phase, when relief efforts are in the early stage. During this phase, deaths--in some cases--were 60 times the crude mortality rate (CMR) among non-refugee populations in the country of origin (1). Although the quality of international disaster response efforts has steadily improved, the human cost of forced migration remains high. Since the early 1960s, most emergencies involving refugees and displaced persons have taken place in less developed countries where local resources have been insufficient for providing prompt and adequate assistance. The international community's response to the health needs of these populations has been at times inappropriate, relying on teams of foreign medical personnel with little or no training. Hospitals, clinics, and feeding centers have been set up without assessment of preliminary needs, and essential prevention programs have been neglected. More recent relief programs, however, emphasize a primary health care (PHC) approach, focusing on preventive programs such as immunization and oral rehydration therapy (ORT), promoting involvement by the refugee community in the provision of health services, and stressing more effective coordination and information gathering. The PHC approach offers long-term advantages, not only for the directly affected population, but also for the country hosting the refugees. A PHC strategy is sustainable and strengthens the national health development program.

Handling hunger strikers

Hunger strikes are being used increasingly and not only by those with a political point to make. Whereas in the past, hunger strikes in the United Kingdom seemed mainly to be started by terrorist prisoners for political purposes, the most recent was begun by a Tamil convicted of murder, to protest his innocence. In the later stages of his strike, before calling it off, he was looked after at the Hammersmith Hospital. So it is not only prison doctors who need to know how to handle a hunger strike. The following guidelines, adopted by the 43rd World Medical Assembly in Malta in November 1991, are therefore a timely reminder of the doctor's duties during a hunger strike.

Effect of intravenous feeding on wound healing in starvation: an experimental study on the rabbit

The effects of modified protein sparing therapy (PSP) and total parenteral nutrition (TPN) on total and wound metabolism were studied for 96 hours after laparotomy and a small gastric excision in 40 rabbits starved for seven days. A further eight starved and eight non-starved animals served as controls for the blood variables. Normal healing up to day 14 was studied in 20 non-starved animals. The difference in deaths and animals in poor condition, 42.1 per cent in PSP and 18.6 per cent in TPN, respectively, was clear but statistically non-significant. PSP led to a lower mean serum albumin concentration than TPN, 25.7 +/- 3.7 (SD) and 28.7 +/- 3.0 (p = 0.02), respectively. The animals receiving PSP excreted significantly more 3-methylhistidine. TPN maintained a positive nitrogen balance, but PSP produced a negative one. The collagen content of the skin scar was lower after PSP (3.1 +/- 0.7 mg) than after TPN (4.5 +/- 1.3 mg) (p less than 0.05), the latter coming close to the level for normal 4-day healing, 4.5 +/- 1.2 mg. Prolyl 4-hydroxylase (PPH) activity showed no difference. No inter-group differences in collagen were found in the stomach. Both regimens totally reversed the starvation-induced decrease in PPH activity in the stomach, but only partially in skin. Thus TPN produced better total and skin wound metabolism after laparotomy and starvation than did PSP. No differences in visceral wound healing were observed.

Recombinant growth hormone enhances muscle myosin heavy-chain mRNA accumulation and amino acid accrual in humans

A potentially lethal complication of trauma, malignancy, and infection is a progressive erosion of muscle protein mass that is not readily reversed by nutritional support. Growth hormone is capable of improving total body nitrogen balance, but its role in myofibrillar protein synthesis in humans is unknown. The acute, in situ muscle protein response to an infusion of methionyl human growth hormone was investigated in the limbs of nutritionally depleted subjects during a period of intravenous refeeding. A 6-hr methionyl growth hormone infusion achieved steady-state serum levels comparable to normal physiologic peaks and was associated with a significant increase in limb amino acid uptake, without a change in body amino acid oxidation. Myosin heavy-chain mRNA levels, measured by quantitative dot blot hybridization, were also significantly elevated after growth hormone administration. The data indicate that methionyl growth hormone can induce intracellular amino acid accrual and increased levels of myofibrillar protein mRNA during hospitalized nutritional support and suggest growth hormone to be a potential therapy of lean body wasting.

Polyribosome concentration in human skeletal muscle after starvation and parenteral or enteral refeeding

Posttraumatic and septic states cause a loss of body proteins resulting in a negative nitrogen balance. The major part of the excreted nitrogen is derived from the proteins of skeletal muscle. The loss in proteins is due to a decrease in protein synthesis rather than an increase in protein degradation. Nutritional support may increase protein synthesis, and determination of its activity in skeletal muscle will give information on the utilization of nutrients in catabolic patients. The effect of nutritional support on healthy subjects was studied to achieve a background for future clinical studies. Male volunteers between 20 and 40 years old were refed parenterally or enterally after three days of starvation. Muscle biopsies (50 mg) were analyzed for the size distribution of ribosomes in a sucrose density gradient, and the ribosome concentration was determined per mg of DNA. Changes in the percentage content of polyribosomes preceded those of the total ribosome concentration. The total polyribosome concentration per gram wet weight of skeletal muscle decreased significantly during starvation. After one and two days of refeeding, a significant increase was observed, but the original level of the nonstarved subjects was not reached. The total ribosome concentration increased upon refeeding, but was not significantly different from that of the starved condition. The nitrogen balance was negative during starvation but attained equilibrium after two days of refeeding. Nutrition administered by the parenteral or enteral route were equally effective in restoring protein synthesis.

Force-feeding: the physician's dilemma

The right to treatment and the right to refuse treatment are parallel legal rights which, when in opposition, pose a dilemma. In this paper the issues surrounding the possible force-feeding of a hunger striker are examined together with the pertinent legal precedents and possible courses of action. Although the discussion is particularly relevant to hunger strikers, the principles may be applicable to other circumstances.