Nutritional support and parenteral nutrition in cancer patients: an expert consensus report.

BACKGROUND: Malnutrition is a frequent medical problem of cancer patients that negatively impacts their quality of life. METHODS: A multidisciplinary group of experts in Medical Oncology, Pharmacy, and Nutrition convened to discuss the management of the nutritional support in cancer patients. RESULTS: Of the 18 questions addressed, 9 focused on nutritional support, 5 were related to parenteral nutrition (PN) and 4 about home PN (HPN). The panel of experts recommends using nutritional screening routinely, at diagnosis and throughout the disease course, for detecting the risk of malnutrition and, if it is positive, to perform a complete nutritional assessment, to diagnose malnutrition. Currently, there are different screening tools and methods that allow us to detect nutritional risk. Based on the evidence and experience, the panel stated that PN is indicated mainly when it is not possible to use the digestive tract and/or oral feeding and/or enteral nutrition is not sufficient or possible. The nutritional needs of the cancer patients, except in those cases where individualized measures are required, should be considered similar to healthy individuals (25-30 kcal/kg/day). The panel considers that the nutritional monitoring of the cancer patient should be multidisciplinary and adapted to the characteristics of each center. Additionally, the objective of the HPN is to improve or maintain the nutritional status of a patient at home. CONCLUSIONS: This document seeks to lay down a set of recommendations and to identify key issues that may be useful for the nutritional management of cancer patients.

Assessing the impact of pulmonary rehabilitation on functional status in COPD.

BACKGROUND: The optimal way of assessing the impact of pulmonary rehabilitation on functional status in chronic obstructive pulmonary disease (COPD) is currently unknown. The minimal clinically important difference for the constant work rate cycling exercise test also needs to be investigated to facilitate its interpretation. A study was undertaken to evaluate the changes in the 6-min walking test and in the constant work rate cycle endurance test immediately following and 1 year after pulmonary rehabilitation, together with the importance of these changes in terms of health status in patients with COPD. METHODS: Patients with COPD of mean (SD) age 65 (8) years and mean (SD) forced expiratory volume in 1 s (FEV1) 45 (15)% predicted were recruited from a multicentre prospective cohort study and evaluated at baseline, immediately after a pulmonary rehabilitation programme (n = 157) and at 1 year (n = 106). The 6-min walking test and the cycle endurance test were performed at each evaluation. Health status was evaluated with the St George Respiratory Questionnaire. RESULTS: Following pulmonary rehabilitation, cycle endurance time increased (198 (352) s, p<0.001) and stayed over baseline values at 1 year (p<0.001). The 6-min walking distance also showed improvements following rehabilitation (25 (52) m, p<0.001) but returned to baseline values at the 1-year follow-up. Changes in cycle endurance time were more closely associated with changes in health status than with the 6-min walking test. An improvement of 100-200 s in the cycle endurance time was associated with clinically meaningful changes in the St George Respiratory Questionnaire scores. CONCLUSIONS: The cycle endurance test was more responsive than the 6-min walking test in detecting improvement in exercise tolerance following pulmonary rehabilitation, and was also better correlated with improvements in health status. An improvement in the cycle endurance time of 100-200 s appeared to be clinically meaningful.

Oxidative enzyme activities of the vastus lateralis muscle and the functional status in patients with COPD.

BACKGROUND: Enzymatic and histochemical abnormalities of the peripheral muscle may play a role in exercise intolerance in patients with chronic obstructive pulmonary disease (COPD). A study was undertaken to measure the mitochondrial enzyme activity of the vastus lateralis muscle in patients with COPD and to evaluate the relationship between enzyme activities and functional status. METHODS: Fifty seven patients with COPD of mean (SD) age 66 (7) years with forced expiratory volume in one second (FEV(1)) 39 (15)% predicted and peak oxygen uptake (VO(2)) of 14 (4) ml/min/kg and 15 normal subjects of similar age were included in the study. Each subject performed a stepwise exercise test up to maximal capacity during which five-breath averages of VO(2) were measured. Muscle specimens were obtained by percutaneous needle biopsy of the vastus lateralis muscle and the activity of two mitochondrial enzymes (citrate synthase (CS) and 3-hydroxyacyl CoA dehydrogenase (HADH)) was measured. The functional status of the patients was classified according to peak VO(2). RESULTS: CS and HADH activities were markedly reduced in patients with COPD compared with normal subjects (22.3 (2.7) versus 29.5 (7.3) micromol/min/g muscle (p<0.0001) and 5. 1 (2.0) versus 6.7 (1.9) micromol/min/g muscle (p<0.005), respectively). The activity of CS decreased progressively with the deterioration in the functional status while that of HADH was not related to functional status. Using a stepwise regression analysis, percentage predicted functional residual capacity (FRC), the activity of CS, oxygen desaturation during exercise, age, and inspiratory capacity (% pred) were found to be significant determinants of peak VO(2). The regression model explained 59% of the variance in peak VO(2) (p<0.0001). CONCLUSIONS: The oxidative capacity of the vastus lateralis muscle is reduced in patients with moderate to severe COPD compared with normal subjects of similar age. In these individuals the activity of CS correlated significantly with peak exercise capacity and independently of lung function impairment.

Intensity of training and physiologic adaptation in patients with chronic obstructive pulmonary disease.

The applicability of high-intensity training and the possibility of inducing physiologic adaptation to training are still uncertain in patients with severe chronic obstructive pulmonary disease (COPD). The purposes of this study were to evaluate the proportion of patients with moderate to severe COPD in whom high-intensity exercise training (30-min exercise session at 80% of baseline maximal power output [Wmax]) is feasible, and the response to training in these patients. We also sought to evaluate the possible influence of disease severity on the training intensity achieved and on the development of physiologic adaptation following endurance training. Forty-two patients with COPD (age = 66 +/- 7 yr, FEV1 = 38 +/- 13% predicted, [mean +/- SD]) were evaluated at baseline and after a 12-wk endurance training program. Each evaluation included a stepwise exercise test on an ergocycle up to the individual maximal capacity during which minute ventilation (VE), oxygen consumption (VO2), carbon dioxide production (VCO2), and arterial lactic acid concentrations were measured. The training consisted of 25 to 30-min exercise sessions on a calibrated ergocycle three times a week, with a target training intensity at 80% of Wmax. The training intensity was adjusted with the objective of reaching the target intensity, but also to ensure that the cycling exercise could be maintained for the specified duration. The training intensity sustained for the duration of each exercise session averaged 24.5 +/- 12.6, 51.7 +/- 17.4, 63.8 +/- 22.4, and 60.4 +/- 22.7% of Wmax at Weeks 2, 4, 10, and 12, respectively. High-intensity training was achieved in zero, three, five, and five patients at Weeks 2, 4, 10, and 12, respectively. A significant increase in VO2max and Wmax occurred with training (p < 0.0002). This improvement in exercise capacity was accompanied by a 6% and 17% reduction in VE and in arterial lactic acid concentration for a given work rate, respectively (p < 0.0001), suggesting that physiologic adaptation to training occurred. The intensity of training achieved, in % Wmax, was not influenced by the initial VO2max, age, or FEV1. The effects of training were compared in patients with an FEV1 > or = 40% or < 40% predicted. Percent changes in VO2max, Wmax, and VE, were significant and of similar magnitude for both groups, whereas the decrease in arterial lactic acid for a given work rate reached statistical significance only in those patients with an FEV1 > or = 40% predicted. We conclude that although most patients were unable to achieve high-intensity training as defined in this study, significant improvement in their exercise capacity was obtained and physiologic adaptation to endurance training occurred. The training intensity expressed as a percent of the individual maximum exercise capacity, and the relative effectiveness of training, were not influenced by the severity of airflow obstruction.