Nutrition risk screening and implications for patients with gynaecological cancers undergoing pelvic radiotherapy and/or other treatment modalities: A retrospective observational study.

AIM: There is scarcity of research for the nutritional management of pelvic radiotherapy in gynaecological malignancies and delivery of specialised nutrition care is limited due to the current knowledge gap in guidelines. This study aimed to better understand the nutritional risk, weight changes and pattern of nutrition impact symptoms occurring at various treatment timepoints in this population, to inform an effective model of care. METHODS: This retrospective, observational study included women with gynaecological cancers receiving pelvic radiotherapy at a tertiary hospital from January 2017 to December 2018 (n = 104). Information was collected on: first day of radiotherapy; weekly during treatment; acute-phase post-treatment (0-6 weeks); and intermediate-phase post-treatment (6 weeks to 6 months). This study reported on incidence of clinically significant weight change (±5%), documented nutrition impact symptoms and the current nutrition care model (nutrition screening, referral, assessment and interventions). RESULTS: Clinically significant weight loss was experienced by 38% (n = 40/104) of patients prior to commencing treatment and 19% (n = 14/73) during treatment. Diarrhoea (n = 40/79), fatigue (n = 54/79), nausea (n = 38/79) and pain (n = 31/79) were frequently reported during treatment, and fatigue (n = 33/92) and pain (n = 25/92) continued acutely post-treatment. Despite high rates of weight loss and prevalence of nutrition impact symptoms, only 38% (n = 40/104) of patients were referred to a dietitian. CONCLUSIONS: A considerable proportion of patients with gynaecological cancers are at nutrition risk before and during treatment due to clinically significant weight loss and prevalence of nutrition impact symptoms experienced. This highlights the importance of nutrition-risk screening and access to specialised dietetic care as part of their model of care.

Exploration of current dietetic practices for patients with gynaecological cancers undergoing radiotherapy in Australia: a cross-sectional survey.

PURPOSE: Radiotherapy for gynaecological cancers often causes gastrointestinal (GI) toxicities such as diarrhoea. Evidence for the potential benefits of dietary interventions on the management of acute GI toxicities is inconclusive and of low quality, with no clear evidence-based guidelines to inform clinical practice. This study aims to provide an overview of current opinions and clinical practice of dietitians treating this cohort and to examine existing models of nutrition care in Australian cancer centres. METHODS: Semi-structured interviews were conducted over a video conferencing service to collect information relating to: demographic characteristics; referral protocol and post-treatment pathways; management strategies and interventions prescribed; and attitudes and confidence in service provided. Descriptive analysis was performed on quantitative data, and thematic analysis was performed on qualitative data. RESULTS: In total, 17 dietitians across Australia participated in the study. Almost all centres (94%) had dietetics services available for this patient cohort; however, most did not have an automatic referral pathway (94%) or post-treatment pathway (88%). The opinions and prescription of dietary interventions for symptom management had multiple variations of a 'low' or 'modified-fibre' diet with differing ratios of soluble and insoluble fibre. Over half of the respondents believed that practice was not standardized within their workplace (58%) or Australia (82%). CONCLUSION: There are variations in service provision with respect to opinions and prescription of dietary modifications within dietetic practice across Australia. The present study highlights the need to investigate the efficacy of dietary interventions on symptom management to better inform evidence-based models of care.

Back in Time for Breakfast: An Analysis of the Changing Breakfast Cereal Aisle.

Breakfast cereal improves overall diet quality yet is under constant scrutiny with assertions that the category has not improved over time. This study aimed to comprehensively analyse the category of breakfast cereals, the nutritional values, and health claims across eight distinct sub-categories at four time points (2013, 2015, 2018, and 2020). An audit of products from four major supermarkets in metropolitan Sydney (Aldi, Coles, IGA, and Woolworths) collected ingredient lists, nutrition information, claims and Health Star Rating (HSR) for biscuits and bites; brans; bubbles, puffs, and flakes; granola and clusters; hot cereal flavoured; hot cereal plain; muesli; breakfast biscuits. The median (IQR) were calculated for energy, protein, fat, saturated fat, carbohydrate, sugars, dietary fibre, and sodium for comparisons over time points by nutrient. Data from 2013 was compared with 2020 (by sub-category and then for a sub-section of common products available at each time point). Product numbers between 2013 (n = 283) and 2020 (n = 543) almost doubled, led by granola and clusters. Whole grain cereals ≥ 8 g/serve made up 67% of products (↑114%). While there were positive changes in nutrient composition over time within the full data set, the most notable changes were in the nutrition composition of cereals marketed as the same product in both years (n = 134); with decreases in mean carbohydrate (2%), sugar (10%) and sodium (16%) (p < 0.000), while protein and total fat increased significantly (p = 0.036; p = 0.021). Claims regarding Dietary Fibre and Whole Grain doubled since 2013. Analysis of sub-categories of breakfast cereal assisted in identifying some changes over time, but products common to both timeframes provided a clearer analysis of change within the breakfast category, following introduction of HSR. Whole grain products were lower in the two target nutrients, sodium and sugars, and well-chosen products represent a better choice within this category.

The Efficacy of Dietary Fiber in Managing Gastrointestinal Toxicity Symptoms in Patients with Gynecologic Cancers undergoing Pelvic Radiotherapy: A Systematic Review.

BACKGROUND: Pelvic radiotherapy is a common part of treatment used in gynecologic malignancies. The side effects associated with treatment, such as gastrointestinal toxicity, can be acute and chronic. Previous studies have provided little clarity in regard to the best dietary intervention for management of symptoms. OBJECTIVE: The aim of this systematic review was to summarize the evidence on the efficacy of nutrition interventions involving fiber modification in patients with gynecologic cancers undergoing pelvic radiotherapy to prevent or alleviate gastrointestinal side effects, in comparison to standard care, placebo, or no intervention. METHODS: Studies, inclusive of any language and date, up to December 1, 2019, were selected from eight electronic databases: PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature, Scopus, Science direct, Clinical Key, Web of Science, and Cochrane. Key study outcomes included gastrointestinal toxicity such as diarrhea/bowel changes, abdominal pain or bloating, and nausea; nutritional status; and quality of life. All studies underwent a quality appraisal using the Academy of Nutrition and Dietetics Quality Criteria Checklist and certainty of evidence was assessed via the Grading of Recommendations Assessment, Development, and Evaluation criteria. RESULTS: Four studies were included (total number of participants = 89), with quality ratings of neutral or negative. Due to the risk of bias, inconsistency, indirectness, and imprecision, there was very low certainty of evidence that dietary fiber modifications improved these outcomes. Some positive trends regarding improvements in incidence and severity of diarrhea and bowel symptoms were reported; however, the body of evidence was insufficient to form specific recommendations for clinical practice. This is reflected in the Grading of Recommendations Assessment, Development, and Evaluation criteria rating (very low level of certainty) for quality of life and gastrointestinal toxicity outcomes. CONCLUSIONS: This systematic review suggests that supplementary fiber modification during radiation therapy may have some potential benefits with improving gastrointestinal symptoms; however, more definitive evidence and further exploration of fiber in a therapeutic role is required to inform dietary practice.

Assessing the Concurrent Validity and Interrater Reliability of Patient-Led Screening Using the Malnutrition Screening Tool in the Ambulatory Cancer Care Outpatient Setting.

BACKGROUND: The prevalence of malnutrition in cancer patients is reported as high as 65%; however, malnutrition screening is often substandard. The Malnutrition Screening Tool (MST) has been validated for use by health care professionals to detect at-risk patients; however, there is a gap in the literature regarding validation of patient-led MST screening. OBJECTIVE: The aim of the study was to assess the concurrent validity of patient-led MST against the Subjective Global Assessment (SGA) and the interrater reliability of patient-led MST against dietitian-led MST in patients attending ambulatory cancer care services for chemotherapy or supportive treatments. DESIGN/PARTICIPANTS: A single-site diagnostic accuracy study of 201 patients between May and June 2017 attending the ambulatory cancer care setting at an Australian metropolitan tertiary hospital in Queensland. MAIN OUTCOME MEASUREMENTS: The primary outcome measures were concurrent validity and interrater reliability of MST scores as determined by patients (patient-MST), dietitians (dietitian-MST), and SGA as completed by the dietitian. STATISTICAL ANALYSIS: Concurrent validity of patient-led MST scores against the SGA was determined using specificity, sensitivity, positive predictive values, and negative predictive values. Interrater reliability of patient-MST and dietitian-MST was assessed using κ coefficient. RESULTS: The ability of the patient-led MST scores (0 to 1 vs 2 to 5) to indicate nutrition status was found to have a sensitivity of 94% (95% CI 81% to 99%), a specificity of 86% (95% CI 79% to 91%), and an area under the receiver operating characteristic curve of 0.93 (95% CI 0.89 to 0.96). The positive predictive value was 59% (95% CI 45% to 71%), and the negative predictive value was 99% (95% CI 95% to 100%). A weighted κ of 0.83 (95% CI 0.82 to 0.87) between patient-MST and dietitian-MST was found. CONCLUSION: Patient-led MST screening is a reliable and valid measure that can accurately identify ambulatory cancer care patients as at risk or not at risk of malnutrition.

Glial degeneration and reactive gliosis in alpha-synucleinopathies: the emerging concept of primary gliodegeneration.

The concept of gliodegenerative diseases has not been widely established although there is accumulating evidence that glial cells may represent a primary target of degenerative disease processes. In the central nervous system (CNS), examples that provide a "proof of concept" include at least one alpha-synucleinopathy, multiple system atrophy (MSA), but this disease is conventionally discussed under the heading of "neurodegeneration". Additional evidence in support of primary glial affection has been reported in neurodegenerative disorders such as Parkinson's disease, Alzheimer's disease and transmissible spongiform encephalopathies. Based on biochemical, genetic and transcriptomic studies it is also becoming increasingly clear that the molecular changes measured in whole tissue extracts, e.g. obtained from Parkinson's disease brain, are not based on a purely neuronal contribution. This important evidence has been missed in cell culture or laser capture work focusing on the neuronal cell population. Studies of animal and in vitro models of disease pathogenesis additionally suggest glial accountability for some CNS degenerative processes. This review provides a critical analysis of the evidence available to date in support of the concept of gliodegeneration, which we propose to represent an essential although largely disregarded component of the spectrum of classical "neurodegeneration". Examples from the spectrum of alpha-synucleinopathies are presented.

Microglial inflammation in the parkinsonian substantia nigra: relationship to alpha-synuclein deposition.

BACKGROUND: The role of both microglial activation and alpha-synuclein deposition in Parkinson's disease remain unclear. We have tested the hypothesis that if microglia play a primary role in Parkinson's disease pathogenesis, the microglial "activated" phenotype should be associated with histopathological and/or clinical features of the disease. METHODS: We have examined microglial MHC class II expression, a widely used marker of microglial activation, the occurrence of CD68-positive phagocytes and alpha-synuclein immunoreactivity in post-mortem human substantia nigra affected by idiopathic Parkinson's disease (PD). Using semi-quantitative severity ratings, we have examined the relationship between microglial activation, alpha-synuclein deposition, classical neuropathological criteria for PD, subtype of the disease and clinical course. RESULTS: While we did not observe an association between microglial MHC class II expression and clinical parameters, we did find a correlation between disease duration and the macrophage marker CD68 which is expressed by phagocytic microglia. In addition, we observed a significant correlation between the degree of MHC class II expression and alpha-synuclein deposition in the substantia nigra in PD. CONCLUSION: While microglia appeared to respond to alpha-synuclein deposition, MHC class II antigen expression by microglia in the substantia nigra cannot be used as an indicator of clinical PD severity or disease progression. In addition, a contributory or even causative role for microglia in the neuronal loss associated with PD as suggested by some authors seems unlikely. Our data further suggest that an assessment of microglial activation in the aged brain on the basis of immunohistochemistry for MHC class II antigens alone should be done with caution.