[Cancer and nutrition - a paradigma shift]. / Krebs und Ernährung ­ ein Paradigmenwechsel.

Substantial international differences in the prevalence of cancer disease suppose that nutrition may be an important factor in the development of cancer. Many experts believe, that nutritional factors may contribute up to 35 % to the development of malignant tumors. Many patients have lost substantial body weight already at the time of the diagnosis of the disease as consequence of undernutrition and malnutrition, respectively. During the course of the disease the nutritional status often is deteriorating further. Caused by both the cancer disease itself and the treatment, loss of appetite, changes in taste, nausea and vomiting may additionally contribute to undernutrition. Undernutrition is a relevant factor for the outcome of the disease and for the tolerance of the treatment as well. Therefore, supporting the heavily impaired patients in nutritional intake is of paramount importance and an urgent task for physicians and nurses. In view of physiology, pathophysiology, genetics and molecular biology, metabolic processes in cancer are highly complex regulated and there is increasing evidence that a diet rich in fat and protein is favourable. This, however, implies a paradigma shift away from the "healthy" balanced diet rich in fruit, vegetable and complex carbohydrates. So far, the evidence based data of this new concept is, however, a controversial issue.

Regulation of electrolyte and fluid metabolism in multi-stage ultra-marathoners.

The purposes of this study were (i) to determine the prevalence of exercise-associated hyponatremia (EAH) in multi-stage ultra-marathoners and (ii) to gain more insight into fluid and electrolyte regulation during a multi-stage race. Body mass, sodium concentration ([Na⁺]), potassium concentration ([K⁺]), creatinine, urea, specific gravity, and osmolality in urine were measured in 25 male ultra-marathoners in the 'Swiss Jura Marathon' 2008 with 11,000 m gain of altitude over 7 stages covering 350 km, before and after each stage. Haemoglobin, haematocrit, creatinine, urea, [Na⁺], [K⁺], and osmolality were measured in plasma before stage 1 and after stages 1, 3, 5, and 7. Two athletes (8%) showed plasma [Na⁺] <135 mmol/l. Body mass, plasma [Na⁺], and plasma [K⁺] remained unchanged (p>0.05). Urine specific gravity (p<0.001) and osmolality in both plasma (p<0.01) and urine (p<0.001) were increased and haematocrit (p<0.0001), haemoglobin (p<0.0001) and plasma albumin were decreased (p<0.001). Plasma volume (p<0.01) and plasma urea (p<0.001) were increased. The K⁺/Na⁺ ratio in urine increased >1.0 after each stage and returned to <1.0 the morning of the next stage (p<0.001). To summarize, more sodium than potassium was excreted during rest. The increased urinary sodium losses during rest are compatible with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) or the cerebral salt-wasting syndrome (CSWS). Further studies are needed to determine the antidiuretic hormone (ADH) and both the atrial natriuretic peptide (ANP) and the brain natriuretic peptide (BNP) during multi-stage races.

[Neuroborreliosis--a disease with many faces]. / Die Neuroborreliose - eine Erkrankung mit vielen Gesichtern.

Borreliosis has been widely recognized in Switzerland and is often used in unclear cases with non-specific symptoms. Two illustrative cases should emphasize the current options for diagnosis and therapy of neuroborreliosis. The keystones of the diagnostic instruments are a history with typical symptoms and analysis of the cerebrospinal fluid with determination of appropriate antibodies. Therapy deals with ceftriaxon with intravenous and doxycyclin with oral application making ambulatory treatment possible.

[Clinic-internal and -external factors of length of hospital stay]. / Klinikinterne und -externe Determinanten der Spitalaufenthaltsdauer.

In the context of forthcoming initiation of Diagnosis Related Groups (DRG) in Switzerland, the objective of the study was to find factors having an impact on the inpatient's length of hospital stay. The study was performed on two general-medical wards of the Kantonsspital Winterthur, where all admitted patients were included in the study over two months. The various periods of diagnostic and therapeutic management of the patients and all diagnostic and therapeutic measures plus the arrangements after hospitalization were recorded. The determinants influencing the length of hospital stay were classified in clinic-internal or -external. 124 inpatients entered the study. 91 (73.4%) had a length of hospital stay without delay, whereas 33 (26.6%) patients had an extended length of hospital stay. The cumulative length of hospital stay of all patients was 1314 days, whereof 216 days (16.4%) were caused by delays. 67 days were caused by clinic-internal (5.1%) and 149 days by clinic-external factors (11.3%). Delays were substantially more generated by clinic-internal than -external factors. Clinic-internal factors were mainly weekends with interruption of the diagnostic and therapeutic procedures, dead times waiting for diagnostic results and waiting times for consultations. Clinic-external factors were caused by delayed transfer in nursing homes or rehabilitation institutions, waiting for family members for the backhaul and by indetermination of the patient. Also factors relating to the patients' characteristics had an influence on the length of hospital stay. Summing up, a substantial part of the length of hospital stay was caused by delays. However, the many different clinic-internal factors complicate solutions to lower the length of hospital stay. Moreover, factors that cannot be influenced such as waiting for microbiological results, contribute to extended length of hospital stay. Early scheduling of post-hospital arrangements may lower length of hospital stay. Moreover, when cantonal restriction falls away in 2012, patients may be transferred to rehabilitation institutions more rapidly. Also the insurance companies may possibly strengthen their organisation and thus may meet the costs more quickly.

[Eating and drinking during aging]. / Essen und Trinken.

The retirement is a good moment in life to mirror one's health behaviour in regard to eating habits and physical activity. Based on the literature we recommend the Mediterranean "diet" in all ages. This diet is characterized by the intake of fresh fruit, vegetables, cereals, olive oil, fish, little meat, legumes, spices and herbs such as basil and garlic. A glass wine a day is legitimate. In increasing age total energy needs are decreasing. Therefore the energy intake has to be adjusted. Caloric restriction per se is a powerful means to reduce cardiovascular morbidity and mortality. However, not only the eating habits but also the entire lifestyle are important factors to influence cardiovascular mortality. Thus, the "low risk factors", i.e. Mediterranean diet, moderate alcohol consumption, physical activity and non-smoking must be controlled to improve health. In the HALE project the control of these factors reduced over-all mortality by 65 percent!

[Nutritional support for critically ill and dying patients]. / Ernährung Schwerkranker und Sterbender.

There is evidence in the literature that oral nutritional supplements, total enteral and parenteral nutrition can expand life expectancy and improve quality of life in patients suffering from undernutrition. In the present review, we outline whether these treatments regimens are also effective in severely ill patients. Moreover, the usefulness of nutritional interventions in patients sick unto death, e.g. by stroke, cancer or dementia, is broadly discussed. The controversy about terminal dehydration is shortly reviewed.

Acute metabolic acidosis decreases muscle protein synthesis but not albumin synthesis in humans.

Chronic metabolic acidosis induces negative nitrogen balance by either increased protein breakdown or decreased protein synthesis. Few data exist regarding effects of acute metabolic acidosis on protein synthesis. We investigated fractional synthesis rates (FSRs) of muscle protein and albumin, plasma concentrations of insulin-like growth factor-I (IGF-I), thyroid-stimulating hormone (TSH), and thyroid hormones (free thyroxin [fT(4)] and triiodothyronine [fT(3)]) in seven healthy human volunteers after a stable controlled metabolic period of 5 days and again 48 hours later after inducing metabolic acidosis by oral ammonium chloride intake (4.2 mmol/kg/d divided in six daily doses). Muscle and albumin FSRs were obtained by the [(2)H(5)ring]phenylalanine flooding technique. Ammonium chloride induced a significant decrease in pH (7.43 +/- 0.02 versus 7.32 +/- 0.04; P < 0.0001) and bicarbonate concentration (24.6 +/- 1.6 versus 16.0 +/- 2.7 mmol/L; P < 0.0001) within 48 hours. Nitrogen balance decreased significantly on the second day of acidosis. The FSR of muscle protein decreased (1.94 +/- 0.25 versus 1.30 +/- 0.39; P < 0.02), whereas the FSR of albumin remained constant. TSH levels increased significantly (1.1 +/- 0.5 versus 1.9 +/- 1.1 mU/L; P = 0.03), whereas IGF-I, fT(4), and fT(3) levels showed no significant change. We conclude that acute metabolic acidosis for 48 hours in humans induces a decrease in muscle protein synthesis, which contributes substantially to a negative nitrogen balance. In contrast to prolonged metabolic acidosis of 7 days, a short period of acidosis in the present study did not downregulate albumin synthesis.

Determination of plasma volume by indocyanine green--validation of the method and use in patients after cardiopulmonary bypass.

OBJECTIVE: Validation of plasma volume (PV) determination by indocyanine green (ICG) in comparison to the gold-standard method with radioiodinated albumin, and investigation of the effect of commonly used plasma expanders (albumin, hydroxyethyl starch, and polygelatine) on PV in the early postoperative phase in patients undergoing cardiac surgery. DESIGN: Prospective clinical study. SETTING: Department of medicine and intensive care unit at a university hospital. PATIENTS AND PARTICIPANTS: Ten healthy volunteers and 21 patients after elective open-heart surgery. MEASUREMENTS AND RESULTS: PV of subjects was measured by i.v. injecting 5 microCi [125I]albumin (I-ALB). One hour later, PV was determined by a peripheral i. v. injection of 0.25 mg/kg body weight ICG (ICG1). In five subjects PV was measured repeatedly by ICG (ICG2) 1 h after ICG1. Mean PV of I-ALB and ICG1 or ICG2 showed consistent results. Further, we investigated central vs peripheral intravenous injection of ICG in six patients after open-heart surgery compared to [125I]albumin. There was no difference between mean PV measured by [125I]albumin and peripheral ICG (P = 0.40). PV determined by central injection of ICG was significantly higher than by the other methods. In 15 patients PV was determined by [125I]albumin. Thereafter, patients were randomly divided into three groups. Group ALB was infused with 1.75 ml/kg body weight human albumin 20%, group HAES with 5.25 ml/kg body weight hydroxyethyl starch 6%, and group HAEM with 7.0 ml/kg body weight polygelatine 3.5%. PV was measured 1 h and 4 h after infusion by ICG. There were no significant changes in PV between the groups. CONCLUSIONS: PV determination by peripheral i. v. injection of ICG produced reliable and consistent results when a reactive hyperaemia was produced by a tourniquet prior to injection. Therefore, central venous injection of ICG may not be prerequisite for precise measurements of PV. The expected acute increase in PV after infusion of commonly used plasma expanders after cardiac surgery was not found.

Enhanced synthesis of albumin and fibrinogen at high altitude.

The acute effects of active and passive ascent to high altitude on plasma volume (PV) and rates of synthesis of albumin and fibrinogen have been examined. Measurements were made in two groups of healthy volunteers, initially at low altitude (550 m) and again on the day after ascent to high altitude (4,559 m). One group ascended by helicopter (air group, n = 8), whereas the other group climbed (foot group, n = 9), so that the separate contribution of physical exertion to the response could be delineated. PV was measured by dilution of (125)I-labeled albumin, whereas synthesis rates of albumin and fibrinogen were determined from the incorporation of isotope into protein after injection of [ring-(2)H(5)]phenylalanine. In the air group, there was no change in PV at high altitude, whereas, in the foot group, there was a 10% increase in PV (P < 0.01). Albumin synthesis (mg. kg(-1). day(-1)) increased by 13% in the air group (P = 0.058) and by 32% in the foot group (P < 0.001). Fibrinogen synthesis (mg. kg(-1). day(-1)) increased by 40% in the air group (P = 0.068) and by 100% in the foot group (P < 0.001). Hypoxia and alkalosis at high altitude did not differ between the groups. Plasma interleukin-6 was increased modestly in both groups but C-reactive protein was not changed in either group. It is concluded that increases in PV and plasma protein synthesis at high altitude result mainly from the physical exercise associated with climbing. However, a small stimulation of albumin and fibrinogen synthesis may be attributable to hypobaric hypoxia alone.

[Recurrent Clostridium difficile enterocolitis]. / Rezidivierende Clostridium-difficile-Enterokolitis.

Pseudomembranous enterocolitis generally occurs after antibiotic treatment. The standard treatment is oral metronidazol or vancomycin. Nevertheless, relapses of Clostridium difficile enterocolitis are observed in 10-25% of cases. Factors associated with recurrences include endogenous reinfection by spore formation, selective IgG1 or IgA deficiency or infection with mutated strains of Clostridium difficile. Recurrent Clostridium difficile enterocolitis may be treated with repeat oral vancomycin combined with Sacchoromyces boulardii, with intravenous immunoglobulin for severe colitis.

[Obesity: principles of drug therapy]. / Adipositas: Grundlagen--medikamentöse Therapie.

Obesity is a major global public health problem. In many instances, a combination of diet modification, increased physical activity and behavior therapy fail or are insufficient for sustained weight loss. In these situations, drug therapy may be helpful. However, drug treatment of obesity resulted in unexpected devastating events in recent years. In the late sixties, aminorex caused an epidemic of pulmonary hypertension with high mortality rates. Dexfenfluramine and phentermine were also associated with the development of pulmonary hypertension and with alarming reports of cardiac valvular abnormalities. Therefore, these drugs were withdrawn from the market. Newer drugs, like sibutramine, a serotonin and norepinephrine reuptake inhibitor, and orlistat, a specific lipase inhibitor, reduce body weight significantly compared to placebo. In combination with a hypocaloric diet, weight loss of three to ten kilos can be achieved. Pharmacotherapy is limited to patients with a body mass index greater than 30 kg/m2, if non-pharmacological treatment programs have failed. The drugs should be prescribed under strict medical surveillance only.

[Junk food revolution or the cola colonization]. / Junk food Revolution oder die Cola-Kolonisation.

In ancient times, the main problem was to get food. Nowadays the difficulty is to decide for or against some foodstuff. In industrialized countries, this abundance led to the fact that people eat differently from what they should. Traditional populations were subject to periods of feast and famine. Those with a metabolism which stored energy with high energetic efficiency had a survival advantage. This is called the 'thrifty' genotype hypothesis. With the secured supply of calories, coupled with a sedentary lifestyle, the thrifty genotype becomes disadvantageous, causing obesity. Industrialization or 'cola-colonization' also leads to a dramatic increase in obesity and non-insulin dependent diabetes mellitus in developing countries. The spread of fast food restaurants all over the world has changed modern nutrition fundamentally. Influence begins early in childhood. Advertising concentrates on the selling of image over substance. However, fast food contains high levels of fat, especially trans fatty acids. Higher consumption of trans fatty acids was associated with a higher incidence of and mortality from coronary heart disease.

[Rhabdomyolysis in carnitine palmitoyltransferase II deficiency: developments in pathophysiology, diagnosis and therapy]. / Rhabdomyolyse bei Carnitin-Palmitoyltransferase-II-Mangel: aktuelle Entwicklungen in Pathophysiologie, Diagnostik und Therapie.

In hospitalized patients rhabdomyolysis is an important clinical entity, leading to myoglobinuria and acute renal failure in 8-25% of cases. When common causes of rhabdomyolysis, such as crush, trauma, infections, and drug abuse are excluded, inherited disorders of energy metabolism, in particular lipid metabolism, should be considered. Carnitine palmitoyltransferase (CPT) II deficiency is a common disorder of mitochondrial lipid oxidation. There are two distinct clinical forms: a severe and usually fatal infantile form and a benign classical muscular form. Usually, patients with CPT II deficiency present with episodic myoglobinuria, muscle cramps and weakness prompted by strenuous exercise or prolonged fasting. Liver and cardiac dysfunction are rarely seen and indicate severe disease. Most affected patients are males, although CPT II deficiency shows an autosomal recessive mode of inheritance. The human CPT II gene has been cloned, sequenced and localised to chromosome 1p32. Several mutations have been detected in the human gene which differ in the remaining enzyme activity and may explain the heterogeneity in the clinical picture of this disorder. Diagnosis is by muscle biopsy. Normally, light microscopy shows no pathological findings, and diagnosis must be established by biochemical and molecular methods. In our report on two typical cases we set out to promote knowledge of this disorder and discuss the diagnostic approach, which requires a specialised laboratory.