Nutritional management in head and neck cancer: United Kingdom National Multidisciplinary Guidelines.

Nutritional support and intervention is an integral component of head and neck cancer management. Patients can be malnourished at presentation, and the majority of patients undergoing treatment for head and neck cancer will need nutritional support. This paper summarises aspects of nutritional considerations for this patient group and provides recommendations for the practising clinician. Recommendations • A specialist dietitian should be part of the multidisciplinary team for treating head and neck cancer patients throughout the continuum of care as frequent dietetic contact has been shown to have enhanced outcomes. (R) • Patients with head and neck cancer should be nutritionally screened using a validated screening tool at diagnosis and then repeated at intervals through each stage of treatment. (R) • Patients at high risk should be referred to the dietitian for early intervention. (R) • Offer treatment for malnutrition and appropriate nutrition support without delay given the adverse impact on clinical, patient reported and financial outcomes. (R) • Use a validated nutrition assessment tool (e.g. scored Patient Generated-Subjective Global Assessment or Subjective Global Assessment) to assess nutritional status. (R) • Offer pre-treatment assessment prior to any treatment as intervention aims to improve, maintain or reduce decline in nutritional status of head and neck cancer patients who have malnutrition or are at risk of malnutrition. (G) • Patients identified as well-nourished at baseline but whose treatment may impact on their future nutritional status should receive dietetic assessment and intervention at any stage of the pathway. (G) • Aim for energy intakes of at least 30 kcal/kg/day. As energy requirements may be elevated post-operatively, monitor weight and adjust intake as required. (R) • Aim for energy and protein intakes of at least 30 kcal/kg/day and 1.2 g protein/kg/day in patients receiving radiotherapy or chemoradiotherapy. Patients should have their weight and nutritional intake monitored regularly to determine whether their energy requirements are being met. (R) • Perform nutritional assessment of cancer patients frequently. (G) • Initiate nutritional intervention early when deficits are detected. (G) • Integrate measures to modulate cancer cachexia changes into the nutritional management. (G) • Start nutritional therapy if undernutrition already exists or if it is anticipated that the patient will be unable to eat for more than 7 days. Enteral nutrition should also be started if an inadequate food intake (60 per cent of estimated energy expenditure) is anticipated for more than 10 days. (R) • Use standard polymeric feed. (G) • Consider gastrostomy insertion if long-term tube feeding is necessary (greater than four weeks). (R) • Monitor nutritional parameters regularly throughout the patient's cancer journey. (G) • Pre-operative: ○ Patients with severe nutritional risk should receive nutrition support for 10-14 days prior to major surgery even if surgery has to be delayed. (R) ○ Consider carbohydrate loading in patients undergoing head and neck surgery. (R) • Post-operative: ○ Initiate tube feeding within 24 hours of surgery. (R) ○ Consider early oral feeding after primary laryngectomy. (R) • Chyle Leak: ○ Confirm chyle leak by analysis of drainage fluid for triglycerides and chylomicrons. (R) ○ Commence nutritional intervention with fat free or medium chain triglyceride nutritional supplements either orally or via a feeding tube. (R) ○ Consider parenteral nutrition in severe cases when drainage volume is consistently high. (G) • Weekly dietetic intervention is offered for all patients undergoing radiotherapy treatment to prevent weight loss, increase intake and reduce treatments interruptions. (R) • Offer prophylactic tube feeding as part of locally agreed guidelines, where oral nutrition is inadequate. (R) • Offer nutritional intervention (dietary counselling and/or supplements) for up to three months after treatment. (R) • Patients who have completed their rehabilitation and are disease free should be offered healthy eating advice as part of a health and wellbeing clinic. (G) • Quality of life parameters including nutritional and swallowing, should be measured at diagnosis and at regular intervals post-treatment. (G).

Using a wiki platform to promote guidelines internationally and maintain their currency: evidence-based guidelines for the nutritional management of adult patients with head and neck cancer.

BACKGROUND: The present study describes the development of evidence-based practice guidelines for the nutritional management of adult patients with head and neck cancer using a wiki platform to enable wide international stakeholder consultation and maintain currency. METHODS: A dietitian steering committee and a multidisciplinary steering committee were established for consultation. Traditional methods of evidence-based guideline development were utilised to perform the literature review, assess the evidence and produce a draft document. This was transferred to a wiki platform for stakeholder consultation and international endorsement processes in Australia, New Zealand and the UK. Data were collected on website traffic utilising Google Analytics. RESULTS: In addition to broad stakeholder consultation through the steering committees, an additional twenty comments were received via the wiki by twelve individuals covering six different professions from three different countries, compared to four comments by e-mail. The guidelines were subsequently endorsed by the dietetic associations of Australia, New Zealand and the UK. During a 4-month period monitoring the use of the guidelines, there were 2303 page views to the landing page from 33 countries. The average number of pages accessed per visit was five and the duration of time spent on the website was approximately 6 min. CONCLUSIONS: Using a wiki platform for guideline development and dissemination is a successful method for producing high-quality resources that can undergo wide international stakeholder review and include open public consultation. This can replace conventional methods whereby guidelines can quickly become outdated.

A focus on soft tissue in dental implantology.

Most of the focus in the early dental implant literature is on the bone to titanium interface because a successful Osseo integrated implant requires direct bone contact to the implant surface. The importance of soft tissue in the ability of dental implants to restore function and esthetics has often been underestimated. This paper reviews the pertinent literature on soft tissue healing and management in partially edentulous dental implant patients. Patients seek treatment to replace missing teeth and to improve comfort, function and/or esthetics. Healing around dental implants is affected by the patient's health, soft and hard tissue contours, and the use and care of the prosthesis, surgical augmentation and placement, and the design of the definitive prosthesis. Several surgical and non-surgical procedures have been proposed to treat the soft tissue deformities in the interproximal areas. This review also discusses the interdental papilla and various approaches to preserve and restore the same. Most of the research was based on scientifically legitimate sources of information obtained from primary literature, other appropriate technical references and searching using various online resources.

Different experiences and perspectives between head and neck cancer patients and their care-givers on their daily impact of a gastrostomy tube.

BACKGROUND: Gastrostomy feeding in head and neck cancer patients is recognised standard practice in some cancer centres with beneficial effects on outcomes for appropriately selected patients. However, the impact on patients and care-givers needs consideration. The present study aimed to understand the daily impact of gastrostomy feeding on head and neck cancer patients and their care-givers to identify improvements to services. METHODS: Twenty-one adult patients were randomly selected from the Head and Neck centre at University College London Hospital. Six head and neck cancer patients and three care-givers participated in focus groups. The sessions were recorded, fully transcribed and qualitatively thematically analysed, and the resulting data were tabulated. RESULTS: Patients and care-givers expressed opposite experiences within knowledge and understanding of why the tube was necessary; their personal perceptions and objectives of nutritional support. Themes expressing similar experiences included: developing positive coping strategies; preventing nutritional decline; tube dependency; dentures; finance; active care; and psychological support. Furthermore, both groups expressed the benefits of retaining a support network for rehabilitation with the hospital-based specialist team. Also patients and carers recognised that the gastrostomy tube helped patient survival and, with timely dietetic management, helped them wean off the tube reliance with more confidence. CONCLUSIONS: It is essential that patients and care-givers attend pretreatment clinics to discuss nutritional support via the artificial route; their quality of life can be enhanced if guided through a specialist support pathway based at the clinical site where they initiated their care, with links to key agencies.

Impact assessment of respirable suspended particulate matter from diesel generator sets used for pumping station.

Prediction of respirable suspended particulate matter impacts of diesel generator sets used for pumping station has been made using meteorological data, information on stack characteristics and emission rate, baseline ambient particulate matter and Industrial Source Complex Short Term (ISCST-3) model. It is observed that particulate matter emission from pumping station-S workplace diesel generator sets ranged from 2.4 to 436.5 mg Nm⁻³ and while at pumping station-C, it ranged from 23.2 to 186.5 mg Nm⁻³. The predicted and ambient respirable suspended particulate matter concentrations are below the national air quality standard for respirable suspended particulate matter in a mixed industrial area. Metals contents in respirable suspended particulate matter indicate the origin of crustal and mobile sources. Therefore, the impact of diesel generator sets used for pumping of crude oil on local air quality would be acceptable.

Abdominal tuberculosis in children: an Indian experience.

The hospital records of 125 children, aged 14 years or less treated for abdominal tuberculosis (TB) at Jawahar Lal Nehru Medical College and Hospital, Ajmer, India between January 1987 and December 1996, were studied to analyse the various patterns of abdominal TB in children and to evaluate the role of various investigations in researching a diagnosis. Abdominal pain was the presenting symptom in 100 (80 per cent) patients. Detectable ascites was present in 55 (44 per cent) and visible peristalsis in 45 (36 per cent) cases. Laboratory investigations and radiographs were not conclusive in the majority of the patients. In 45 (36 per cent) patients in whom no tissue diagnosis was available, the diagnosis was based on a dramatic clinical response to anti-tuberculous chemotherapy. Fifty (40 per cent) patients were treated conservatively with anti-tuberculous drugs alone; the remaining patients underwent laparotomy for diagnosis and relief of bowel obstruction. There were no post-operative deaths and on follow-up, good recovery was observed in these patients. Abdominal TB in children is of a non-specific nature and defies diagnosis with non-invasive investigations; laparotomy is required for a definitive diagnosis in the majority of the patients. However, if a high index of suspicion is maintained in endemic areas, a therapeutic trial of anti-tuberculous chemotherapy is justified.

Gall bladder perforations.

Twenty-seven patients with gall bladder perforation were reviewed. Free perforation into the peritoneal cavity producing bile peritonitis occurred in 45% of patients. Bilio-enteric fistulae were encountered in 48% of our patients. Five patients had gall stone ileus. A mortality of 11% reflects the serious nature of the condition. Selection of the optimum surgical procedure is based on the evaluation of the individual patient which should include an estimate of the general condition of the patient as well as the evaluation of anatomic situation at operation. Our experience suggests that cholecystostomy may be life-saving in these patients. Surgery in patients with gall stone ileus should be directed towards relief of obstruction only.

Acute segmental enteritis.

PIP: Clinicopathological features and follow-up of 13 cases of acute segmental enteritis, representing the Chandigarh experience over the last 4 years, are reviewed. Symptoms and signs were those of small bowel obstruction, lower gastrointestinal hemorrhage and peritonitis. The ischemic lesions mainly affected the proximal jejunum. The involved segment was edematous, congested, and spastic with loss of normal luster. The mesenteric vessels and vascular arcades were pulsatile. The lesion was characterized by mucosal ulceration of variable lengths in the small bowel, progressing to full thickness necrosis in some cases. The histopathological examination revealed a number of scattered segments of acute necrotizing enteritis. Resection of the diseased segment was performed in all the patients. 1 patient died, giving an operative mortality of 7.7%. No single cause was implicated. Although the disease is not common, it should be considered in the differential diagnosis of acute abdomen when diarrhea or intestinal bleeding is present at the onset.^ieng

Amebic perforation of the colon.

Acute necrotising colitis and perforation of the colon due to amebic infection is usually fatal. Only three patients in the present series of nine survived surgery. Preoperative diagnosis was not possible and because of an extremely friable, blotting paper like colon, this condition was only suspected at laparotomy. Examination of ulcer scrapings for the presence of Entamoeba histolytica or histopathology is confirmatory. Resection anastomosis is mandatory as less extensive local procedures or bypass surgery are not always feasible.

Massive lower gastrointestinal bleeding in patients with typhoid fever.

The classical approach to management of intestinal hemorrhage due to typhoid ulceration has been conservative. In, however, the event of massive, persistent and life-threatening hemorrhage not responding to conservative measures, early surgical intervention is life-saving, controls typhoid toxemia rapidly and presents no special difficulties. A right hemicolectomy is recommended. Four such patients treated by us with bowel resection have had an uneventful recovery.