Effect of combined therapies including nutrition and physical exercise in advanced cancer patients: A pooled analysis.

Background and aims: Although many cancer patients suffer from malnutrition or cancer cachexia, there is no standard of care so far due to limited intervention trials. Pooled data from two combined trials were analyzed regarding nutritional status and survival time. Materials and methods: Data from two trials with advanced cancer patients were included. In both trials, patients in the intervention group received at least three times nutritional counseling and supervised training sessions. Patients in the control group continued being treated according to usual care. Nutritional status was measured using BMI, body composition and handgrip strength. Survival time was analyzed using the Cox proportional hazard model with the period between the beginning of the trial and death as underlying time scale. Results: 68 men (61.8%) and 42 women (38.2%) were randomized either to the intervention (n = 56) or the control (n = 54) group. The inter-group difference for changes in BMI and body composition was not statistically significant after 3 months. Handgrip strength improved significantly from 34.4 ± 10.2 kg to 36.3 ± 9.9 kg at 3 months in the intervention compared to 33.9 ± 9.2 kg to 34.9 ± 9.1 kg in the control group (p = 0.006). The analysis of survival time showed no inter-group difference for all patients. A detailed analysis for different diagnoses showed that in patients with lung cancer, the covariates "CRP value," "days from first diagnosis to randomization" as well as "gender" were significantly associated with survival time. Patients with higher CRP value had a shorter survival time and female patients had a shorter survival time than male patients in our analysis. In addition, patients with pancreatic cancer randomized to the control group had a 20% shorter survival time than those in the intervention group (p = 0.048). Conclusion: The pooled analysis showed a significant improvement of handgrip strength in advanced cancer patients through the implementation of a combined therapy. Handgrip strength is of prognostic significance in hospitalized patients due to its association with mortality and morbidity. However, no improvements in further tests were detected. There is great need for further investigations examining the effect of nutritional and exercise therapy on survival time with focus on different cancer diagnoses.

NRS-2002 components, nutritional score and severity of disease score, and their association with hospital length of stay and mortality.

BACKGROUND: Malnutrition is a substantial issue in hospitals, leading to prolonged length of hospital stay, increased perioperative morbidity and increased mortality. There are several validated screening tools for malnutrition, one of which is the Nutritional Risk Screening 2002 (NRS). It screens patients based on recent weight loss, reduction of recent food intake, body mass index (BMI), severity of disease and age. Higher NRS scores have been shown to be negatively associated with patients’ outcomes such as increased morbidity and mortality. OBJECTIVES: The aim of the study was to evaluate how the two NRS components Nutritional Score (NS) and Severity of Disease Score (SDS) are associated with patients’ length of hospital stay and mortality. METHODS: All patients admitted to the medical department of a large community hospital in Switzerland were screened for malnutrition using the nutrition screening NRS during the years 2014 to 2017. Data on patients’ NRS, primary diagnosis, number of secondary diagnoses, mortality, length of stay (LOS), discharge, sex and age were collected. The association between the NRS components and LOS/mortality was estimated using a linear mixed-effects regression model and a logistic regression model, respectively, with adjustment for confounders (age, sex, comorbidity, diagnosis group, mode of discharge and year of hospitalisation). RESULTS: The evaluation of the outcomes of 21,855 hospitalisations demonstrated that the NS was associated with an increment in the LOS of 5.5–12.3% per score point, depending on the diagnosis group. An increase in the SDS by one point was associated with an increase in the LOS of 2.2–11.3%. The odds for all-cause in-hospital mortality were increased by 44.1% (95% confidence interval [CI] 33.7–55.2%) per point in the NS, and by 73% (95% CI 57.5–90.1%) per point in the SDS. CONCLUSIONS: Increases in both components of the NRS are associated with longer LOS. The NS has a slightly stronger impact on LOS compared to the SDS and its effect is dependent on the patient’s diagnosis group. Increases in the SDS are linked to a higher mortality than increases in the NS.

Results from an Epidemiological Follow-Up Survey on Home Artificial Nutrition in Switzerland from 2010 to 2015.

BACKGROUND: Home artificial nutrition (HAN) is an established treatment for malnourished patients. Since July 2012, the costs for oral nutrition supplements (ONS) are covered by the compulsory health insurance providers in Switzerland if the patient has a medical indication based on the Swiss Society for Clinical Nutrition guidelines. Therefore, the purpose of our study was to analyse the development of HAN, including ONS, before and after July 2012. METHODS: We obtained the retrospective and anonymized data from the Swiss association for joint tasks of health insurers (SVK), who registered patients on HAN. Since not all health insurers are working with SVK, this retrospective study recorded nearly 65% of all new patients on HAN in Switzerland from January 1, 2010, to December 31, 2015. RESULTS: A total of 33,410 patients (49.1% men and 50.9% women) with a mean BMI of 21.3 ± 4.5 kg/m2 and mean age of 68.9 ± 17.8 years were recorded. The number of patient cases on ONS increased from 808 cases in 2010 to 18,538 cases in 2015, while patient cases on home enteral nutrition (HEN) and home parenteral nutrition (HPN) remained approximately the same. The relative distribution of type of HAN changed from 26.2% cases on ONS, 68.7% cases on HEN and 5.1% cases on HPN in 2010 to 86.1% cases on ONS, 12.8% cases on HEN, and 1.1% cases on HPN in 2015. Treatment duration decreased for ONS from 698 ± 637 days to 171 ± 274 days, for HEN from 416 ± 553 days to 262 ± 459 days, and for HPN from 96 ± 206 days to 72 ± 123 days. Mean costs per patient decreased for ONS from 1,330 CHF in 2010 to 606 CHF in 2015. Total costs for HAN increased from 16,895,373 CHF in 2010 to 32,868,361 CHF in 2015. CONCLUSION: Our epidemiological follow-up study showed an immense increase in number of patients on HAN in Switzerland after July 2012. Due to shorter therapy duration and reduced mean costs per patient, total costs were only doubled while the number of patients increased 7-fold.

The well-being of Swiss general internal medicine residents.

BACKGROUND: Physician well-being has an impact on productivity and quality of care. Residency training is a particularly stressful period. OBJECTIVE: To assess the well-being of general internal medicine (GIM) residents and its association with personal and work-related factors. METHODS: We conducted an anonymous electronic survey among GIM residents from 13 Swiss teaching hospitals. We explored the association between a reduced well-being (≥5 points based on the Physician Well-Being Index [PWBI]) and personal and work-related factors using multivariable mixed-effects logistic regression. RESULTS: The response rate was 54% (472/880). Overall, 19% of residents had a reduced well-being, 60% felt burned out (emotional exhaustion), 47% were worried that their work was hardening them emotionally (depersonalisation), and 21% had career choice regret. Age (odds ratio [OR] 1.19, 95% confidence interval [CI] 1.05–1.34), working hours per week (OR 1.04 per hour, 95% CI 1.01–1.07) and <2.5 rewarding work hours per day (OR 3.73, 95% CI 2.01–6.92) were associated with reduced well-being. Administrative workload and satisfaction with the electronic medical record were not. We found significant correlations between PWBI score and job satisfaction (rs = -0.54, p<0.001), medical errors (rs = 0.18, p<0.001), suicidal ideation (rs = 0.12, p = 0.009) and the intention to leave clinical practice (rs = 0.38, p <0.001) CONCLUSIONS: Approximately 20% of Swiss GIM residents appear to have a reduced well-being and many show signs of distress or have career choice regret. Having few hours of rewarding work and a high number of working hours were the most important modifiable predictors of reduced well-being. Healthcare organisations have an ethical responsibility to implement interventions to improve physician well-being.

Effect of a leucine-rich supplement in combination with nutrition and physical exercise in advanced cancer patients: A randomized controlled intervention trial.

BACKGROUND & AIMS: Branched-chain amino acids and specifically leucine stimulate protein synthesis and may overcome an anabolic resistance in malnourished and cachectic cancer patients. Therefore, we hypothesized that the addition of a leucine-rich supplement to a multimodal therapy improves physical function in advanced cancer patients. METHODS: This single center, randomized trial examined a multimodal therapy over 12 weeks in patients with advanced cancer. The intervention group received a leucine-rich supplement in combination with a nutrition and physical exercise program. Patients in the control group received standard care. Primary endpoint was physical function measured with the short physical performance battery (SPPB). Secondary endpoints were further physical performance tests, nutritional status, dietary intake, fatigue, quality of life (QoL) and clinical course. All parameters were evaluated at baseline, after three and at six months. RESULTS: 23 women and 29 men with an average age of 63.1 ± 10.3 (range 30-81) years and BMI of 25.4 ± 4.7 kg/m2 were randomized either to the intervention (n = 27) or control (n = 25) group. Patients in the intervention group joined a mean of 28.4 ± 7.4 training sessions (78.8%), 3.2 ± 0.6 nutritional counselling sessions (106.7%) and consumed on average 85.4 ± 33.2 supplements (71.2%). Inter-group comparison showed no significant difference in the primary endpoint SPPB after three (p = 0.184, 95% CI: -1.43, 0.29) and six months (p = 0.986, 95% CI: -0.87, 0.89). However, the secondary endpoint handgrip strength improved significantly from 35.8 ± 9.8 kg at baseline to 37.6 ± 10.0 kg at three months in the intervention group compared to 35.7 ± 8.8 kg at baseline to 34.0 ± 10.1 kg at three months in the control group (p < 0.001, 95% CI: -6.03, -1.97). The inter-group difference for changes in the further secondary endpoints nutritional status, dietary intake, fatigue, QoL and clinical course showed a trend towards an improvement in the intervention group, however, the differences were not significant after three and six months. CONCLUSIONS: The present trial demonstrated a good adherence to the multimodal therapy as well as a significant improvement of handgrip strength in patients with advanced cancer. In addition, the clinical course data underlined the safety of the program. However, we failed to show significant improvements in further physical performance tests, especially our primary outcome factor SPPB as well as nutritional status, fatigue or QoL.

Nutrition in Gastrointestinal Disease: Liver, Pancreatic, and Inflammatory Bowel Disease.

Liver, pancreatic, and inflammatory bowel diseases are often associated with nutritional difficulties and necessitate an adequate nutritional therapy in order to support the medical treatment. As most patients with non-alcoholic fatty liver disease are overweight or obese, guidelines recommend weight loss and physical activity to improve liver enzymes and avoid liver cirrhosis. In contrast, patients with alcoholic steatohepatitis or liver cirrhosis have a substantial risk for protein depletion, trace elements deficiency, and thus malnutrition. Patients with chronic pancreatitis and patients with inflammatory bowel disease have a similar risk for malnutrition. Therefore, it clearly is important to screen these patients for malnutrition with established tools and initiate adequate nutritional therapy. If energy and protein intake are insufficient with regular meals, oral nutritional supplements or artificial nutrition, i.e., tube feeding or parenteral nutrition, should be used to avoid or treat malnutrition. However, the oral route should be preferred over enteral or parenteral nutrition. Acute liver failure and acute pancreatitis are emergencies, which require close monitoring for the treatment of metabolic disturbances. In most patients, energy and protein requirements are increased. In acute pancreatitis, the former recommendation of fasting is obsolete. Each disease is discussed in this manuscript and special recommendations are given according to the pathophysiology and clinical routine.

The Ganz acetabular reinforcement ring shows excellent long-term results when used as a primary implant: a retrospective analysis of two hundred and forty primary total hip arthroplasties with a minimum follow-up of twenty years.

PURPOSE: The acetabular reinforcement ring with a hook (ARRH) has been designed for acetabular total hip arthroplasty (THA) revision. Additionally, the ARRH offers several advantages when used as a primary implant especially in cases with altered acetabular morphology. The implant facilitates anatomic positioning by placing the hook around the teardrop and provides a homogenous base for cementing the polyethylene cup. Therefore, the implant has been widely used in primary total hip arthroplasty at our institution. The present study reports the long-term outcome of the ARRH after a minimum follow-up of 20 years. METHODS: Two hundred and ten patients with 240 primary THAs performed between April 1987 and December 1991 using the ARRH were retrospectively reviewed after a minimum follow-up of 20 years. Twenty-three of 240 hips were lost to follow-up, 110 patients with 124 THAs had deceased without having a revision surgery performed. This left 93 hips for final evaluation. Of those, 75 hips were assessed clinically and radiographically after a mean follow-up of 23.1 years (range 21.1-26.1 years). In 18 cases, clinical and radiographic assessment was omitted because implant revision had been performed prior to the follow-up investigation. The primary endpoint was defined as revision for aseptic loosening. RESULTS: Out of the 93 hips available for final evaluation, 14 hips were revised for aseptic loosening; another four were revised for other reasons (deep infection n = 2, recurrent dislocation n = 2). The survival probability of the cup was 0.96 (95% confidence interval 0.93-0.99) after 20 years with aseptic loosening as endpoint. Radiographic analysis of the surviving 75 hips showed at least one sign of radiographic loosening in 24 hips. The mean Merle d'Aubigne score increased from 8 points pre-operatively to 15 points at final follow-up (7.5 ± 1.8 vs 15.0 ± 2.3, p < 0.001). The mean HHS was 85 ± 14 at final follow-up. Radiographic loosening did not correlate with the clinical outcome. CONCLUSIONS: The long-term results of the ARRH in primary THA are comparable to results with standard cemented cups and modern cementless cups. We believe that the ARRH is a versatile implant for primary THA, especially in cases with limited acetabular coverage and altered acetabular bone stock where the ARRH provides sufficient structural support for a cemented cup.

Autopsy case of aortic dissection after transcatheter aortic valve implantation (TAVI).

Aortic dissection is one of the severe but rare vascular complications arising from transcatheter aortic valve implantation (TAVI). This paper presents an autopsy case of an 81-year-old male patient with delayed aortic dissection with underlying haemorrhages and acute inflammation 3 years after TAVI.

Effects of nutrition and physical exercise intervention in palliative cancer patients: A randomized controlled trial.

BACKGROUND & AIMS: Cancer cachexia is multifactorial and should be targeted using a multimodal form of intervention. The purpose of the present trial was to test the effects of a combined nutrition and physical exercise program on cancer patients with metastatic or locally advanced tumors of the gastrointestinal and lung tracts. METHODS: Patients were randomized into two groups: One group received a minimum of three standardized individual nutritional counselling sessions and participated in a 60-min exercise program twice a week. The second group received their usual care. The intervention spanned a period of three months. Quality of life (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire version 3.0), physical performance (hand-grip strength, 6-min walk test, timed sit-to-stand test and 1 repetition maximum leg press), nutritional status (body weight, bioelectrical impedance analysis), dietary intake (three-day dietary record) and clinical data (unexpected hospital days, performance status) were tested at baseline and after three and six months. RESULTS: In total, 18 women and 40 men (mean age 63, range 32-81) with metastatic or locally advanced tumors of the gastrointestinal (n = 38) and lung (n = 20) tracts were included. Median adherence to the supervised exercise program was 75%. The median number of individual nutritional counselling sessions was 3.0 (range 0-7 sessions). Post intervention, no difference in global health status/quality of life (overall QoL) was observed. Intervention was superior to UC for the patient-rated symptom scale regarding nausea and vomiting (p = 0.023) and protein intake (p = 0.01). No statistical differences were observed for energy intake, nutritional status and physical performance. CONCLUSIONS: The results show good adherence to a combined nutrition and exercise program. The multimodal intervention did not improve overall QoL, but contributed to an adequate protein intake and to the general well-being of the patient by reducing nausea and vomiting.

Are Four Simple Questions Able to Predict Weight Loss in Outpatients With Metastatic Cancer? A Prospective Cohort Study Assessing the Simplified Nutritional Appetite Questionnaire.

BACKGROUND: Severe weight loss is directly responsible for up to one-fifth of all cancer deaths and has a major impact on quality of life. The simplified nutritional appetite questionnaire (SNAQ) was validated to predict weight loss within 6 mo in community-dwelling adults and nursing home residents. METHODS: We prospectively assessed the SNAQ in 133 palliative cancer outpatients. The SNAQ predictions were validated after 3 and 6 mo with the observed weight change. In addition, the treating oncologists gave their predictions concerning future weight loss according to their clinical judgment. RESULTS: A significant weight loss of 5% of the original body weight within 6 mo occurred in 20 (24%) of the 133 patients. The SNAQ predicted weight loss with a sensitivity of 0.38 and a specificity of 0.66 (P-value 0.81). The treating oncologists predicted weight loss with a sensitivity of 0.67 and a specificity of 0.7 (P-value 0.002). CONCLUSION: The SNAQ does not represent a useful tool to predict impending weight loss in palliative cancer outpatients. The predictions of the treating oncologists were more reliable than those from the SNAQ, but remain poor. Better methods to predict weight loss in this patient group are therefore required.

Detection and treatment of medical inpatients with or at-risk of malnutrition: Suggested procedures based on validated guidelines.

OBJECTIVE: Despite the high prevalence of malnutrition in the general inpatient population, there is a lack of knowledge in regard to detecting disease-related malnutrition and implementing nutritional support. Our aim was to suggest practical procedures for screening and treating malnourished or at-risk patients hospitalized in medical wards, thereby fostering a straightforward implementation of nutritional therapy independent of the underlying disease and comorbidities. METHODS: A working group of experts in clinical nutrition selected and analyzed published disease-specific European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines relevant for our aim. Eight questions in population, intervention, control, outcome format were defined to cover topics such as screening, nutritional targets, and routes of feeding. Individual studies were extracted from the guidelines by applying inclusion and exclusion criteria targeting the heterogeneous population of medical inpatients with or at-risk of disease-related malnutrition. We used those studies as evidence, as well as recommendations from the selected ESPEN guidelines, to formulate answers to the questions. Final agreement with the statement was obtained by consensus of the whole working group. RESULTS: Procedures on how to provide integrated nutritional therapy (oral, enteral, and parenteral) to a heterogeneous patient population were suggested, including how to identify malnourished or at-risk patients, nutrient targets, choice of feeding route, monitoring, and assessment of patients. We also developed a simple algorithm to facilitate the implementation of a nutritional care plan for the general medical inpatient population. CONCLUSION: By compiling evidence and recommendations from disease-specific guidelines, we were able to suggest a nutritional strategy applicable to large and heterogeneous group of malnourished or at-risk patients admitted to hospitals. A large randomized controlled trial is currently investigating whether this strategy improves clinical outcomes of patients.

ESPEN guideline on ethical aspects of artificial nutrition and hydration.

BACKGROUND: The worldwide debate over the use of artificial nutrition and hydration remains controversial although the scientific and medical facts are unequivocal. Artificial nutrition and hydration are a medical intervention, requiring an indication, a therapeutic goal and the will (consent) of the competent patient. METHODS: The guideline was developed by an international multidisciplinary working group based on the main aspects of the Guideline on "Ethical and Legal Aspects of Artificial Nutrition" published 2013 by the German Society for Nutritional Medicine (DGEM) after conducting a review of specific current literature. The text was extended and introduced a broader view in particular on the impact of culture and religion. The results were discussed at the ESPEN Congress in Lisbon 2015 and accepted in an online survey among ESPEN members. RESULTS: The ESPEN Guideline on Ethical Aspects of Artificial Nutrition and Hydration is focused on the adult patient and provides a critical summary for physicians and caregivers. Special consideration is given to end of life issues and palliative medicine; to dementia and to specific situations like nursing care or the intensive care unit. The respect for autonomy is an important focus of the guideline as well as the careful wording to be used in the communication with patients and families. The other principles of Bioethics like beneficence, non-maleficence and justice are presented in the context of artificial nutrition and hydration. In this respect the withholding and withdrawing of artificial nutrition and/or hydration is discussed. Due to increasingly multicultural societies and the need for awareness of different values and beliefs an elaborated chapter is dedicated to cultural and religious issues and nutrition. Last but not least topics like voluntary refusal of nutrition and fluids, and forced feeding of competent persons (persons on hunger strike) is included in the guideline.

Management of Home Parenteral Nutrition: A Prospective Multicenter Observational Study.

BACKGROUND: There are no specific Swiss home parenteral nutrition (HPN) data showing patient characteristics, quality of life (QoL) and complications. The goal of this study was to collect representative nationwide data on current adult HPN patients in Switzerland for international comparability and benchmarking. METHODS: This was a multicenter, nationwide, observational study. We conducted interviews for demographics, PN characteristics, QoL and complications. The data were assessed at baseline and after a follow-up of 3 months using a questionnaire. RESULTS: Thirty-three adult patients were included. The most common underlying diseases were cancer, radiation enteritis and state after bariatric surgery, and the most prevalent indication was short bowel syndrome. During the 3-month observation period, significant increase or stabilization of body weight occurred in the patients, physical activity scores improved from 34.0 to 39.4 and mental scores improved from 41.9 to 46.4. HPN dependency and traveling restrictions were of the greatest concern. Diarrhea, xerostomia and/or thirst were frequent complaints. CONCLUSION: Anthropometric parameters and QoL improved during the observational period in this HPN cohort. These Swiss HPN data are prerequisite for evaluation and comparison of HPN recommendations and best clinical practice, status of professional care instructions related to HPN effectiveness, quality of treatment and patient safety.

Mediterranean diet and mortality in Switzerland: an alpine paradox?

PURPOSE: Reports on the protective effect of a Mediterranean diet on mortality usually refer to populations from Mediterranean countries, leaving uncertain whether really diet is the fundamental cause. Our aim was to examine the effect of a Mediterranean diet on mortality in Switzerland, a country combining cultural influences from Mediterranean and Central European countries within a common national health and statistical registry. METHODS: In this prospective investigation, we included 17,861 men and women aged ≥16 years who participated 1977-1993 in health studies and were followed up for survival until 2008 by anonymous record linkage with the Swiss National Cohort. A 9-point score Mediterranean Diet Score (MDS) was used to assess adherence to a Mediterranean diet. Mortality hazard ratios (HR) and 95% confidence intervals (CIs) were calculated by using Cox regression models adjusted for age, sex, survey wave, marital status, smoking, body mass index, language region and nationality. RESULTS: In all language regions, MDS was inversely associated with mortality. Consumption of dairy products was also consistently associated with lower mortality. When categorizing dairy food consumption as beneficial instead of harmful, this association between MDS and mortality increased in strength and was partly statistically significant. For all causes of death combined (HR for a one-point increase in MDS 0.96, 95% CI 0.94-0.98), in men (0.94, 0.92-0.97), in women (0.98, 0.95-1.02) for cardiovascular diseases (CVD, 0.96, 0.92-0.99; 0.95, 0.90-1.00; 0.98, 0.92-1.04) and for cancer (0.95, 0.92-0.99; 0.92, 0.88-0.97; 0.98, 0.93-1.04). CONCLUSIONS: Stronger adherence to a Mediterranean diet was associated with lower all-cause, CVD and cancer mortality, largely independently of cultural background. These associations were primary due to the effect in men. Our finding of a beneficial rather than a deleterious impact of dairy products consumption prompts at considering culturally adapted Mediterranean diet recommendations. However, results should be interpreted with caution since only a crude 1-day dietary estimate was available to assess individuals' habitual dietary intake.

[Comparison of management of ambulatory emergency patients in the family practice and the hospital emergency center]. / Vergleich der Betreuung ambulanter Notfallpatienten in der hausärztlichen Praxis und dem Zentrumsspital.

The increase in health care cost is broadly discussed in the public, either in the hospital or ambulatory setting. With the present study we compared the invoice amount generated by a first doctor's advice in the general practitioner to the one in the emergency room. In addition, we compared the diagnostic procedures used in the general practice to the one in the hospital, and whether the choice of diagnostic procedures would substantially influence the invoice amount. The invoice amount in the hospital setting was on average CHF 197.-, i. e. 134%, higher compared to the general practice. The difference in the invoice amount was largely explained by more diagnostic procedures in the hospital. Moreover, part of the higher invoice amount was generated by the extensive physical examination by doctors in the hospital.

L'augmentation des coûts en soins médicaux, en particulier en médecine ambulatoire, est largement discutée ces derniers temps. Au moyen d'une étude comparant les premières consultations au Service d'urgence interdisciplinaire (INO) de l'hôpital cantonal de Winterthur (KSW), respectivement du Service d'urgence des généralistes, nous avons éxaminé quels montants sont facturés lors d'une première consultation ambulatoire. En outre, nous avons comparé le traitement effectué par les généralistes à celui de l'hôpital et nous avons analysé si le choix du traitement influence le montant de la facture. Nos résultats ont démontré que le coût moyen du traitement par patient à l'hôpital était de CHF 197.­ (134%) supérieur à celui des généralistes. Cette différence des coûts a pu être expliquée en grande partie qu'au KSW plus de mesures diagnostiques furent prises. Les dépenses accrues ont été provoquées non seulement par les examens techniques, mais aussi par l'importance de la participation des médecins aux soins à en milieu hospitalier.