Chronic intestinal pseudo-obstruction (CIP) is a rare and serious disorder of the gastrointestinal (GI) tract characterized as a motility disorder with the primary defect of impaired peristalsis; symptoms are consistent with a bowel obstruction, although mechanical obstruction cannot be identified. CIP is classified as a neuropathy, myopathy, or mesenchymopathy; it is a neuropathic process in the majority of patients. The natural history of CIP is generally that of a progressive disorder, although occasional patients with secondary CIP note significant symptomatic improvement when the underlying disorder is identified and treated. Symptoms vary from patient to patient depending on the location of the luminal GI tract involved and the degree of involvement; however, the small intestine is nearly always involved. Common symptoms include dysphagia, gastroesophageal reflux, abdominal pain, nausea, vomiting, bloating, abdominal distension, constipation or diarrhea, and involuntary weight loss. Unfortunately, these symptoms are nonspecific, which can contribute to misdiagnosis or a delay in diagnosis and treatment. Since many of the symptoms and signs suggest a mechanical bowel obstruction, diagnostic tests typically focus on uncovering a mechanical obstruction, although routine tests do not identify an obstructive process. Nutrition supplementation is required for many patients with CIP due to symptoms of dysphagia, nausea, vomiting, and weight loss. This review discusses the epidemiology, etiology, pathogenesis, diagnosis, and treatment of patients with CIP, with an emphasis on nutrition assessment and treatment options for patients with nutrition compromise.

Anorexia of aging is a physiologic decrease in food intake, which gradually leads to weight loss accompanied by age-related changes in body composition. Animal experiments have revealed that advanced age is associated with altered regulation of food intake and energy homeostasis: suppression of orexigenic mechanisms mediated by neuropeptide Y, orexins, and ghrelin, and by increased activity of the major anorexigenic neuropeptide, α-MSH. In the elderly, a reduced sense of smell and taste may contribute to the loss of appetite, and in old humans, increased serum cholecystokinin concentration may delay gastric emptying resulting in a prolonged feeling of satiety. Although leptin and insulin play a major role in the control of energy homeostasis, their role in the loss of body weight in healthy elderly persons remains to be established. In some of the elderly, loss of body mass may result in malnutrition or even cachexia. Anorexia of aging plays some role in sarcopenia, involuntary loss of muscle mass and strength; however, there are intrinsic age-related changes in skeletal muscle, which underlie this health-endangering condition. Currently, there is no efficient pharmacological treatment for the anorexia of aging; however, it may be partially prevented by improved processing and presenting of food, physical training, and an appropriate social environment.

Emerging evidence suggests muscle depletion predicts survival of patients with cancer.At a cancer center in Alberta, Canada, consecutive patients with cancer (lung or GI; N = 1,473) were assessed at presentation for weight loss history, lumbar skeletal muscle index, and mean muscle attenuation (Hounsfield units) by computed tomography (CT). Univariate and multivariate analyses were conducted. Concordance (c) statistics were used to test predictive accuracy of survival models.Body mass index (BMI) distribution was 17% obese, 35% overweight, 36% normal weight, and 12% underweight. Patients in all BMI categories varied widely in weight loss, muscle index, and muscle attenuation. Thresholds defining associations between these three variables and survival were determined using optimal stratification. High weight loss, low muscle index, and low muscle attenuation were independently prognostic of survival. A survival model containing conventional covariates (cancer diagnosis, stage, age, performance status) gave a c statistic of 0.73 (95% CI, 0.67 to 0.79), whereas a model ignoring conventional variables and including only BMI, weight loss, muscle index, and muscle attenuation gave a c statistic of 0.92 (95% CI, 0.88 to 0.95; P < .001). Patients who possessed all three of these poor prognostic variables survived 8.4 months (95% CI, 6.5 to 10.3), regardless of whether they presented as obese, overweight, normal weight, or underweight, in contrast to patients who had none of these features, who survived 28.4 months (95% CI, 24.2 to 32.6; P < .001).CT images reveal otherwise occult muscle depletion. Patients with cancer who are cachexic by the conventional criterion (involuntary weight loss) and by two additional criteria (muscle depletion and low muscle attenuation) share a poor prognosis, regardless of overall body weight.

Involuntary weight loss (IWL) is frequent in advanced cancer patients causing compromised anticancer treatment outcomes and function. Cancer cachexia is influenced by nutrition impact symptoms (NIS). The aim of this study was to explore the frequency of NIS in advanced patients and to assess specific interventions guided by a 12-item NIS checklist.Consecutive patients from an outpatient nutrition-fatigue clinic completed the NIS checklist. The NIS checklist was developed based on literature review and multiprofessional clinical expert consensus. Chart review was performed to detect defined NIS typical interventions. Oncology outpatients not seen in the nutrition-fatigue clinic were matched for age, sex, and tumor to serve as controls.In 52 nutrition-fatigue clinic patients, a mixed cancer population [IWL in 2 months 5.96 % (mean)], the five most frequent NIS were taste and smell alterations 27 %, constipation 19 %, abdominal pain 14 %, dysphagia 12 %, and epigastric pain 10 %. A statistically significant difference for NIS typical interventions in patients with taste and smell alterations (p = 0.04), constipation (p = 0.01), pain (p = 0.0001), and fatigue (p = 0.0004) were found compared to the control population [mixed cancer, 3.53 % IWL in 2 months (mean)].NIS are common in advanced cancer patients. The NIS checklist can guide therapeutic nutrition-targeted interventions. The awareness for NIS will likely evoke more research in assessment, impact, and treatment.

Cachexia is a state of involuntary weight loss common to many chronic diseases. Experimental data, showing that cachexia is related to the enhancement of acute phase response reaction, led to the new definition of cachexia that included, aside from the principal criterion of weight loss, other "minor criteria", Amongst them are levels of C-reactive protein (CRP), albumin and hemoglobin. However, there is paucity of data regarding possible differences of these laboratory parameters in patients with various diseases known to be related to cachexia.CRP, albumin and hemoglobin were evaluated in 119 patients, divided into two disease groups, hematological (ones with diagnosis of non-Hodgkin lymphoma or Hodgkin disease) and non-hematological (solid tumor patients and patients with chronic heart failure). Patients were further subdivided into two nutritional groups, cachectic and non-cachectic ones according to the principal criterion for cacxehia i.e. loss of body weight.We found that cachectic patients had higher levels of CRP, and lower levels of both hemoglobin and albumin compared to non-cachectic patients, regardless of the disease group they fitted. On the other hand, the group of hematological patients had lower levels of CRP primarily due to the differences found in the non-cachectic group. Higher levels of albumin were also found in the hematological group regardless of the nutritional group they fitted. Limitations of cut-off values, proposed by definition, were found, mostly regarding their relatively low sensitivity and low negative predictive value.As expected, differences in values of routine laboratory parameters used in definition of cachexia were found between cachectic and non-cachectic patients. Their values differed between hematological and non-hematological patients both in cachectic and non-cachectic group. Cut-off levels currently used in definition of cachexia have limitations and should be further evaluated.

The awareness of cardiac cachexia, i.e. involuntary weight loss in patients with underlying cardiovascular disease, has increased over the last two decades.This mini-review looks at recent research in the cardiovascular literature that is relevant to the areas of interest of the Journal of Cachexia, Sarcopenia and Muscle. It identifies significant research in the last 3 years on the obesity paradox, the causes and effects of skeletal muscle wasting, animal models of cachexia and emerging treatment ideas in cardiac cachexia.Assuming a similar literature in the fields of cancer, chronic obstructive pulmonary disease, chronic renal failure and chronic liver failure, the emergence of cachexia as a vibrant area of clinical and experimental research seems assured.

It is well documented in the current literature that chronic heart failure is often associated with cachexia, defined as involuntary weight loss of 5 % in 12 month or less. Clinical studies unraveled that the presence of cachexia decreases significantly mean survival of the patient. At the molecular level mainly myofibrillar proteins are degraded, although a reduced protein synthesis may also contribute to the loss of muscle mass. Endocrine factors clearly regulate muscle mass and function by influencing the normally precisely controlled balance between protein breakdown and protein synthesis The aim of the present article is to review the knowledge in the field with respect to the role of endocrine factors for the regulation of cachexia in patients with CHF and deduce treatment perspectives.

To compare anaesthesia and recovery parameters of racemic ketamine or S(+)-ketamine in combination with medetomidine for intramuscular (IM) field anaesthesia in the European brown hare (EBH) (Lepus europaeus).Randomized, prospective, blinded clinical trial.20 adult EBH (eight male, 12 female), mean ± SD weight 3360 341).Medetomidine (0.2 mg kg(-1) ) and ketamine (30 mg kg(-1) ) (K-M group) or S(+)-ketamine (15 mg kg(-1) ) (S-M group) were administered by IM injection. Time until first effect and loss of righting reflex were recorded. During sedation and anaesthesia heart rate, saturation of arterial haemoglobin, respiratory rate, side stream end tidal CO(2) (Pe'CO(2) ), non invasive blood pressure, body temperature, cardiorespiratory parameters, palpebral reflex, jaw tone and nociception were recorded every 5 minutes. Medetomidine was antagonized with IM atipamezole (1 mg kg(-1) ) 45 minutes after treatment injection. Time until first head lift, standing and total recovery time (T-Recov) were recorded. Incidences of falling and involuntary movements during recovery were counted. Recovery quality was scored by visual analogue scale. Descriptive statistics were used to visualize maintenance data. All other data were included in multiple linear regression models.Surgical anesthesia was not produced reliably with either protocol. Hypoxaemia occurred in both groups (SpO(2) < 90%). During recovery, falling was noted significantly less often (p < 0.001) in the S-M group (13 ± 7) versus the K-M group (27 ± 13). T-Recov was long, lasting for more than 3 hours in individuals with no significant differences between groups.S(+)-ketamine showed only minor advantages over racemic ketamine. Surgical anaesthesia was not achieved reliably with either protocol. Oxygen supplementation should be considered to prevent hypoxaemia. Further research is needed to develop an injectable field protocol adequate for surgical procedures, but with a rapid smooth recovery.

A tenth of patients with involuntary weight loss (IWL) have gastrointestinal cancer. Ferritin is the first parameter to be modified during the process leading to iron deficiency anaemia, therefore it should be the most sensitive. The aim of this study was to assess the ability of ferritin to rule out gastrointestinal cancer in patients with involuntary weight loss.All consecutive patients with IWL admitted in a secondary care university hospital were prospectively studied. Ferritin, haemoglobin with erythrocyte indices and serum iron were recorded for all patients. The reference standard was bidirectional endoscopy and/or 6 months follow-up.290 patients were included, a quarter had cancer, of which 22 (7.6%) had gastrointestinal cancer (8 gastric cancer, 1 ileum cancer, 13 colorectal cancer). Ferritin had the best area under the curve (AUC), both for gastrointestinal cancer (0.746, CI: 0.691-0.794), and colorectal cancer (0.765, CI: 0.713-0.813), compared to the other parameters of iron deficiency. In the diagnosis of colorectal cancer, ferritin with a cut-off value of 100 mcg/L had a sensitivity of 93% (CI: 69-100%), and negative likelihood ratio of 0.13, with a negative predictive value of 99% (96-100%), while for gastrointestinal cancer, the sensitivity was lower (89%, CI: 67-95%), with a negative likelihood ratio of 0.24. There were three false negative patients, two with gastric cancer, and one with rectal cancer.In patients with involuntary weight loss, a ferritin above 100mcg/L could rule out colon cancer, but not gastric or rectal cancer.

Nutritional evaluation may predict clinical outcomes, such as hospital length of stay (LOS). We aimed to assess the value of nutritional risk and status methods, and to test standard anthropometry percentiles v. the 50th percentile threshold in predicting LOS, and to determine nutritional status changes during hospitalisation and their relation with LOS. In this longitudinal prospective study, 298 surgical patients were evaluated at admission and discharge. At admission, nutritional risk was assessed by Nutritional Risk Screening-2002 (NRS-2002), Malnutrition Universal Screening Tool (MUST) and nutritional status by Subjective Global Assessment (SGA), involuntary % weight loss in the previous 6 months and anthropometric parameters; % weight loss and anthropometry were reassessed at discharge. At admission, risk/undernutrition results by NRS-2002 (P< 0.001), MUST (P< 0.001), % weight loss (P< 0.001) and SGA (P< 0.001) were predictive of longer LOS. A mid-arm circumference (MAC) or a mid-arm muscle circumference (MAMA) under the 15th and the 50th percentile, which was considered indicative of undernutrition, did predict longer LOS (P< 0.001); conversely, there was no association between depleted triceps skinfold (TSF) and longer LOS. In-hospital, there was a high prevalence of weight, muscle and fat losses, associated with longer LOS. At discharge, patients with a simultaneous negative variation in TSF+MAC+MAMA (n 158, 53 %) had longer LOS than patients with a TSF+MAC+MAMA positive variation (11 (8-15) v. 8 (7-12) d, P< 0.001). We concluded that at risk or undernutrition evaluated by all methods, except TSF and BMI, predicted a longer LOS. Moreover, MAC and MAMA measurements and their classification according to the 50th percentile threshold seem reliable undernutrition indicators.