Beliefs and Perceptions About Parenteral Nutrition and Hydration By Advanced Cancer Patients

PurposeObjectives of this study are to clarify the beliefs and perceptions of parenteral nutrition and hydration (PNH) by patients with advanced cancer and to examine the relationships between their beliefs and perceptions and cachexia stages.MethodsWe conducted a questionnaire survey. We asked about patient characteristics and anthropometric measurements. We subsequently asked patients to answer 15 items regarding their beliefs and perceptions. The proportions of patients were calculated. Comparisons were performed using the Mann-Whitney U test. We conducted an explanatory factor analysis and calculated Cronbach’s alpha coefficients to assess the internal consistency. A multiple logistic regression analysis was performed to identify the independent factors affecting cancer cachexia stages.ResultsAmong 495 patients, 378 responded. Due to missing data, 357 remained in the frequency distribution analysis and explanatory factor analysis, and 344 were classified into the non-cachexia group (n = 174) and cachexia group (n = 170). Approximately 60% of patients thought that PNH were beneficial. Approximately 70% considered PNH as a standard medical practice. Approximately 70% did not feel that they received a sufficient explanation. There were no significant differences in any items between the two groups. We extracted four conceptual groups and Cronbach’s alpha coefficients were 0.87, 0.73, 0.71, and 0.48, respectively. The concept of ‘Belief that PNH are harmful’ was identified as an independent factor [odds ratio 2.57 (95% confidence interval 1.10-6.01), P = 0.030].ConclusionsThis study revealed that patients had a strong preference for receiving PNH with or without cancer cachexia.

Consistency Is Key When Setting a New World Record for Running 10 Marathons in 10 Days

Background: We describe the requirements and physiological changes when running 10 consecutive marathons in 10 days at the same consistent pace by a female ultra-endurance athlete. Methods: Sharon Gayter (SG) 54 yrs, 162.5 cm, 49.3 kg maximal oxygen uptake (VO2 max) 53 mL/kg−1/min−1. SG completed 42.195 km on a treadmill every day for 10 days. We measured heart rate (HR), Rating of Perceived Exertion (RPE), oxygen uptake (VO2), weight, body composition, blood parameters, nutrition, and hydration. Results: SG broke the previous record by ~2.5 h, with a cumulative completion time of 43 h 51 min 39 s. Over the 10 days, weight decreased from 51 kg to 48.4 kg, bodyfat mass from 9.1 kg to 7.2 kg (17.9% to 14.8%), and muscle mass from 23.2 kg to 22.8 kg. For all marathons combined, exercise intensity was ~60% VO2 max; VO2 1.6 ± 0.1 L.min−1/32.3 ± 1.1 mL.kg−1.min−1, RER 0.8 ± 0, HR 143 ± 4 b.min−1. Energy expenditure (EE) was 2030 ± 82 kcal/marathon, total EE for 10 days (including BMR) was 33,056 kcal, daily energy intake (EI) 2036 ± 418 kcal (20,356 kcal total), resulting an energy deficit (ED) of 12,700 kcal. Discussion: Performance and pacing were highly consistent across all 10 marathons without any substantial physiological decrements. Although overall EI did not match EE, leading to a significant ED, resulting in a 2.6 kg weight loss and decreases in bodyfat and skeletal muscle mass, this did not affect performance.

Risk factors for heat-related illnesses during the Hajj mass gathering: an expert review

Human exposure to a hot environment may result in various heat-related illnesses (HRIs), which range in severity from mild and moderate forms to life-threatening heatstroke. The Hajj is one of the largest annual mass gatherings globally and has historically been associated with HRIs. Hajj attracts over two million Muslim pilgrims from more than 180 countries to the holy city of Makkah, Kingdom of Saudi Arabia. Several modifiable and non-modifiable factors render Hajj pilgrims at increased risk of developing HRIs during Hajj. These include characteristics of the Hajj, its location, population, and rituals, as well as pilgrims’ knowledge of HRIs and their attitude and behavior. Makkah is characterized by a hot desert climate and fluctuating levels of relative humidity. Pilgrims are very diverse ethnically and geographically, with different adaptations to heat. Significant proportions of the Hajj population are elderly, obese, and with low levels of fitness. In addition, many have underlying health conditions and are on multiple medications that can interfere with thermoregulation. Other factors are inherent in the Hajj and its activities, including crowding, physically demanding outdoor rituals, and a high frequency of infection and febrile illness. Pilgrims generally lack awareness of HRIs, and their uptake of preventive measures is variable. In addition, many engage in hazardous behaviors that increase their risk of HRIs. These include performing rituals during the peak sunshine hours with no sun protection and with suboptimal sleep, nutrition, and hydration, while neglecting treatment for their chronic conditions. HRIs preventive plans for Hajj should incorporate measures to address the aforementioned factors to reduce the burden of these illnesses in future Hajj seasons. Lessons from the Hajj can be used to inform policy making and HRIs preventive measures in the general population worldwide.

Continuous Deep Sedation until Death in Neonates and Infants in Flanders: A Post-Mortem Survey

<b><i>Background:</i></b> The use of analgesics and sedatives to alleviate pain and discomfort is common in end-of-life care in neonates and infants. However, to what extent those drugs are used in that context with the specific aim of bringing the infant in a state of continuous deep sedation (CDS) is currently unknown. <b><i>Methods:</i></b> We performed a nationwide mortality follow-back survey based on all deaths under the age of 1 over a period of 16 months in Flanders, Belgium. Data on CDS were linked to sociodemographic information from death certificates. Physicians completed an anonymous questionnaire. Questions measured whether CDS preceded death, and which clinical characteristics were associated with the sedation (e.g., type of drugs used and the duration of sedation). <b><i>Results:</i></b> The response rate was 83% (229/276). In 39% of all deceased neonates and infants, death was preceded by CDS. Physicians used a combination of morphine and benzodiazepines in 53%, or morphine alone in 45% of all sedation cases in order to continuously and deeply sedate the infant. In 89% of cases, death occurred within 1 week after sedation was begun, and in 92% of cases, artificial nutrition and hydration were administered until death. In 49% of cases there was no intention to hasten death, and in 40% of cases, the possibility of hastening was taken into account. <b><i>Conclusions:</i></b> CDS precedes about 2 in 5 neonatal and infant deaths. Guidelines for CDS in this age group are non-existent and it is unclear whether the same recommendations as in the adult population apply and can be considered a good practice.

Withholding and withdrawing life-sustaining treatment (including artificial nutrition and hydration)

Life-sustaining treatment is any treatment that serves to prolong life without reversing the underlying medical condition. It includes cardiopulmonary resuscitation, mechanical ventilation, haemodialysis, left ventricular assist devices, antibiotics, and artificial nutrition and hydration. The appropriate use of life-sustaining treatment in seriously ill patients is a controversial topic that continues to generate intense debate among the public, as well as healthcare professionals, bioethicists, lawyers, governments, and religious institutions. This chapter offers a practical guide and sets out important questions clinicians ought to consider before making the decision to withhold or withdraw life-sustaining treatment.

Connections between Different Sports and Ergogenic Aids—Focusing on Salivary Cortisol and Amylase

Athletes are exposed to a tremendous amount of stress, both physically and mentally, when performing high intensity sports with frequent practices, pushing numerous athletes into choose to use ergogenic aids such as caffeine or β-alanine to significantly improve their performance and ease the stress and pressure that is put onto the body. The beneficial or even detrimental effects of these so-called ergogenic aids can be appreciated through the use of numerous diagnostic tools that can analyze various body fluids. In the recent years, saliva samples are gaining more ground in the field of diagnostic as it is a non-invasive procedure, contains a tremendous amount of analytes that are subject to pathophysiological changes caused by diseases, exercises, fatigue as well as nutrition and hydration. Thus, we describe here the current progress regarding potential novel biomarkers for stress and physical activity, salivary α-amylase and salivary cortisol, as well as their use and measurement in combination with different already-known or new ergogenic aids.

Reference Intervals for Selected Hematology and Clinical Chemistry Measurands in Temminck's Pangolin (Smutsia temminckii)

Pangolins are the world's most trafficked non-human mammals. A significant number of Temminck's pangolins (Smutsia temminckii) are presented for veterinary care and rehabilitation in southern Africa. Little is known about the physiology and normal health of this species, making diagnosis and medical management difficult. This study aimed to establish reference intervals (RIs) for hematology and plasma clinical chemistry in the Temminck's pangolin. RIs were generated according to international guidelines using samples from 27 healthy free-living (n = 18) and rehabilitated (n = 9) pangolins. Hematology was performed using the Abaxis VetScan HM5 analyzer with manual differentials; clinical chemistry was performed using heparin plasma on the Abaxis VetScan VS2 and Cobas Integra 400 Plus analyzers. Hematology RIs were: RBC 3.88–8.31 × 1012/L, HGB 73–150 g/L, HCT 26–51%, MCV 59–72 fL, MCH 15.6–21.4 pg, MCHC 257–325 g/L, RDW 14.3–19.1%, WBC 1.80–10.71 × 109/L. Vetscan VS2 clinical chemistry RIs were: albumin 27–41 g/L, ALP 26–100 U/L, ALT 25–307 U/L, amylase 267–826 U/L, bilirubin 4–10 μmol/L, calcium 2.1–2.2 mmol/L, globulin 21–55 g/L, glucose 3.8–10.0 mmol/L, phosphate 1.3–2.6 mmol/L, potassium 3.6–5.9 mmol/L, sodium 132–140 mmol/L total protein 52–84 g/L, and urea 5.3–11.4 mmol/L. RIs for creatinine were not calculated as analytical imprecision exceeded analytical performance goals. Cobas Integra clinical chemistry RIs were: albumin 22–33 g/L, ALP 20–104 U/L, ALT 17–291 U/L, amylase 466–1,533 U/L, bilirubin 1–14 μmol/L, calcium 2.0–2.4 mmol/L, creatinine &lt;58 μmol/L, globulin 23–49 g/L, glucose 3.6–10.1 mmol/L, phosphate 1.0–2.2 mmol/L, potassium 3.1–5.8 mmol/L, sodium 137–150 mmol/L, total protein 47–72 g/L, and urea 6.0–12.5 mmol/L. There was significant bias between the two chemistry analyzers for several measurands. Differences were found for some analytes between free-living and rehabilitated animals, probably reflecting differences in nutrition and hydration. These are the first RIs generated for Temminck's pangolin. These results will allow veterinarians to better determine pangolin health status, formulate optimal treatment plans and increase patient survival rates in this endangered species.

Institutional Issues

Increasingly, older adults wishing to avoid prolonged dying with dementia are completing advance directives to limit oral nutrition and hydration (ONH) in advanced dementia, but resistance to implementing these directives has arisen within the professional long-term care (LTC) community. Some “dementia directives” call for withholding or withdrawing assisted hand-feeding when specific thresholds are met during dementia’s progression. “Comfort feeding only” (CFO) has been suggested as a best practice in advanced dementia, but CFO may not be sufficient for those wishing to hasten death when advanced dementia develops. Of concern, some LTC facility residents desiring comfort-focused care may be harassed or coaxed to eat and drink by staff as part of “basic care.” It may be possible to identify areas of shared understanding between older people who fear living in advanced dementia and staff who find meaning in caring for demented people who appear to accept or even enjoy ONH.