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1/19. Severe malnutrition due to subtle neurologic deficits and epilepsy: report of three cases.

    In southern and eastern africa, where approximately eight per cent of households lack access to adequate food, children suffering from chronic infections such as tuberculosis, gastrointestinal parasites and human immunodeficiency virus, often present with severe protein energy malnutrition. Three cases are described of children presenting to Chikankata Salvation Army Hospital who required hospitalization and urgent feeding due to PEM. No underlying aetiology for their life-threatening PEM could initially be identified and they were all observed to gain weight while in the intensive feeding unit. After discharge, each re-presented with recurrent failure-to-thrive and were found to have subtle neurologic deficits and underlying epilepsy. epilepsy and developmental disabilities should be considered in patients with PEM for whom other aetiologies cannot be identified.
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2/19. Pancreatic involvement in co-infection visceral leishmaniasis and hiv: histological and ultrastructural aspects.

    The involvement of the gastrointestinal tract in the co-infection of hiv and Leishmania is rarely reported. We report the case of an hiv-infected adult man co-infected with a disseminated form of leishmaniasis involving the liver, lymph nodes, spleen and, as a feature reported for the first time in the English literature, the pancreas. light microscopy showed amastigote forms of Leishmania in pancreatic macrophages and immunohistochemical staining revealed antigens for Leishmania and also for hiv p24. Microscopic and ultrastructural analysis revealed severe acinar atrophy, decreased zymogen granules in the acinar cytoplasm and also nuclear abnormalities such as pyknosis, hyperchromatism and thickened chromatin. These findings might correspond to the histologic pattern of protein-energy malnutrition in the pancreas as shown in our previous study in pancreas with AIDS and no Leishmania. In this particular case, the protein-energy malnutrition may be due to cirrhosis, or, Leishmania or hiv infection or all mixed. We believe that this case represents the morphologic substratum of the protein energy malnutrition in pancreas induced by the hiv infection. Further studies are needed to elucidate these issues.
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3/19. Nutritional aspects of acute renal failure.

    The patient with acute renal failure is a very ill patient suffering from high urea levels causing poor appetite, nausea and vomiting.These patients are usually treated with a low sodium, low protein and, if the potassium in the blood is high, with a low potassium diet (1). This paper discusses whether or not this is the correct treatment. The symptoms of high urea levels in the blood together with increased needs for energy and protein makes it very hard to prevent the patient becoming malnourished. Often energy-enriched drinks are necessary to achieve recommendations and it is prudent to let the patient eat and drink what they desire. By calculating the energy and protein needs and comparing these with the intake and the state of illness and by following the patient's body weight over time we can obtain information about the state of nourishment. When we alter the food that's offered we achieve better intake and reduce the risk of malnourishment.
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4/19. The use of indirect calorimetry in the clinical management of adolescents with nutritional disorders.

    Indirect calorimetry is a noninvasive, inexpensive technique used to determine resting energy expenditure. Its use provides the clinician with objective information that can be used to design, implement, and evaluate efficacy of treatment in the nutritional management of adolescents with anorexia nervosa, bulimia nervosa, chronic dieting behavior, and obesity. This chapter outlines the theoretical framework, interpretation of data, and clinical applications of indirect calorimetry and presents case examples to underscore its utility in adolescents with eating disorders.
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5/19. The use of intradialytic parenteral nutrition to treat malnutrition: a case study.

    Protein energy malnutrition in dialysis patients has been well-described in the literature. Most malnourished patients with end stage renal disease (ESRD) suffer from a mixed marasmus-kwashiorkor type of malnutrition with loss of both somatic and visceral protein mass. Malnutrition is associated with increased risk of morbidity and mortality. Up to 50% of patients on dialysis have protein energy malnutrition (Mortelmans & Vanholder, 1999). Malnutrition may be under-recognized and under-reported in dialysis patients. Malnutrition may result from inadequate food intake secondary to the uremic condition, nausea, vomiting, loss of appetite, altered taste and other physiologic conditions that impede food intake or metabolism. The usual indices of nutritional assessment--body weight, body mass index (BMI), anthropometrics, etc., may be inaccurate in patients with ESRD, as the results are often skewed by fluid retention. Therefore, we often rely on weight loss, bloodwork, a pre-dialysis low serum potassium, phosphorus and urea, as early signs of a decreased food intake. When patients are malnourished, measures such as oral supplements and/or tube feedings may be used to augment protein and calorie intake. However, when these interventions are inadequate to reverse the malnutrition condition, intradialytic parenteral nutrition (IDPN) should be implemented. Although there is no definite supportive data to show that the use of IDPN improves morbidity and mortality of dialysis patients, there are data to support that IDPN has positive effects on numerous nutritional parameters (Acchiardo, 2000; Capelli et al., 1994; Foulks, 1999; Hiroshige et al., 1998; Ikizler et al., 1995; Korzets et al., 1999; Mortelmans & Vanholder, 1999; Saunders et al., 1999; Smolle et al., 1995). In this article, we will discuss the causes of malnutrition in dialysis patients, the use of IDPN on one of our patients, and the potential complications associated with IDPN.
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6/19. Integrated medical-psychiatric treatment of the "crisis phase" in severe protein-energy malnutrition secondary to major eating disorders.

    C.A., a 23-year old male was admitted in the clinical nutrition medical ward for severe, complicated protein-energy malnutrition (PEM) [body mass index (BMI) 11.08 kg/m2; body weight kg 35.81 due to major eating disorders. C.A.'s personality was narcissistic, with a rigid psychic structure. During hospitalitation (lasted 72 days) two acute episodes (a possibly self-inflicted damage and a persecution feeling) occurred that we consider as part of the "crisis phase", the period in which the patient's restrictive behaviour is no longer able to keep his personality equilibrium stable. The patient was treated by an integrated medical and psychiatric approach, including periods of never forced parenteral nutrition, nutritional and intensive psychoterapeutic interventions. For a short period the patient received also a pharmacological support (aloperidol orally). Treatment was successful and the patient was discharged completely autonomous and followed up on an outpatient basis. After about one year follow-up he is still in good clinical condition and in sufficient psychological equilibrium.
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7/19. Malnutrition in the institutionalized elderly: the effects on wound healing.

    Under-nutrition and protein-energy malnutrition are seen at alarmingly high rates in institutionalized elderly and in patients admitted to hospitals. A combination of immobility and loss of lean body mass - which comprises muscle and skin - and immune system challenges increases the risk of pressure ulcers by 74%. The development of pressure ulcers in the hospital affects 10% of admissions, with the elderly at the highest risk. Common causes of malnutrition in the elderly involve: decreased appetite, dependency on help for eating, impaired cognition and/or communication, poor positioning, frequent acute illnesses with gastrointestinal losses, medications that decrease appetite or increase nutrient losses, polypharmacy, decreased thirst response, decreased ability to concentrate urine, intentional fluid restriction because of fear of incontinence or choking if dysphagic, psychosocial factors such as isolation and depression, monotony of diet, and higher nutrient density requirements along with the demands of age, illness, and disease on the body. All have been found to delay healing and increase the risk of pressure ulcer development. In addition, what is ingested should contain nutrients to support health and healing. The financial impact of malnutrition is high and the consequences for patient morbidity and mortality are severe. Practical suggestions to improve the nutritional status of long-term care residents include liberalizing previous diet restrictions where safe and appropriate, addressing impairments to dentition and swallowing, addressing physical and/or cognitive deficits, encouraging family and friends to provide favorite foods, auditing/addressing specific food under-consumption, and providing prudent nutrient supplementation. Clinicians must be aware of the numerous factors in play with regard to nutrition and its impact on not only general well-being but also on wound care. Nutritional intervention in pressure ulcer management is truly "healing from the inside out."
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8/19. The use of parenteral nutrition in a severely malnourished hemodialysis patient with hypercalcemia.

    There is a high prevalence of protein-energy malnutrition (PEM) in chronic dialysis patients. Causes of PEM include the catabolic effects of hemodialysis treatments, acidemia associated with end-stage renal disease, common comorbid conditions, and uremia-induced anorexia. morbidity and mortality increase with PEM. Before considering parenteral nutrition (PN) as a nutrition intervention in a maintenance dialysis patient, all other efforts to promote optimal nutrition need to be exhausted. The first step is careful evaluation of protein-energy status, followed by intensive nutrition counseling. If necessary, this is followed by oral nutrition supplementation, appetite stimulation, enteral tube feedings, and finally PN. Short-term parenteral nutrition (PN) became a crucial component of the management of a 38-year-old hemodialysis (HD) patient who endured serious complications after kidney transplant rejection. A profound and prolonged malnourished state followed her treatment for necrotizing pancreatitis. She had developed persistent hypercalcemia believed secondary to tertiary hyperparathyroidism (HPT) and immobilization. Later, she developed hungry bone syndrome (HBS) after parathyroidectomy (PTX). She also developed refeeding syndrome after initiation of PN. The patient's persistent, poorly understood hypercalcemia did not resolve even after PTX and removal of all other sources of vitamin d and calcium from her feedings, medications, and dialysis bath. The close communication of the inpatient and outpatient dialysis multidisciplinary teams became a key component to the successful outcome in this complex patient.
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9/19. bacteremia due to rhodococcus equi--a case report.

    rhodococcus equi (R. equi) primarily causes zoonotic infections affecting grazing animals and is an unusual cause of infection in immunocompetent human beings. We report a case of bacteremia due to R. equi a rare isolate in a child suffering from protein energy malnutrition
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10/19. Severe acute liver damage in anorexia nervosa: two case reports.

    OBJECTIVE: Two female patients (18 and 30 y old, body mass indexes 14.1 and 13.2 kg/m2) with severe, restrictive anorexia nervosa developed sudden severe liver damage. In addition to overt protein-energy malnutrition, they showed marked hypotension, bradycardia, dry skin, acrocyanosis, and hypothermia. Most common causes of liver failure, such as hepatotropic viruses, hepatotoxic drugs, alcohol, cannabis, and cocaine abuse, were excluded. methods: Therapeutic intervention consisted of immediate plasma volume support, progressive parenteral or oral nutritional rehabilitation, and parenteral potassium and phosphorus supplements to avoid the refeeding syndrome. RESULTS AND CONCLUSION: Improvement of initial clinical symptoms and rapid recovery of liver enzymes after this type of treatment suggest that severe liver damage in anorexia nervosa may be secondary to acute hypoperfusion.
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