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1/73. Efficacy of intraperitoneal amino acid (IPAA) dialysate in an Asian vegetarian patient with chronic hypoalbuminaemia.

    Protein-calorie malnutrition is commonly found in chronic CAPD patients and is a matter of concern since low serum albumin levels correlate with an increased risk of morbidity and mortality. Recognition of this link has therefore led to a growing interest in the efficacy of IPAA therapy as a possible treatment option. The present case study took place within a larger, ongoing clinical trial and outlines our experience of administering one exchange of 1.1% IPAA (Nutrineal, Baxter Healthcare Ltd) per day over 18 weeks to a patient identified as being protein malnourished. ( info)

2/73. Treatment of cachexia with recombinant growth hormone in a patient before lung transplantation: a case report.

    OBJECTIVES: To describe the effects of recombinant human growth hormone (rhGH) in a severely malnourished patient before lung transplantation. DESIGN: Case study. SETTING: intensive care unit. patients: A 38-yr-old severely malnourished (body mass index, 15.1 kg/m2) woman (receiving prednisone) with bronchiolitis obliterans evolving during 10 yrs presented with end-stage lung disease and required continuous noninvasive mechanical ventilation. INTERVENTIONS: Two courses of 35 days of 16 IU/day (0.42 IU/kg/day) rhGH administered subcutaneously, with an interruption of 5 wks between the two courses of rhGH. MEASUREMENTS AND MAIN RESULTS: weight gain of 14.7% and 12.8% fat-free mass, as measured by 50-kHz bioelectrical impedance analysis, during treatment during a 3.5-month period. nitrogen excretion decreased from 23.7 g/day before treatment to 8.0 g/day while receiving rhGH. Improvement of pulmonary function was also noted and allowed discharge of the patient from the hospital after the second course of rhGH. She underwent successful lung transplantation 2 months later and reached 48.8 kg of body weight 6 months later. CONCLUSIONS: rhGH treatment is a possible strategy that could be used with malnourished patients who are awaiting lung transplantation to improve the nutritional status and respiratory muscle function to prevent recurring respiratory infection and postoperative complications favored by malnutrition and possibly to decrease the length of hospital stay. ( info)

3/73. Multiple nutritional deficiencies in infants from a strict vegetarian community.

    Severe nutritional deficiencies developed in four infants from a new vegan religious community. They had received breast milk until the age of 3 months; thereafter, breast milk was supplemented with or replaced by extremely low caloric-density preparations. All of the infants had profound protein-caloric malnutrition, severe rickets, osteoporosis, and vitamin B12 and other deficiencies. One infant died, while the three others had an uneventful recovery. After discharge of the infants from the hospital, the community responded well to a modification of the infants' diet, which did not violate their vegetarian philosophy. However, they refused to give their infants vitamin B12 on a regular basis. ( info)

4/73. Malnutrition in infants receiving cult diets: a form of child abuse.

    Severe nutritional disorders, including kwashiorkor, marasmus, and rickets, were seen in four children and were due to parental food faddism, which should perhaps be regarded as a form of child abuse. All disorders were corrected with more normal diets and vitamin supplements. In view of the potentially serious consequences of restricted diets being fed to children, families at risk should be identified and acceptable nutritional advice given. When children are found to be suffering from undernutrition due to parental food faddism a court order will normally be a necessary step in providing adequate treatment and supervision. ( info)

5/73. 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. ( info)

6/73. The human ruminant.

    A five-month-old female infant was admitted to the Tropical metabolism research Unit with a weight for age of 49% and no evidence of oedema giving rise to a diagnosis of marasmus (Wellcome classification). The underlying reason for her malnutrition was the infant Rumination syndrome. This is an uncommon disorder which is thought to have a psychological component. A lack of awareness of the syndrome often leads to delay in diagnosis. ( info)

7/73. Malnutrition-associated rash of cystic fibrosis.

    Rash is a rare presenting sign of cystic fibrosis (CF) complicated by protein-calorie malnutrition. We measured essential fatty acid (EFA) levels in the serum of a 4-month-old girl with an erythematous, desquamating, periorificially accentuated rash in association with malnutrition and her 2-year-old sister who was diagnosed concurrently with CF but had no rash or signs of malnutrition. Both patients had biochemical evidence of EFA deficiency, suggesting that development of the rash is multifactorial. Clinical presentation, management, and possible modes of pathogenesis of the rash are reviewed. Pathogenesis of the rash appears to involve a complex interaction among deficiencies of EFAs, zinc, protein, and possibly copper, leading to disordered prostaglandin metabolism or cytokine production, or free radical-induced damage to cellular membranes due to a lack of nutrient-derived protective antioxidants. ( info)

8/73. Anasarca and small bowel obstruction secondary to endometriosis.

    Intestinal involvement by endometriotic tissue occurs in up to 37% of patients with endometriosis. The vast majority of patients do not experience symptoms related to the gastrointestinal tract. In particular, the complications of intestinal obstruction and malabsorption secondary to endometriosis are exceedingly uncommon. We present a 42-year-old woman with intestinal obstruction, protein-losing enteropathy, and anasarca secondary to endometriosis. She had a 1-year history of watery diarrhea, bloating, and abdominal pain with a 30-lb weight-loss over 3 months. She had no previous history of endometriosis, and laboratory investigations showed severe hypoalbuminemia, hypokalemia, and metabolic acidosis. Abdominal x-rays revealed air-fluid levels and dilated loops of small bowel. She underwent surgical resection with primary anastomosis. Pathologic evaluation showed extensive endometriosis of the small bowel and appendix, which resulted in complete obstruction. Segments of ileum also demonstrated moderate-to-marked blunting of the villi. Postoperatively, the patient had a slow recovery with resolution of anasarca and a gradual increase in her weight. This report illuminates the rare, yet significant, complications of intestinal endometriosis, including small bowel obstruction, the development of a protein-losing enteropathy, and anasarca. One should consider the possibility of intestinal endometriosis in the differential diagnosis of bowel obstruction in women of childbearing age. ( info)

9/73. Enteral and parenteral nutrition in patients with head and neck cancer.

    head and neck cancer patients present with special problems in nutritional homoeostasis because of local phayngeal discomfort and obstruction and difficulty with deglutition due to either the neoplasm or the surgical alterations in the upper aerodigestive tract. Pretreatment malnutrition and vitamin deficiency are only compounded by the nutritional stress imposed by radiation and surgery. Reduced wound complications occur if the patients are nutritionally replenished before treatment. While nasogastric feedings will suffice in many patients, rapid nutritional restoration by this method is limited, and positive nitrogen balance may be difficult to achieve in the severely malnourished patient. Intravenous hyperalimentation offers a rapid and efficacious alternative in selected cases. The case histories of two patients are presented to illustrate these concepts. ( info)

10/73. 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. ( info)
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