Preoperative Nutrition Status and Postoperative Outcomes in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a complex surgery to treat peritoneal surface malignancy (PSM). PSM and gastrointestinal (GI) resection from CRS can lead to significant GI symptoms and malnutrition. There is limited research into the nutrition status of this patient group and the impact of malnutrition on morbidity.

OBJECTIVE

This study aims to determine if preoperative malnutrition, assessed using the Subjective Global Assessment (SGA), is associated with postoperative morbidity and increased length of stay (LOS) in patients undergoing CRS/HIPEC for PSM.

METHODS

This study prospectively assessed the nutritional status of patients undergoing CRS/HIPEC using a validated nutrition assessment tool. Preoperative clinical symptoms, Peritoneal Cancer Index (PCI), intraoperative blood transfusions, operative time, GI resections, postoperative morbidity, and LOS, as well as pre- and postoperative nutritional interventions, were recorded. The impact of preoperative nutritional status was assessed in relation to postoperative complications and hospital LOS.

RESULTS

The study included 102 participants; 34 patients (33%) were classified as malnourished (SGA = B or C). Preoperative weight loss (15% vs. 74%; p ≤ 0.001) and the presence of clinical symptoms (18% vs. 47%; p = 0.002) were significantly higher in malnourished patients. While PCI, intraoperative blood transfusions, and GI resections were independent predictors of morbidity, malnutrition was significantly associated with infectious complications and LOS. For each grade of worsening malnutrition, LOS increased by an average of 7.65 days.

CONCLUSIONS

Preoperative malnutrition is prevalent in patients undergoing CRS/HIPEC and postoperative morbidity is common. Malnutrition is linked to LOS and plays a role in postoperative outcomes such as infection. Clear pre- and postoperative nutrition pathways are needed to optimize nutrition support and postoperative recovery.

Marek's disease virus EcoRI-Q gene (meq) and a small RNA antisense to ICP4 are abundantly expressed in CD4+ cells and cells carrying a novel lymphoid marker, AV37, in Marek's disease lymphomas

Mature lymphomas produced in Rhode Island Red (RIR) chickens infected with the RB1B strain of Marek's disease virus (MDV) were examined for the presence of viral DNA and RNA and expression of viral antigens. In situ hybridization showed that all tumours examined contained viral DNA in areas of lymphoid infiltration. In 3/5 tumours, there was a correlation between the number and distribution of cells expressing the Marek's disease EcoRI-Q gene (meq) and those that carried the lymphoid cell marker AV37. Expression of the MDV-specific phosphoprotein pp38 was infrequent in lymphomas but abundant in a splenic tumour which also expressed the viral glycoprotein gB. Northern blot analysis of lymphocyte fractions purified by immunoaffinity showed that CD4+ and AV37+ fractions from lymphomas expressed meq and the small RNA antisense to ICP4 (SAR). The results are consistent with the notion that transformed cells are CD4+ cells, carrying the AV37 marker and expressing meq and SAR.

Age related changes in the pituitary-testicular axis in normal men; lower serum testosterone results from decreased bioactive LH drive

OBJECTIVE

The mechanism underlying the slight hypoandrogenism associated with normal ageing remains unclear. We have therefore examined age related changes in the activity of the pituitary-testicular axis in healthy normal males.

DESIGN

Random blood samples were obtained from 219 normal men whose ages ranged from 20 to 79 years. At the time of the study, none of the men had received treatment or had ever had any endocrine dysfunction diagnosed.

MEASUREMENTS

Luteinizing hormone was measured in the subjects' plasma using a commercially available immunoradiometric assay (IRMA, Serono Maiaclone) and a fully validated in-vitro bioassay. Testosterone and FSH were measured using standard radioimmunoassays (RIA) whilst sex hormones binding globulin was assayed by an IRMA.

RESULTS

Levels of total testosterone (total-T) and bioactive LH fell with age (r = -0.231 and -0.189 respectively) by 5.9 nmol/l and 2.3 IU/l respectively between grouped patients aged 20-39 years (Group A) and 60-79 years (Group C). In contrast, immunoreactive LH remained unchanged. The LH B:I ratio also fell with age (P < 0.0001) being 5.0 +/- 0.3 (group A) and 3.3 +/- 0.2 (group C), representing a fall of 33%. Since immunoreactivity remained constant, this fall primarily represented the decline in LH bioactivity. Bioactive, but not immunoreactive LH correlated to total-T (P = 0.009, n = 209) and the total-T:LH ratios fell by over 30% between groups A and C using the IRMA, but remained unchanged by bioassay.

CONCLUSIONS

There is an underlying decline in both total-testosterone and free-testosterone index, and bioactive LH levels with advancing age, suggestive of a hypothalamo-pituitary defect which leads to lower bioactive LH levels which in turn are responsible for the diminished gonadal steroidogenesis. Elucidation of the mechanism underlying this slight decline in hypothalamopituitary testicular activity is complicated by differences between the data obtained by immunoassay or bioassay.

Physiological oestradiol administration does not change the biological to immunological ratio of LH in serum from post-menopausal women

OBJECTIVE

We investigated the effect of chronic physiological concentrations of oestradiol on the bioactivity (B) and immunoactivity (I) of LH in serum using radioimmunoassay (RIA) and a sensitive immunoradiometric (IRMA) assay.

DESIGN

Twelve post-menopausal, hysterectomized women received a 50-mg subcutaneous E2 implant, in the absence of progestogen treatment. Pretreatment serum samples were obtained on two occasions for measurement of E2 and FSH by radioimmunoassay and for measurement of LH by bioassay (BIO), immunoradiometric assay and radioimmunoassay. Further serum samples were obtained monthly for 6 months for assay as above.

RESULTS

The serum E2 level (basal levels < 70 pmol/l) rose following implant (P < 0.01) peaking at 1 month (mean 454, range 356-580 pmol/l) and remaining within premenopausal physiological levels for 6 months. There were falls in FSH, LH-RIA, LH-IRMA and LH-BIO (P < 0.001). There was no change in the B:I ratio for B:I-RIA or B:I-IRMA for LH which were 1.8 and 3.3, respectively pretreatment and 1.7 and 2.9 after 1 month's treatment.

CONCLUSION

The treatment of post-menopausal women with 50-mg E2 subcutaneous implants produces physiological premenopausal E2 levels for at least 6 months. There is no change in the B:I ratio of LH using either the RIA or IRMA during chronic E2 treatment.

Pattern of secretion of bioactive and immunoreactive gonadotrophins in normal pubertal children

OBJECTIVE

The aim was to investigate the relationship between the nocturnal pulsatile secretory patterns of immunoreactive and bioactive luteinizing hormone in normal children at various stages of puberty.

DESIGN

Blood samples were taken at 15-minute intervals from 2000 hours to 0800 hours. Pubertal stage was assessed by the method of Tanner (1962).

PATIENTS

Thirty-four healthy siblings (17 males, 17 females) of diabetic children were recruited (median age 13.1, range 9.1-20.9 years). They were of normal height, non-obese, and covered the range of puberty.

MEASUREMENTS

Follicle stimulating and luteinizing hormone levels were measured by radioimmunoassay in all 34 subjects; bioactive LH (B-LH) was assayed in a subgroup of 13 subjects selected to encompass the range of normal puberty. Oestradiol (girls) and testosterone (boys) were also measured at hourly intervals.

RESULTS

Immunoreactive luteinizing and follicle stimulating hormone concentrations showed a progressive rise during puberty in both sexes. FSH concentrations were significantly higher in females than in males at all stages of puberty. Overnight mean bioactive luteinizing hormone concentrations were higher than immunoreactive luteinizing hormone levels in all the girls studied (n = 7). Although the number of bioactive luteinizing hormone pulses (31) was greater than immunoreactive pulses (27), the profiles were generally very similar. In the early pubertal girls an increase in the bioactive: immunoreactive ratio was observed during the middle of the night with the onset of pulsatility. Oestrogen was detected in the girls in breast stage 4-5 but not in two of the early pubertal girls, despite pulses of immunoreactive and bioactive luteinizing hormone. The boys had higher mean bioactive than immunoreactive luteinizing hormone levels and overall bioactive and immunoreactive luteinizing hormone and testosterone concentrations increased with puberty stage. Concordance between bioactive and immunoreactive hormone pulses was good although more immunoreactive pulses (16) were seen than bioactive pulses (14). As in the girls, an increase in the bioactive: immunoreactive ratio was observed in the middle of the night with the onset of pulsatility at genital stage 2 but, in contrast to the oestrogen data in the girls, testosterone secretion always followed luteinizing hormone pulsatility overnight.

CONCLUSION

We conclude that mean overnight immunoreactive luteinizing and follicle stimulating hormone concentrations increase during puberty in both sexes. Bioactive luteinizing hormone levels are two to three times higher than immunoreactive luteinizing hormone in both sexes, but there is very little discordance between immunoreactive and bioactive luteinizing hormone pulsatility. The bioactive: immunoreactive ratio increases with the occurrence of pulsatility overnight in early pubertal children. The relationship between these changes in bioactive and immunoreactive luteinizing hormone and sex steroids is clearest in boys where the nocturnal testosterone rise always follows pulsatile LH secretion.

The effect of danazol and the LHRH agonist analogue goserelin (Zoladex) on the biological activity of luteinizing hormone in women with endometriosis

In an attempt to determine whether the suppression in oestradiol levels caused by danazol is due to an effect on the hypothalamic-pituitary axis, we compared the endocrine effects of danazol with those of the LHRH (GnRH) agonist analogue goserelin. Serum levels of immunoreactive LH (I-LH), FSH, 17 beta-oestradiol (E2) and bioactive LH (B-LH) (using a mouse Leydig cell bioassay), were measured in ten and 20 women with endometriosis treated with danazol and goserelin, respectively. I-LH was measured both by radioimmunoassay (RIA) and immunoradiometric assay (IRMA). During 6 months of treatment with 600 mg of danazol daily, mean serum E2 decreased (P less than 0.05) to levels near the upper limit of the post-menopausal range (to a mean (and 95% confidence interval of the mean) of 117 (65-169) pmol/l) whereas FSH, I-LH (both by RIA and IRMA) and B-LH levels were not significantly altered. During 6 months of treatment with monthly depot injections of 3.6 mg goserelin, mean serum E2 decreased (P less than 0.001) to well within the post-menopausal range (to 23 (18-28) pmol/l). The mean FSH, I-LH and B-LH levels also decreased (P less than 0.05) during therapy with goserelin (from 3.9 (3.1-4.7) to 2.0 (1.6-2.4) IU/l for FSH, from 5.3 (4.5-6.1) to 1.9 (1.7-2.1) IU/l for RIA-LH, from 2.9 (2.5-3.3) to less than 0.5 (less than 0.5) IU/l for IRMA-LH and from 9.1 (7.1-11.1) to 2.9 (2.6-3.2) IU/l for B-LH).(ABSTRACT TRUNCATED AT 250 WORDS)

Location of osteoclast precursors in fetal rat calvaria cultured on collagen gels

Although osteoclasts are derived from hematopoietic cells, the exact identity of their precursors and the mechanism for their recruitment onto bone surfaces remain unclear. We wished to study their differentiation in the fetal rat calvaria and to locate its source of osteoclast precursor cells. Osteoclasts were detected by neutral red staining or cytochemical reaction for acid phosphatase of intact bone (cell number and area measured by computerized image analysis) or in cryostat sections of bone (enzyme activity measured by quantitative cytochemistry). Histology of semithin sections of fixed bones was also examined. The 19 day calvariae contained few mature osteoclasts. After 48 h culture on gels of type 1 collagen (1.5 mg/ml) supplemented with 5 mM calcium beta-glycerophosphate, 10 mM proline, and 2 micrograms/ml ascorbic acid, numerous large osteoclasts were seen on their endocranial surfaces. In contrast, cell morphology and enzyme activity deteriorated in bones cultured in liquid medium. The cells that formed in vitro rapidly responded to calcitonin by contraction. Stripping of endocranial membranes from the calvariae prevented osteoclast formation in culture, but these cells were seen when "stripped" bones had been cocultured with their membranes for 48 h or with intact 16 day calvariae (well before the onset of osteogenesis). Few osteoclasts were found when an 0.22 micron filter was inserted between the stripped calvaria and the endocranial membranes. We conclude that the endocranial membranes, which contain the meningeal blood vessels, are a major source of osteoclast precursors and that these cells are present in calvarial tissue even before the onset of osteogenesis.

The measurement of plasma noradrenaline before and after tilt in young and old healthy subjects

Using a modified sensitive and specific radioenzymatic method we have determined the normal range for plasma noradrenaline in healthy, elderly individuals. The effects of tilt on the cardiovascular system and on plasma noradrenaline responses were found to be different compared with healthy young controls. The elderly had higher resting plasma noradrenaline concentrations with an exaggerated response to head-up tilt. In spite of this higher sympathetic drive, the cardiovascular responses in the elderly were attenuated.