Predicting weight loss in people with cancer

Background: Malnutrition and the cachexia syndrome are common in people with cancer. A combination of reduced nutritional intake and abnormal metabolism can lead to physical and psychological disturbances which may impair quality of life and reduce survival. Improved patient outcomes are more likely if treatments and nutritional support can be initiated before significant weight loss has occurred. Methods: A three phase, mixed methods study was undertaken. The primary aim was to gain a greater understanding of the complex factors that have an effect on, and can predict, weight loss in people with cancer. Phases I and II involved the psychometric testing of the Cancer Appetite and Symptom Questionnaire (CASQ). The instrument was tested for reliability among patients receiving radiotherapy (n=34). Predictive validity of the CASQ, using ROC curve analysis, was determined in patients with lung or upper GI cancer (n=185). Total CASQ scores (possible range, 0 to 48) were assessed at baseline, together with percentage weight change after 3 months. An exploratory qualitative study, following the principles of grounded theory, was conducted to explore the causes and influencing factors on weight change. Results: When tested for reliability, the intra-class correlation coefficient of the CASQ was 0.80 (95% CI 0.68 to 0.92) and the difference between total CASQ scores at the two time points was -0.20 (95% CI -1.21 to 0.80). The optimum cut point of the total CASQ score to predict >5% weight loss was 31/32 (C statistic = 0.64; sensitivity 65%, specificity 62%, PPV 33%, NPV 86%), and to predict >10% weight loss was 29/30 (C statistic = 0.75; sensitivity 71%, specificity 66%, PPV 19%, NPV 95%). Exploratory modelling using multiple linear regression techniques suggested that BMI, MUST score, age and the CASQ items of enjoyment of food and pain, were most predictive of weight loss. Nine patients with lung or upper GI cancer and three carers participated in semi-structured interviews. Analysis of the data confirmed the vulnerability of this patient group in terms of symptom burden and nutritional risk. From the findings, a conceptual model that explains the influences on weight change in people with cancer was proposed. Conclusions: Patients with lung and upper GI cancer are at high risk of malnutrition. Psychometric testing of the CASQ suggests that the instrument can predict weight loss in this patient group. Due to the low PPV, further refinements are needed before the instrument is able to be used in clinical practice. A conceptual model which explains the complex process of influences on weight change in people with cancer can improve knowledge and understanding, ultimately informing healthcare practice

Predicting weight loss in people with cancer

Background: Malnutrition and the cachexia syndrome are common in people with cancer. A combination of reduced nutritional intake and abnormal metabolism can lead to physical and psychological disturbances which may impair quality of life and reduce survival. Improved patient outcomes are more likely if treatments and nutritional support can be initiated before significant weight loss has occurred. Methods: A three phase, mixed methods study was undertaken. The primary aim was to gain a greater understanding of the complex factors that have an effect on, and can predict, weight loss in people with cancer. Phases I and II involved the psychometric testing of the Cancer Appetite and Symptom Questionnaire (CASQ). The instrument was tested for reliability among patients receiving radiotherapy (n=34). Predictive validity of the CASQ, using ROC curve analysis, was determined in patients with lung or upper GI cancer (n=185). Total CASQ scores (possible range, 0 to 48) were assessed at baseline, together with percentage weight change after 3 months. An exploratory qualitative study, following the principles of grounded theory, was conducted to explore the causes and influencing factors on weight change. Results: When tested for reliability, the intra-class correlation coefficient of the CASQ was 0.80 (95% CI 0.68 to 0.92) and the difference between total CASQ scores at the two time points was -0.20 (95% CI -1.21 to 0.80). The optimum cut point of the total CASQ score to predict >5% weight loss was 31/32 (C statistic = 0.64; sensitivity 65%, specificity 62%, PPV 33%, NPV 86%), and to predict >10% weight loss was 29/30 (C statistic = 0.75; sensitivity 71%, specificity 66%, PPV 19%, NPV 95%). Exploratory modelling using multiple linear regression techniques suggested that BMI, MUST score, age and the CASQ items of enjoyment of food and pain, were most predictive of weight loss. Nine patients with lung or upper GI cancer and three carers participated in semi-structured interviews. Analysis of the data confirmed the vulnerability of this patient group in terms of symptom burden and nutritional risk. From the findings, a conceptual model that explains the influences on weight change in people with cancer was proposed. Conclusions: Patients with lung and upper GI cancer are at high risk of malnutrition. Psychometric testing of the CASQ suggests that the instrument can predict weight loss in this patient group. Due to the low PPV, further refinements are needed before the instrument is able to be used in clinical practice. A conceptual model which explains the complex process of influences on weight change in people with cancer can improve knowledge and understanding, ultimately informing healthcare practice

Identifying malnutrition in emergency general surgery:systematic review

Background: Emergency general surgery practice is high risk. Surgery is a key part of treatment, with resultant catabolic stress and frequent need for nutritional support. The aim of this study was to examine the current methods of defining and determining malnutrition in emergency general surgery. This included examining the use of nutrition screening and assessment tools and other measures of malnutrition.Methods: MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, trial registries, and relevant journals published between January 2000 and January 2022 were searched for studies of adult patients with any emergency general surgery diagnosis, managed conservatively or operatively, with an assessment of nutritional status. Mixed populations were included if more than 50 per cent of patients were emergency general surgery patients or emergency general surgery results could be separately extracted. Studies in which patients had received nutritional support were excluded. The protocol was registered with PROSPERO, the international prospective register of systematic reviews (CRD42021285897).Results: From 6700 studies screened, 324 full texts were retrieved and 31 were included in the analysis. A definition of malnutrition was provided in 23 studies (75 per cent), with nutritional status being determined by a variety of methods. A total of seven nutrition screening tools and a total of nine ‘assessment’ tools were reported. To define malnutrition, the most commonly used primary or secondary marker of nutritional status was BMI, followed by albumin level.Conclusion: Wide variation exists in approaches to identify malnutrition risk in emergency general surgery patients, using a range of tools and nutrition markers. Future studies should seek to standardize nutrition screening and assessment in the emergency general surgery setting as two discrete processes. This will permit better understanding of malnutrition risk in surgical patients

Neuromuscular electrical stimulation of the quadriceps in patients with non-small cell lung cancer receiving palliative chemotherapy: a randomized Phase II study

Background A reduced exercise capacity is associated with increased morbidity and mortality in patients with advanced non-small cell lung cancer (NSCLC). Therapeutic exercise can be beneficial and neuromuscular electrical stimulation (NMES) of the quadriceps muscles may represent a practical approach. The primary aim of this study was to determine the acceptability of NMES of the quadriceps to patients with NSCLC used alongside palliative chemotherapy. Secondary aims explored aspects of safety and efficacy of NMES in this setting. Methods Patients with advanced NSCLC due to receive first-line palliative chemotherapy were randomized to usual care with or without NMES. They were asked to undertake 30 minute sessions of NMES, ideally daily, but as a minimum, three times weekly. For NMES to be considered acceptable, it was predetermined that ≥80% of patients should achieve this minimum level of adherence. Qualitative interviews were held with a subset of patients to explore factors influencing adherence. Safety was assessed according to the Common Terminology Criteria for Adverse Events. Quadriceps muscle strength, thigh lean mass, and physical activity level were assessed at baseline and after three cycles of chemotherapy. Results 49 patients (28 male, median (IQR) age 69 (64−75) years) participated. Of 30 randomized to NMES, 18 were eligible for the primary endpoint, of whom 9 (50% [90% CI, 29 to 71]) met the minimum level of adherence. Adherence was enhanced by incorporating sessions into a daily routine and hindered by undesirable effects of chemotherapy. There were no serious adverse events related to NMES, nor significant differences in quadriceps muscle strength, thigh lean mass or physical activity level between groups. Conclusions NMES is not acceptable in this setting, nor was there a suggestion of benefit. The need remains to explore NMES in patients with cancer in other settings

Effects of Non-Pharmacological Interventions as Vaccine Adjuvants in Humans:a systematic review and network meta-analysis

Declaration of interest: We have read and understood the policy on declaration of interests and declare that CMT has received funding from Nestle Nutrition for projects unconnected with this study. All other authors do not have any conflicting interests

Cancer Appetite and Symptom Questionnaire (CASQ) for Brazilian Patients: Cross-Cultural Adaptation and Validation Study

Background Appetite and symptoms, conditions generally reported by the patients with cancer, are somewhat challenging for professionals to measure directly in clinical routine (latent conditions). Therefore, specific instruments are required for this purpose. This study aimed to perform a cultural adaptation of the Cancer Appetite and Symptom Questionnaire (CASQ), into Portuguese and evaluate its psychometric properties on a sample of Brazilian cancer patients. Methods This is a validation study with Brazilian cancer patients. The face, content, and construct (factorial and convergent) validities of the Cancer Appetite and Symptom Questionnaire, the study tool, were estimated. Further, a confirmatory factor analysis (CFA) was conducted. The ratio of chi-square and degrees of freedom (χ2 /df), comparative fit index (CFI), goodness of fit index (GFI) and root mean square error of approximation (RMSEA) were used for fit model assessment. In addition, the reliability of the instrument was estimated using the composite reliability (CR) and Cronbach’s alpha coefficient (α), and the invariance of the model in independent samples was estimated by a multigroup analysis (Δχ2). Results Participants included 1,140 cancer patients with a mean age of 53.95 (SD = 13.25) years; 61.3% were women. After the CFA of the original CASQ structure, 2 items with inadequate factor weights were removed. Four correlations between errors were included to provide adequate fit to the sample (χ2 /df = 8.532, CFI = .94, GFI = .95, and RMSEA = .08). Themodel exhibited a low convergent validity (AVE = .32). The reliability was adequate (CR = .82 α = .82). The refined model showed strong invariance in two independent samples (Δχ2 : λ: p = .855; i: p = .824; Res: p = .390). A weak stability was obtained between patients undergoing chemotherapy and radiotherapy (Δχ2 : λ: p = .155; i: p < .001; Res: p < .001), and between patients undergoing chemotherapy combined with radiotherapy and palliative care (Δχ2 : λ: p = .058; i: p < .001; Res: p < .001). Conclusion The Portuguese version of the CASQ had good face and construct validity and reliability. However, the CASQ still presented invariance in independent samples of Brazilian patients with cancer. However, the tool has low convergent validity and weak invariance in samples with different treatment

Positive mood on the day of influenza vaccination predicts vaccine effectiveness: a prospective observational cohort study

Influenza vaccination is estimated to only be effective in 17–53% of older adults. Multiple patient behaviors and psychological factors have been shown to act as ‘immune modulators’ sufficient to influence vaccination outcomes. However, the relative importance of such factors is unknown as they have typically been examined in isolation. The objective of the present study was to explore the effects of multiple behavioral (physical activity, nutrition, sleep) and psychological influences (stress, positive mood, negative mood) on the effectiveness of the immune response to influenza vaccination in the elderly. A prospective, diary-based longitudinal observational cohort study was conducted. One hundred and thirty-eight community-dwelling older adults (65–85 years) who received the 2014/15 influenza vaccination completed repeated psycho-behavioral measures over the two weeks prior, and four weeks following influenza vaccination. IgG responses to vaccination were measured via antigen microarray and seroprotection via hemagglutination inhibition assays at 4 and 16 weeks post-vaccination. High pre-vaccination seroprotection levels were observed for H3N2 and B viral strains. Positive mood on the day of vaccination was a significant predictor of H1N1 seroprotection at 16 weeks post-vaccination and IgG responses to vaccination at 4 and 16 weeks post-vaccination, controlling for age and gender. Positive mood across the 6-week observation period was also significantly associated with post-vaccination H1N1 seroprotection and IgG responses to vaccination at 16 weeks post-vaccination, but in regression models the proportion of variance explained was lower than for positive mood on the day of vaccination alone. No other factors were found to significantly predict antibody responses to vaccination. Greater positive mood in older adults, particularly on the day of vaccination, is associated with enhanced responses to vaccination

Six weeks of home enteral nutrition versus standard care after esophagectomy or total gastrectomy for cancer: study protocol for a randomized controlled trial

Background: Each year approximately 3000 patients in the United Kingdom undergo surgery for esophagogastric cancer. Jejunostomy feeding tubes, placed at the time of surgery for early postoperative nutrition, have been shown to have a positive impact on clinical outcomes in the short term. Whether feeding out of hospital is of benefit is unknown. Local experience has identified that between 15 and 20% of patients required ‘rescue’ jejunostomy feeding for nutritional problems and weight loss while at home. This weight loss and poor nutrition may contribute to the detrimental effect on the overall quality of life (QoL) reported in these patients. Methods/Design: This randomized pilot and feasibility study will provide preliminary information on the routine use of jejunostomy feeding after hospital discharge in terms of clinical benefits and QoL. Sixty participants undergoing esophagectomy or total gastrectomy will be randomized to receive either a planned program of six weeks of home jejunostomy feeding after discharge from hospital (intervention) or treatment-as-usual (control). The intention of this study is to inform a multi-centre randomized controlled trial. The primary outcome measures will be recruitment and retention rates at six weeks and six months. Secondary outcome measures will include disease specific and general QoL measures, nutritional parameters, total and oral nutritional intake, hospital readmission rates, and estimates of healthcare costs. Up to 20 participants will also be enrolled in a qualitative sub-study that will explore participants’ and carers’ experiences of home tube feeding. The results will be disseminated by presentation at surgical, gastroenterological and dietetic meetings and publication in appropriate peer review journals. A patient-friendly lay summary will be made available on the University of Leicester and the University Hospitals of Leicester NHS Trust websites. The study has full ethical and institutional approval and started recruitment in July 2012. Trial registration: UKClinical Research Network ID #12447 (Main study); UKCRN ID#13361 (Qualitative sub study); ClinicalTrials.gov #NCT01870817 (First registered 28 May 2013

Whole Genome Sequencing of Australian Candida glabrata Isolates Reveals Genetic Diversity and Novel Sequence Types

Candida glabrata is a pathogen with reduced susceptibility to azoles and echinocandins. Analysis by traditional multilocus sequence typing (MLST) has recognized an increasing number of sequence types (STs), which vary with geography. Little is known about STs of C. glabrata in Australia. Here, we utilized whole genome sequencing (WGS) to study the genetic diversity of 51 Australian C. glabrata isolates and sought associations between STs over two time periods (2002–2004, 2010–2017), and with susceptibility to fluconazole by principal component analysis (PCA). Antifungal susceptibility was determined using Sensititre YeastOneTM Y010 methodology and WGS performed on the NextSeq 500 platform (Illumina) with in silico MLST STs inferred by WGS data. Single nucleotide polymorphisms (SNPs) in genes linked to echinocandin, azole and 5-fluorocytosine resistance were analyzed. Of 51 isolates, WGS identified 18 distinct STs including four novel STs (ST123, ST124, ST126, and ST127). Four STs accounted for 49% of isolates (ST3, 15.7%; ST83, 13.7%; ST7, 9.8%; ST26, 9.8%). Split-tree network analysis resolved isolates to terminal branches; many of these comprised multiple isolates from disparate geographic settings but four branches contained Australian isolates only. ST3 isolates were common in Europe, United States and now Australia, whilst ST8 and ST19, relatively frequent in the United States, were rare/absent amongst our isolates. There was no association between ST distribution (genomic similarity) and the two time periods or with fluconazole susceptibility. WGS identified mutations in the FKS1 (S629P) and FKS2 (S663P) genes in three, and one, echinocandin-resistant isolate(s), respectively. Both mutations confer phenotypic drug resistance. Twenty-five percent (13/51) of isolates were fluconazole-resistant (MIC ≥ 64 μg/ml) of which 9 (18%) had non wild-type MICs to voriconazole and posaconazole. Multiple SNPs were present in genes linked to azole resistance such as CgPDR1 and CgCDR1, as well as several in MSH2; however, SNPs occurred in both azole-susceptible and azole-resistant isolates. Although no particular SNP in these genes was definitively associated with resistance, azole-resistant/non-wild type isolates had a propensity to harbor SNPs resulting in amino acid substitutions in Pdr1 beyond the first 250 amino acid positions. The presence of SNPs may be markers of STs. Our study shows the value of WGS for high-resolution sequence typing of C. glabrata, discovery of novel STs and potential to monitor trends in genetic diversity. WGS assessment for echinocandin resistance augments phenotypic susceptibility testing

Construire des politiques alimentaires urbaines

Porté par les industries agroalimentaires, le système alimentaire dominant actuellement n’est pas durable. Les études et les expertises se multiplient pour en montrer les limites en termes d’usage des ressources, de distanciation, de santé, d’équité, d’emploi etc… Face à ces constats, des acteurs publics ou privés se mobilisent et l’on voit émerger des initiatives où les « gouvernements urbains » apparaissent comme de plus en plus actifs et puissants. Écrit par un collectif de chercheurs, cet ouvrage décrit les cadres conceptuels existants pour une démarche d’analyse des politiques alimentaires urbaines, au croisement des concepts de système alimentaire et de ville durable. Il constitue une base de travail pour identifier des questions de recherche, en relation avec les initiatives des gouvernements locaux urbains, au Nord et au Sud. Il est issu des travaux menés au sein d’Agropolis International dans le cadre du programme Surfood (Sustainable urban food systems) ainsi que d’une recherche-action menée en appui à Montpellier Méditerranée Métropole pour la construction de sa politique agroécologique et alimentaire. Les auteurs s’adressent aux scientifiques et aux experts qui analysent et accompagnent les politiques alimentaires urbaines. Les experts de politiques locales dans leur globalité trouveront également un intérêt à la lecture de l’ouvrage