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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population 10 Nutrition Support Nutrition support, defined as the provision of enteral or parenteral nutrition, has made great strides over the past three decades. Enteral nutrition includes oral ingestion of foods or supplements as well as the non-volitional administration of nutrients by tube into the gastrointestinal tract. Parenteral nutrition is the intravenous administration of nutrients into the bloodstream, by either peripheral or central venous access routes. Nutrition administered by the peripheral route is termed peripheral parenteral nutrition, and by the central route total parenteral nutrition (TPN). Improvements in enteral and parenteral techniques, equipment, nutrient formulations, and gastrointestinal and venous access devices have enabled the provision of nutrients to many patients who might otherwise have received inadequate or inappropriate nutrition. Reflecting shifting health care demographics in America, Medicare beneficiaries comprise a substantial proportion of all adult patients who receive parenteral or enteral nutrition in hospitals. Although it is generally accepted that adequate nutrition plays an important role in maintaining optimal health, many hospitalized patients have compromised nutrient intakes for extended periods (Sullivan et al., 1999). Studies document a prevalence of protein–energy undernutrition among hospitalized older persons that exceeds one-third of all admissions (Constans et al., 1992; Mowé and Bøhmer, 1991; Sullivan et al., 1989). Many elderly are undernourished prior to hospitalization (Mowé et al., 1994). The nutritional status of older patients at hospital discharge is
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population also predictive of the need for early nonelective readmission to the hospital (Friedmann et al., 1997; Sullivan, 1992). The indications for providing nutrients by the enteral or parenteral route have not been well defined, and the efficacy of nutrition support is unproven in many circumstances. Nutrition support is most frequently used as short-term therapy for hospitalized patients with protein–energy undernutrition. The consequences of protein–energy undernutrition include depletion of body cell mass and decline of vital tissue and organ functions (see chapter 4). Compromise in host defense and wound-healing functions can result in suboptimal response to medical and surgical therapies. Complications may include hospital-acquired infections and wound breakdown. Adverse outcomes that may result include increased morbidity and mortality with associated increased length of hospital stay and increased use of health care resources (Friedmann et al., 1997; Incalzi et al., 1998; Jensen et al., 1997; Marinella and Markert, 1998; Sullivan et al., 1999). The rationale for the provision of nutrition support includes (1) to mitigate the effects of semi-starvation, and (2) to favorably alter the natural history or response to treatment for a disease. Nutrition support is clearly indicated when food intake or nutrient assimilation will be compromised for an extended period, since starvation and death will otherwise result. Such patients may include those with inadequate gastrointestinal function (e.g., short-bowel syndrome or chronic intestinal obstruction), as well as those with severe oropharyngeal dysfunction or permanent neurological impairment. Enteral and parenteral nutrition support of shorter duration can also prevent and treat protein–energy undernutrition among other selected Medicare beneficiaries in the hospital setting. Complications can be reduced among patients who are either undernourished or at high risk of becoming undernourished. Such patients may include those who have suffered major abdominal trauma or who undergo major elective abdominal surgery (Heyland, 1998; Kudsk et al., 1992; Moore et al., 1992; Müller et al., 1982; Senkal et al., 1997; VA TPN Cooperative Study Group, 1991). Reported benefits have included decreased rates of septic and wound complications, with resulting reductions in number of hospital days and cost. There are also risks associated with enteral and parenteral nutrition support that must be taken into consideration. Serious complications include aspiration of enteral feedings and infectious and thrombotic events related to parenteral venous access (Cataldi-Betcher et al., 1983; Ryan et al., 1974). Appreciable under- or overfeeding can result in adverse metabolic consequences (Dark et al., 1985; Keys et al., 1950). Feeding intolerance, derangement of fluid balance, and laboratory abnormalities may be
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population observed with refeeding of the undernourished patient (Solomon and Kirby, 1990; Weinsier and Krumdieck, 1981). Such complications can also be associated with increased lengths of hospital stay and health care expenditures. LITERATURE REVIEW The Committee on Nutrition Services for Medicare Beneficiaries sought to critically review the available nutrition support literature according to the guidelines of the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research). The committee was greatly assisted in this process by the availability of several recent review articles of this literature that served as a strong foundation (ASPEN, 1993; Heyland et al., 1998; Klein et al., 1997; Pillar and Perry, 1990; Souba, 1997). In addition to systematic examination of the literature used to support these reviews, relevant new material was examined from the past 5 years, corresponding to more than 1,500 parenteral and 2,000 enteral citations from Medline in both the English and the non-English scientific literature. The general approach taken by the committee was to clarify the type of evidence available and to specifically highlight evidence in relation to persons 65 years of age or older. When there was no specific evidence available in relation to older persons, the committee attempted to ascertain what might reasonably be generalized from studies of middle-aged adults. Both the types of evidence and any relevant assumptions are clearly highlighted for each section. The limitations of current data and future research needs and recommendations are summarized for each indication for nutrition support. INDICATIONS FOR THE USE OF NUTRITION SUPPORT GASTROINTESTINAL DISEASES Short-Bowel Syndrome Extensive resection of the small intestine can result in inadequate intestinal length and/or function to maintain normal fluid, electrolyte, and nutritional homeostasis. Short-bowel syndrome is characterized by severe malabsorption and resulting dehydration, electrolyte losses, metabolic abnormalities, and undernutrition (Purdum and Kirby, 1991). Since clinical experience has demonstrated the clear efficacy of nutrition support in this setting, prospective randomized trials that include nonintervention arms have not been and are unlikely to be conducted. No studies have focused specifically on older persons with short-bowel syndrome,
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population but many of the patients who have benefited from nutrition support intervention for this condition are Medicare eligible. Indeed 21 percent of all registrants in the North American Home Parenteral and Enteral Nutrition Patient Registry with a diagnosis of motility disorder were Medicare beneficiaries (Howard and Malone, 1997). Patients with substantial intestinal resection will often require TPN temporarily until adequate adaptation of the remaining intestine occurs to facilitate transition to enteral feedings by tube or mouth. The use of TPN in these patients hastens rehabilitation and transition to the home care setting. Some patients with profound malabsorption require indefinite parenteral support for survival. The degree of impairment of nutrient assimilation is determined by the remaining bowel anatomy and function. The least favorable anatomical alteration is to have combined resections of both the small and the large intestines and resulting decreased function (Gouttebel et al., 1986; Nightingale et al., 1990). Nonetheless, even in the setting of long-term TPN dependence, it is sometimes possible with aggressive enteral nutritional supplementation and rehydration therapies, in combination with pharmacologic interventions, to modulate gut secretions and transit in order to obviate the need for parenteral support (Cosnes et al., 1985; Lennard-Jones, 1990). The applications of specific hormonal and nutrient growth factors to increase intestinal mass and absorptive function are being tested in active research and may offer important therapeutic opportunities (Byrne et al., 1995). Enterocutaneous Fistulas Case series demonstrate a high prevalence of undernutrition among fistula patients and suggest that the most undernourished patients have the worst clinical outcomes (Chapman et al., 1964; Dudrick et al., 1999; Rose et al., 1986; Soeters et al., 1979). Prior to the use of nutrition support, many of these patients suffered severe dehydration, electrolyte derangements, and undernutrition. The role of nutrition intervention is primarily supportive care to prevent further deterioration. Retrospective analysis of clinical experience with patients having small-bowel fistulas found that those patients who received nutrition support had lower mortality rates, higher rates of spontaneous fistula closure, and superior surgical closure outcomes (Himal et al., 1974). Prospective randomized trials have not been conducted that rigorously evaluate the role of nutrition support in the treatment of enterocutaneous fistulas, and older patients have not been specifically investigated. Such studies are unlikely to be undertaken because it appears likely that medical therapy that includes TPN in conjunction with bowel rest and pharmaco-
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population logic intervention (i.e., octreotide and histamine receptor antagonists) favors spontaneous fistula closure and improved clinical outcomes (di Costanzo et al., 1987; Dudrick et al., 1999; Meguid and Campos, 1996). Spontaneous closure will occur within 5 weeks in 40 to 60 percent of patients treated with this approach, and if surgical intervention to close the fistula proves necessary then nutritional status will be maintained. Although elemental diets have been successfully used for enteral feeding in patients with fistulas, there are no randomized prospective studies that contrast this approach with TPN (Dudrick et al., 1999; Meguid and Campos, 1996). Inflammatory Bowel Disease Protein–energy undernutrition and specific nutrient deficiencies are common among patients with inflammatory bowel disease. Even patients with long-standing Crohn’s disease in remission demonstrate a variety of nutritional deficiencies (Geerling et al., 1998). Sequelae of inflammatory bowel disease and related treatment interventions can result in decreased nutrient intake, malabsorption, enteropathy, and drug–nutrient interactions. Although nutrition therapy is often part of the overall management plan, its role in primary therapy remains controversial. However, in those patients who suffer inadequate intestinal length or function as a result of surgery or complications associated with inflammatory bowel disease (short-bowel syndrome or enterocutaneous fistula), nutrition support clearly will be efficacious. A number of randomized prospective trials have examined the roles of bowel rest and TPN in inducing remission in patients with active Crohn’s disease (Greenberg et al., 1988; Lochs et al., 1984; Wright and Adler, 1990). None of these studies focused specifically on older persons. Bowel rest alone, independent of nutritional support, did not appear necessary to achieve clinical remission, and long-term outcome was not affected. There was also no apparent role for TPN as primary therapy in the specific treatment of Crohn’s disease or ulcerative colitis (Dickinson et al., 1980; McIntyre et al., 1986). Patients randomized to bowel rest and TPN had no better outcomes than those assigned to enteral feedings (González-Huix et al., 1993). Enteral diets using elemental formula1 have been suggested to be as effective as glucocorticoid therapy in inducing remission of Crohn’s disease, but the majority of randomized prospective trials suffer from small size, heterogeneous participants, variable diet composition and intake, 1 A liquid formula designed for easy digestion and absorption and leaves minimal residue in the bowel.
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population and disproportionate withdrawals among the enteral treatment arm (Bernstein and Shanahan, 1996). Again no studies focus specifically on older persons. Meta-analysis of prospective randomized trials suggests that enteral nutrition may not be as effective as corticosteroids (Fernández-Bañares et al., 1995; Griffiths et al., 1995; Trallori et al., 1996). Since there are no studies that randomize to enteral feedings versus placebo, it is not possible to discern the therapeutic benefit of enteral feeding alone. Pancreatitis No studies of nutrition support in pancreatitis have focused specifically on older persons. The potential benefits of nutrition support for patients with acute pancreatitis may be best determined by the severity of the disease. The majority of patients with acute pancreatitis have mild or moderate disease. Prospective randomized trials indicate that the provision of enteral or parenteral nutrition does not alter the natural history of pancreatitis in this setting (Sax et al., 1987). Indeed, the administration of TPN to patients with pancreatitis resulted in greater insulin requirements and higher prevalence of catheter-related sepsis than that observed in a control group who received only intravenous fluids (Sax et al., 1987). McClave and coworkers (1997) found that enteral feedings were well tolerated in such patients and that clinical outcomes were comparable to TPN. Beneficial effects of aggressive nutrition support on morbidity or mortality have not been realized and hospital costs are elevated in those who receive TPN. Although most patients with mild or moderate pancreatitis require only routine supportive measures, it is not clear how long such patients will tolerate semistarvation. If the course is protracted, severe, or complicated, nutrition support may be indicated (Baron and Morgan, 1999; Wyncoll, 1999). Recent prospective trials have randomized patients with severe pancreatitis to enteral feeding versus TPN (Kalfarentzos et al., 1997; Windsor et al., 1998). The enteral feedings were well tolerated and had no adverse clinical effects. There were fewer total and infectious complications, and the acute-phase response and disease severity scores were favorably attenuated with enteral nutrition. Liver Disease Although many patients with chronic liver disease suffer protein– energy undernutrition (Lautz et al., 1992; Mendenhall et al., 1984), the efficacy of nutrition support for these patients is not yet established. Older persons with liver disease have not been specifically evaluated in this
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population regard. Whereas some laboratory measures of liver function appear to be improved with the provision of enteral or parenteral nutrition to patients with chronic alcoholic liver diseases, other outcomes are less clear (Mizock, 1999). Some prospective randomized trials have observed improved survival among patients with chronic alcoholic liver diseases who receive enteral or parenteral nutrition (Cerra et al., 1985), while others have not (Nasrallah and Galambos, 1980; Naveau et al., 1986; Naylor et al., 1989). Meta-analysis of prospective randomized trials that evaluated TPN formulations enriched with branched-chain amino acids suggests that recovery from acute hepatic encephalopathy may be hastened (Naylor et al., 1989). The follow-up for these studies was, however, of short duration, and many of the control subjects received TPN that contained no amino acids. In a prospective randomized trial that included control patients who received TPN with a standard amino acid formulation, a beneficial effect of branched-chain amino acids was not observed (Michel et al., 1985). Enteral nutrition is well-tolerated by many patients with liver diseases (Cabré et al., 1990; Hirsch et al., 1993; Kearns et al., 1992) and clinical trials suggest that simple casein-based enteral feeding may be efficacious in promoting recovery from acute hepatic encephalopathy (Christie et al., 1985; Horst et al., 1984; Kearns et al., 1992). Gastrointestinal Disease Summary Short-Bowel Syndrome. Provision of enteral and parenteral nutrition support has established efficacy in the prevention of life-threatening undernutrition for patients with inadequate intestinal length and/or function. Enterocutaneous Fistulas. Parenteral nutrition in combination with bowel rest and pharmacologic intervention to diminish gastrointestinal secretions appears likely to improve the opportunity for spontaneous fistula closure and more favorable clinical outcomes. Studies are insufficient to address the role of enteral nutrition in fistula management. Inflammatory Bowel Disease. Enteral and parenteral nutrition support is likely to be indicated for inflammatory bowel disease patients who suffer undernutrition related to compromised intestinal length and/or function. Although enteral nutrition may have a therapeutic role in the treatment of Crohn’s disease, it appears that corticosteroids are more effective. In addition, the use of TPN is not supported as primary therapy.
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Pancreatitis. The routine use of enteral and parenteral nutrition is not indicated in patients with mild or moderate pancreatitis. If the course is protracted or severe, nutrition support may be considered. Studies are inadequate to clarify the optimal timing, feeding route, or formulation for this indication. Enteral feedings may be well tolerated in selected patients. Liver Disease. Enteral and parenteral nutrition may improve some laboratory measures of liver function in patients with chronic alcoholic liver diseases. Studies are conflicting with regard to whether there are associated improvements in survival. It is also unclear whether branchedchain amino acid-enriched formulations offer advantage in accelerated recovery from acute hepatic encephalopathy. Gastrointestinal Disease Recommendations There is a need for well-designed clinical trials of nutrition support interventions for gastrointestinal disease. Studies should include older persons. Indications for nutrition support require further clarification for inflammatory bowel disease, pancreatitis, and liver diseases. The use of specific nutrients, growth factors, and modified nutrient formulations warrants further investigation. The use of enteral and parenteral nutrition is recommended as life-sustaining and supportive therapy for patients with short-bowel syndrome and enterocutaneous fistula. HUMAN IMMUNODEFICIENCY VIRUS AND ACQUIRED IMMUNE DEFICIENCY SYNDROME Even though the incidence of acquired immune deficiency syndrome (AIDS) is higher among younger age groups, persons aged 50 years or older accounted for 11 percent of all AIDS cases in the United States in 1996 (CDC, 1998). The Centers for Disease Control and Prevention (CDC) estimated that newly reported AIDS cases among persons ages 50 years and older increased by 12.6 percent (from 55,819 to 62,874) from mid-1996 to mid-1997 (CDC, 1997). This increase is alarming since the number of new AIDS cases reported annually is declining among younger persons. Because many older persons do not perceive themselves to be at risk for human immunodeficiency virus (HIV)/AIDS, they may delay testing and be diagnosed at a later stage of disease, placing them at increased risk of malnutrition associated with AIDS. AIDS-related malnutrition is associated with loss of lean body mass, which in turn can lead to reduced functional capacity and diminished quality of life (Grinspoon et al., 1999;
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Wilson and Cleary, 1997). In two studies (Turner et al., 1994; Wilson and Cleary, 1997), loss of lean body mass, resulting in fatigue and weakness, was closely associated with functional status, an important aspect of quality of life. Although wasting is less common, significant loss of lean body mass occurs even in patients who are receiving highly active antiretroviral therapy (Grinspoon et al., 1997). Moreover, highly active antiretroviral therapy may contribute to deleterious fat redistribution, as well as the premature development of cardiovascular disease and diabetes mellitus in some patients (Carr et al., 1998; Dubé et al., 1997; Henry et al., 1998). Other studies have documented a correlation between weight loss and more rapid disease progression, increased risk for hospitalization and opportunistic infections, and reduced tolerance of and response to treatments (Rivera et al., 1998; Wheeler et al., 1998; Wilson and Cleary, 1997). A growing body of evidence suggests that nutrition counseling and/ or nutrition support may improve nutritional status in persons with HIV/ AIDS. In a 6-week randomized, controlled trial, Rabeneck and colleagues (1998) found that nutrition counseling, with or without oral supplementation, achieved a substantial increase in energy intake in nearly half of their malnourished HIV-infected patients. Compared to the counseling-only group, the supplement group had greater increases in fat-free mass and grip strength. A study by Stack and colleagues (1996) found that HIV-infected patients without secondary infections were able to maintain or gain weight with a high-energy, high-protein supplement used in conjunction with nutrition counseling. Studies of omega-3 fatty acid supplementation have shown that fish oil may be efficacious in lowering hypertriglyceridemia and increasing lean body mass (Bell et al., 1996; Hellerstein et al., 1996). Studies of oral and enteral supplements designed especially for HIV/AIDS indicate that these products are associated with greater weight gain when compared to standard supplements (Pichard et al., 1998; Süttmann et al., 1996). The majority of weight gain in these studies was fat, however, as opposed to lean body mass. In a randomized study comparing total parenteral nutrition to dietary counseling in severely malnourished men (loss of more than 10 percent usual body weight and concomitant diarrhea), weight increased by a mean of 8 kg in the parenteral nutrition group and decreased by a mean of 3 kg in the dietary counseling group (Melchior et al., 1996). The administration of TPN increased body cell mass in men with AIDS wasting and malabsorption and gastrointestinal disease, but those with secondary infections continued to lose body cell mass despite TPN administration. A recent study by Kotler et al. (1998) compared TPN to a semielemental diet given to AIDS patients with malabsorption syndrome. Patients receiving TPN consumed more calories and gained more weight than patients receiving the oral formula; however, weight gain was a function of total calorie intake. As in other
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population studies, the composition of weight gained was predominantly fat. In this study, the semielemental diet was less costly than TPN and associated with improvement in quality of life, specifically functional status. In summary, there are limited but consistent data that nutrition counseling and support in HIV/AIDS are associated with greater calorie intake and weight gain. Because the weight gain was due to fat deposition as opposed to lean body mass accrual in some of the studies, exercise and pharmacologic agents may be indicated as adjuncts to nutrition interventions to produce an increase in lean body mass. Further research is needed to identify optimum combinations of nutrition interventions, pharmacologic approaches, and exercise that will maximize nutritional status and clinical outcomes in HIV/AIDS in a cost-effective manner, particularly in persons aged 50 years and older. Methodological problems of the studies discussed in this section include the short-term nature of the nutrition interventions, the lack of inclusion of clinical outcome measures (e.g., functional status, quality of life) that may respond to nutrition therapy, and the homogeneity of the study populations which consist of mostly younger, homosexual white males. HIV/AIDS Summary Weight loss in patients with AIDS is correlated with more rapid disease progression, increased risk of hospitalization and opportunistic infections, and reduced tolerance of and response to treatments. Loss of lean body mass is correlated with diminished functional status, a component of quality of life. There are limited, but consistent, data that nutrition counseling and oral, enteral, and parenteral nutrition promote calorie intake and weight gain in AIDS patients who have experienced significant weight loss or have malabsorption, but who do not have secondary infections. There are limited data which indicate that total parenteral nutrition may be more costly and associated with lower quality of life than either oral or enteral nutrition. HIV/AIDS Recommendations Nutrition therapy to improve caloric intake and weight gain in persons with AIDS is recommended using a multidisciplinary team of nutrition support professionals. Parenteral nutrition is costly and may therefore be indicated only in select cases. Further research should focus on the development of the most effective combinations of nutrition and adjunctive (e.g., exercise) therapies which increase lean body mass, especially in persons with AIDS who are aged 50 years and older.
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population CANCER AND BONE MARROW TRANSPLANTATION Chemotherapy and Radiation Therapy The CDC (1999) estimated that there were 1,374,000 cancer-related hospital discharges in 1996, with an average length of stay of 7 days. More than two-thirds of cancer patients lose weight during their disease course (Rowan Chlebowski, Harbor-UCLA Medical Center, personal communication, 1999). Since 60 percent of all cancers occur in older adults who may already have preexisting special nutritional needs, this is a significant problem. Studies of nutrition support during cancer chemotherapy, radiation therapy, and bone marrow transplantation report mixed results. Three meta-analyses that examined the use of TPN in cancer patients undergoing chemotherapy or radiation therapy reported no benefit of TPN in terms of tumor response, treatment tolerance, or survival. Moreover, TPN administration in these patient populations was associated with higher rates of pneumonia and sepsis (ACP, 1989; Klein et al., 1986; McGeer et al., 1990). Systematic reviews have also indicated that enteral and parenteral nutrition may not be efficacious for cancer patients undergoing these particular treatments (Klein and Koretz, 1994; Klein et al., 1997). However, the reviews point out that serious shortcomings in study design and methods make it difficult to draw definitive conclusions from the data. Since these reviews (Klein and Koretz, 1994; Klein et al., 1997), a few studies have evaluated the use of nutrition support in cancer patients treated with chemotherapy. In one clinical trial, malnourished gastrointestinal cancer patients who received both parenteral nutrition and chemotherapy preoperatively had fewer complications and more tumor sensitivity to chemotherapy than patients without nutrition support (Jin et al., 1999). In another trial involving metastatic cancer patients treated with high doses of interleukin-2, a brief course of TPN during treatment corrected calorie and protein undernutrition, improved control of serum electrolytes, and was well tolerated (Samlowski et al., 1998). A prospective study of nutrition support in patients receiving antineoplastic therapy indicated that parenteral nutrition successfully maintained the body weight of patients who were unable to receive enteral nutrition (Lees, 1997). A retrospective study of chemotherapy and TPN for advanced ovarian cancer patients with bowel obstruction found that median survival was 17 days longer (p < 0.05) for patients who received chemotherapy with TPN than for patients who received chemotherapy alone (Abu-Rustum et al., 1997). In a retrospective study of nutrition support during chemoradiation therapy in esophageal cancer, parenteral nutrition facili-
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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Medicare reimbursement to hospitals for nutrition support-related activities should be continued and periodically re-evaluated for adequacy. REFERENCES Abel RM, Beck CH Jr, Abbott WM, Ryan JA Jr, Barnett GO, Fischer JE. 1973. Improved survival from acute renal failure after treatment with intravenous essential L-amino acids and glucose. Results of a prospective, double-blind study. N Engl J Med 288:695–699. Abu-Rustum NR, Barakat RR, Venkatraman E, Spriggs D. 1997. Chemotherapy and total parenteral nutrition for advanced ovarian cancer with bowel obstruction. Gynecol Oncol 64:493–495. ACP (American College of Physicians). 1989. Parenteral nutrition in patients receiving cancer chemotherapy. Ann Intern Med 110:734–736. Aker SN, Cheney CL, Sanders JE, Lenssen PL, Hickman RO, Thomas ED. 1982. Nutritional support in marrow graft recipients with single versus double lumen right atrial catheters. Exp Hematol 10:732–737. Alexander JW, MacMillan BG, Stinnett JD, Ogle C, Bozian RC, Fischer JE, Oakes JB, Morris MJ. 1980. Beneficial effects of aggressive protein feeding in severely burned children. Ann Surg 192:505–517. ASPEN (American Society for Parenteral and Enteral Nutrition). 1993. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. J Parenter Enteral Nutr 17:1SA–52SA. Atkinson S, Sieffert E, Bihari D. 1998. A prospective, randomized, double-blind, controlled clinical trial of enteral immunonutrition in the critically ill. Crit Care Med 26:1164–1172. Baron TH, Morgan DE. 1999. Acute necrotizing pancreatitis. N Engl J Med 340:1412–1417. Bastow MD, Rawlings J, Allison SP. 1983. Benefits of supplementary tube feeding after fractured neck of femur: A randomised controlled trial. Br Med J 287:1589–1592. Beier-Holgersen R, Boesby S. 1996. Influence of postoperative enteral nutrition on postsurgical infections. Gut 39:833–835. Bell SJ, Chavali S, Bistrian BR, Connolly CA, Utsunomiya T, Forse RA. 1996. Dietary fish oil and cytokine and eicosanoid production during human immunodeficiency virus infection. J Parenter Enteral Nutr 20:43–49. Bernstein CN, Shanahan F. 1996. Critical appraisal of enteral nutrition as primary therapy in adults with Crohn’s disease. Am J Gastroenterol 91:2075–2079. Borzotta AP, Pennings J, Papasadero B, Paxton J, Mardesic S, Borzotta R, Parrott A, Bledsoe F. 1994. Enteral versus parenteral nutrition after severe closed head injury. J Trauma 37:459–468. Bower RH, Cerra FB, Bershadsky B, Licari JJ, Hoyt DB, Jensen GL, Van Buren CT, Rothkopf MM, Daly JM, Adelsberg BR. 1995. Early enteral administration of a formula (Impact®) supplemented with arginine, nucleotides, and fish oil in intensive care unit patients: Results of a multicenter, prospective, randomized, clinical trial. Crit Care Med 23:436–449. Braga M, Gianotti L, Vignali A, Cestari A, Bisagni P, Di Carlo V. 1998. Artificial nutrition after major abdominal surgery: Impact of route of administration and composition of the diet. Crit Care Med 26:24–30. Braunschweig CL, Raizman DJ, Kovacevich DS, Kerestes-Smith JK. 1988. Impact of the clinical nutritionist on tube feeding administration. J Am Diet Assoc 88:684–686.
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