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Objective(s) We modified the resident selection strategy in an attempt to reduce resident attrition (RA). Summary background data Despite implementation of the Accreditation Council for Graduate Medical Education work rules, lifestyle and generational priorities have fostered a persistent and relatively high attrition rate for surgical trainees. Methods An independent external review of residents who left the training program and a detailed analysis of the resident selection strategy were performed by an organizational management expert. Modifications implemented in 2005 (the intervention) included standardization of the screening and interview format. Applicants were required to submit a 500 words essay related to stress management, organizational skills, future aspirations, and prioritization abilities. Their responses formed the basis of an extended, personalized, and structured interview script. Candidate characteristics and RA were compared for the 5 years before and after the intervention, using Fisher exact test or chi2. Results Age, sex, birthplace, medical school ranking, step 1 score, and American Board of Surgey In-Training Examination performance were not significantly different between the selection strategy groups. Risk factors for RA included ABSITE performance and gender. Resident performance and subsequent RA were significantly affected by the resident selection strategy. Conclusions RA was dramatically reduced following the intervention. A custom designed process to identify candidates most likely to succeed substantially improved resident retention in a demanding academic training program.

Background Much has been written about the influences of Accreditation Council for Graduate Medical Education (ACGME) work restrictions, the litigious climate in American medicine, and the proliferation of subspecialty fellowships on general surgery training. Few previous studies have addressed general surgical residents' perceptions of surgical training on a national level. Methods A 38-question Institutional Review Board-approved survey was sent via e-mail to the program directors at all ACGME-approved general surgical training programs for distribution to categorical general surgery residents. Voluntary responses to statements focusing on job satisfaction, quality of life, and the influences of operative experience, work hours, fellows, physician extenders, as well as faculty and administration on resident training were solicited. Results Overall, 997 responses were received from residents of all clinical levels from 40 states. Most respondents were from university-based programs (79%) with a broad representation of program sizes (mean of 6 graduates per year; range 2 to 11). Residents believe that they will be prepared to enter clinical practice at the conclusion of their training (86%), that the duration of surgical training is adequate (85%), and that they are exposed to sufficient case volume and complexity (85% and 84%, respectively). Only 360 respondents (36%) believe that they are financially compensated appropriately. Although most respondents support the ACGME work-hour restrictions (70%), far fewer feel that they improve their training or patient care (46.6% and 46.8%, respectively). Most respondents are proud to be surgical residents (88%), view surgery as a rewarding profession (87%), and would choose surgery as a profession again (77%). Conclusions Surgical residents are positive regarding the quality of their training and life, although they feel poorly compensated for their work. Most residents intend to pursue fellowship training. Survey responses were consistent irrespective of gender, ethnicity, and program type.

Little is known about the relationship between resident performance and patient satisfaction. To this end, our institution added housestaff-specific questions to Press-Ganey surveys (Press-Ganey, South Bend, Indiana) administered to patients. This study sought to investigate the impact residents have on patients' overall rating of care compared with faculty and nursing staff. Our hypothesis was that residents play an important but historically underappreciated role in patient satisfaction.Between April 2005 and June 2006, half of all discharged patients randomly received Press-Ganey surveys, including questions on the following categories: admissions, patient room, food, diagnostic testing, guest services, faculty/attending physician, discharge, emotional needs, housestaff, nurse practitioners, and primary nurse. responses were grouped into overall category scores and used as predictor variables for regression analysis. a separate question asked patients to rate overall care provided. Chief resident schedules and evaluation scores by faculty were provided by the Division of Surgery Education. Regression, and ANOVA models were run using JMP 6 software (JMP 6, SAS Institute, Cary, North Carolina).During this period, 49,081 patients were discharged, 24,540 surveys were mailed, and 5828 surveys were returned (24% response rate). In a simple regression analysis, the predictor variables for nursing, housestaff, and faculty accounted for 57%, 33%, and 28%, respectively, of the variation of overall rating of care delivered (p0.005). The actual overall score for each group varied slightly: faculty (89.8), nursing (86.6), and housestaff (84.2) (p0.005). In a multiple regression analysis, all predictors above were significant (p0.05). A small difference in scores existed between surgical (83.9) and nonsurgical (85.0) housestaff (p0.05). When data were sorted by surgical services, ratings of surgical housestaff ranged from a high of 86.8 (thoracic) to a low of 79.0 (orthopedics) (p0.05). Admission month had no significant effect on overall rating of care (range, 85-90), although comparing the means of resident scores by month (range, 81-86) showed that at the end (May-June) and at the beginning (July-Aug) of an academic year, a significant reduction in resident scores occurred (p0.05). The lowest score of the year (82.4) occurred in June, whereas the highest scores occurred in January-April (85-86). Resident evaluation scores by faculty and ratings of housestaff by patients were completely uncorrelated, although certain housestaff achieved significantly higher ratings by patients than others.Compared with faculty and residents, nurses have a greater impact on the variation of patient satisfaction. However, the actual scores given to residents, faculty, and nurses are all high. A slight difference exists in scores of surgical and nonsurgical residents. For all residents, the time of the academic year impacts resident scores positively in the middle and negatively in the beginning and end. For surgical residents clear differences exist between specialty services, but it is not apparent whether these differences are caused by individual residents or by the clinical service milieu. Residents contribute significantly to overall satisfaction, and additional investigation of the variation in resident scores is needed.

This paper traces the 29-year survival of Robert Thomas, who received home parenteral nutrition (PN), and contrasts his oral narrative with the clinical history of PN.Interviews, chart review, review of the literature, and historical analysis.Bobby Thomas was part of an early group of patients scattered throughout the country who, with their medical team, provided the foundation for more successful survival with home PN. They learned together and taught numerous nutrition support clinicians the intricacies of patient management. The importance of the patient to the teaching function of new and experienced practitioners is highly critical. Patients like Robert Thomas gave practitioners firsthand evidence of both the tenacity of the human spirit and the complexity and difficulties of chronic illness and its treatments.While Bobby struggled with the complications and difficulties that came with the disease and the treatment keeping him alive, his own experiences over 29 years, as told to his medical team during his treatment and to informed interviewers before he died, tell a story that is both intersecting and parallel to the medical history. Pioneering patients like Bobby Thomas confirm the possibility of survival. They also, through their own negotiations to maintain a sense of control, can live lives they themselves help define.

Background Surgical educators are charged with ensuring that their trainees conduct themselves in a professional manner. The authors retrospectively reviewed a 10-year experience of incident reports on surgical housestaff to determine patterns and predictors of behavior. Methods A retrospective review of all letters, e-mails, and incident reports was conducted for general surgery residents from 1995 to 2005. Descriptive variables were selected for binary categorization (not mutually exclusive): poor professional conduct, protocol violation, administrative deficiency, verbal mistreatment, physical boundary issues, mistreatment of superiors, and deficient medical student interaction. Resident status was defined as current, graduate, and attrition. Results Of 110 residents {90 [82%] categorical, 23 [21%] undesignated preliminary (3 overlapped both groups); 87 [79%] male, 23 [21%] female} who trained at the University of Pennsylvania during this period, 66 complaints were generated about 29 individuals. Overall, 50 of the 66 complaints (76%) were directed toward men and the remaining 16 (24%) toward women; 24% of all men and 35% of all women received 1 or more complaints. A total of 76% of complaints concerned categorical residents and 24% undesignated preliminary residents. And 26% of all categorical residents and 26% of all preliminary residents received at least 1 complaint. The most common complaints concerned professional conduct (83%), protocol violation (33%), verbal mistreatment (23%), deficiencies of administrative duties (8%), violations of physical boundaries (5%), deficient medical student interaction (5%), and mistreatment of attendings by residents (3%). Recipients of verbal mistreatment included staff nurses (27%), radiology technicians (13%), medical students (13%), environmental services employees (7%), security guards (7%), patients (7%), surgery attendings (7%), anesthesia attendings (7%), internal medicine chief residents (7%), and pharmacists (7%). A total of 31% of the complaints were regarding residents who involuntarily departed and 7% regarding residents who left voluntarily before completion. The mean PGY level at first complaint was 2.2 years. Of the 29 residents receiving complaints, 16 had recurrent offenses (range 2 to 7 total complaints, positive predictive value [PPV] 53%). Conclusion Resident misbehavior manifests early and recurs often. Furthermore, it is frequently directed toward perceived subordinates. Nondesignated preliminary status, premature departure from the program, and the eventual selection of specific subspecialty fellowships seems to increase the risk for resident misbehavior. Identified residents require close surveillance and remediation.

The traditional mission of an academic medical center is a 3-tiered goal to engage in tertiary clinical care, education, and research. However, the decline of the fee-for-service reimbursement system, the encroachment of managed care, the cost-containment strategies of payers, and the malpractice crisis have all contributed to the increasing difficulty of sustaining and fulfilling this mission. In addition, in the past 2 years, both academic medical centers and physician practices have had to cope with the imposition of resident work hour limitations, forcing many hospitals and practices to hire costly nurse practitioners and physician assistants to perform the work lost because of the duty hour restrictions.1 The cost to employ these healthcare providers is significantly greater than that expended for a resident, and it effectively takes 4 of these individuals to compensate for the loss of a single resident from a clinical service, often mandated by the shifts required in resident allocation to compensate for the lost work hours. These nonphysician providers work only one-half the number of hours as a resident and usually see only one-half as many patients. Both hospitals and physician practices are suffering as reimbursement continues to fall, costs continue to climb, and the malpractice crisis looms large. Many academic medical centers are struggling financially as a result of the current environment, and if financial conditions do not improve, the traditional academic mission may be forced to change.2 From a financial standpoint, options include further reductions in costs or even elimination of certain service lines found to be unprofitable. Although possible on a small scale, widespread adoption of this kind of policy would truly jeopardize the mission of academic medical centers across the country. The resource-based relative value system (RBRVS) was instituted in the late 1980s as Medicare set out to contain increasing costs in the healthcare system. However, several academic institutions have demonstrated that the system reimburses too little such that hospitals and practices may be losing money by performing certain types of procedures. The RBRVS system was instituted with the goal of containing costs, but the calibration was not intended to reimburse below costs. One obvious explanation for this discrepancy is that physician effort has been underestimated and thus underpaid. In addition, because academic medical centers usually are in the position that they accept all patients as part of their mission and thus tend to have more complex, more highly variable, and more costly cases than community hospitals, they have higher financial risk that is inadequately compensated by the RBRVS.3 Costs continue to increase and reimbursement remains inadequate. Although many academic medical centers continue to focus on cost containment at a macro level, there has been inadequate investigation into the relationship between hospital margin and the clinical practices. An unfortunate explanation for this is that most hospitals do not have adequate cost-accounting systems, and the information that is shared between medical centers and clinical practices is insufficient. Taheri and colleagues rigorously examined a trauma service line margin, finding that although losses were rare on fee-for-service patients, they were common on fixed-fee patients.4 This group proposed that payers potentially could game the system by moving patients to hospitals in which they had more favorable contracts, using as an example their own medical center where a fixed-fee trauma patient, on average, would result in a $500 loss for the hospital and trauma service. Academic medical centers are vulnerable to this kind of strategy by payers because of their obligation to accept all patients. Medical centers and practices across the country are putting considerable effort into cost containment, but as a result of the complexity of clinical care and the separation of hospital and practice operational data, little is known about what case mixes are profitable for practices, medical centers, or both. Because most hospitals and surgical services have only crude cost-accounting systems, neither hospitals nor practices have enough information to make appropriate and advantageous strategic decisions, giving payers a clear information advantage. As the financial situation becomes more precarious for both practices and medical centers, this information becomes increasingly important. Standard operational management from other industries demonstrates that optimizing a value chain in its entirety is always the best financial strategy for a whole system. Increasing the transparency and accuracy of the cost-accounting systems for both practices and hospitals, in addition to sharing more information, should lead us closer to this goal. The question remains which specialties produce high margins on the professional fee side and which produce high margins on the hospital side. Although few academic medical centers likely would consider managing risk by dropping entire surgical service lines, this information would allow hospitals and practices to see where better-negotiated reimbursement contracts need to be created, where further cost cutting might be most helpful, and where resources should be allocated. At a minimum, those service lines with high margins for both the hospital and the practice should be strongly supported, whereas those with negative margins for both should be more closely monitored. In certain situations, depending on the employment model, this creates a need for transfer of dollars between the institution and individual practices. This becomes particularly important for those services providing a high margin to the hospital where the professional fees generated do not adequately support the individual practitioners. Unfortunately, this situation is becoming all too common among surgical specialties where hospital reimbursement has remained strong and the Medicare payment to the practitioner has continued to be cut on a yearly basis. It is well known that other third party payers tend to follow Medicare's lead when it comes to physician reimbursement, thus creating the crunch on the professional fee side that the majority of surgeons now face. It is a sad commentary when the costs to a cardiac surgical practice exceed the payment received for performing a coronary artery bypass, a situation that currently exists in a number of regions in this country. Cardiac surgery, as well as a number of other surgical specialties, has provided a particularly vulnerable target to professional fee reductions despite the best efforts of the specialty societies to resist these changes. The dichotomy that exists between hospital reimbursement and professional fees has to be addressed, in many situations, by a funds flow model, and surgeons should be aware of their leverage when entering into negotiations regarding these types of models.

Decreasing reimbursement, an ongoing malpractice crisis, workrule limits for surgical residents, and an increased focus on patient safety at a national level have created new obstacles to the traditional surgical residency education program. Historically, surgical education involved a huge commitment on the part of residents: commitment of time, of effort, and of financial opportunity costs. The response to all of these problems at many institutions was to hire nurse practitioners, physician assistants, and other healthcare providers. As this process evolves, it is important to determine how these additions to the surgical teams have changed resident education, patient outcomes, and patient and staff satisfaction. There is growing evidence that nurse practitioners and physician assistants can work collectively with physicians in collaborative practice models to optimize surgical outcomes. Collaboration is the art of working together to achieve a common goal. The goal of nurse practitioners, physician assistants, and physicians is to combine the knowledge and skills of all health care specialists to enhance patient care. However, as dozens of new nurse practitioners and physician assistants begin to take over many of the tasks historically reserved for surgical residents, it is important to ensure that roles are well-defined, lines of communication are clear, and the chain of command does not become confusing to those on the surgical teams. In the national

To evaluate resting energy expenditure compared to predicted energy expenditure in patients with cervical or ovarian carcinoma who require specialized nutritional support.Women with biopsy-proven cervical or ovarian carcinoma referred to the Nutrition Support Service were studied. Resting energy expenditure was measured by indirect calorimetry and compared to predicted energy expenditure (PEE) as determined by the Harris-Benedict equation for females.Sixty one patients were studied. Patients with ovarian cancer (n = 31) had a significantly higher measured resting energy expenditure (% PEE) than patients with cervical cancer (109 +/- 18% vs. 98 +/- 16%, p0.02, respectively). This difference in measured resting energy expenditure between groups could not be explained by differences in the extent of disease, nutritional status, body temperature, or nutrient intake between groups. A greater proportion of patients with ovarian cancer were hypermetabolic (110% of predicted) in comparison to patients with cervical cancer (55% vs. 13%, p0.01, respectively). Measured resting energy expenditure varied between 53% and 157% of predicted for the entire population.Ovarian cancer patients are more hypermetabolic than cervical cancer patients. The Harris-Benedict equation for females is a unreliable estimate of caloric expenditure in patients with cervical or ovarian cancer receiving specialized nutritional support.

Aspiration pneumonia is a serious complication of enteral feeding. Many critically ill patients are particularly at risk for aspiration. Few studies have rigorously compared various access devices. Risk factors for aspiration and studies examining aspiration associated with enteral feeding devices are reviewed. We recommend a surgical jejunostomy for all patients at high risk for aspiration who require more than 3 weeks of enteral nutrition support.

Low profile, self-retaining feeding conduits ("buttons") inserted percutaneously through a mature gastrostomy stoma are ideal for prepyloric feeding. We tested the efficacy of a surgically inserted button (Button, C.R. Bard, Inc) in the jejunum for long-term postpyloric feeding. Forty-two aspiration risk patients were prospectively randomized to receive a standard No. 14 French red rubber catheter (n = 21, mean age 68 +/- 17 years) or the button (n = 21, mean age 68 +/- 18 years). Common indications for jejunal feeding were aphagia due to obtundation (41%) and esophageal dysmotility (41%). All feeding devices were inserted 20 cm distal to the ligament of Treitz via a serosal tunnel (catheter) or double pursestring (button) technique. No patient required reoperation, and cardiopulmonary failure was the most frequent cause of death, occurring in 11 patients (26%). Goal feedings were obtained in 91% of the catheter patients and 100% of the button patients by postoperative day 4.7 +/- 1.9 and 4.2 +/- 2.2, respectively. At a follow-up of 43 +/- 13 days, 12 (92.3%) of 13 catheter patients and 9 (81.8%) of 11 button patients were receiving goal feedings. Three patients in the catheter group and four patients in the button group had resumed an oral diet. Device-related complications (dislodgment, occlusion, peritubular leak, or bowel obstruction) and total number of patients with complications were significantly lower in the button group (one [5%] vs eight [38%] for device-related complications and one [5%] vs six [29%] for incidence of complications for the button and catheter groups, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

The goal of nutritional assessment is to identify prospectively all those patients who would develop a nutrition-related complication. In practical terms, there is no single test capable of achieving this goal. At present, the best method of nutritional assessment is an organized step-by-step multifactorial approach. This involves assessment of the primary illness, the patient history, and the prognosis. A nutritional status examination is done, and the current intake is compared with the nutritional goals. A decision is then made whether to force feed. If forced feeding is initiated, the effectiveness of the therapy must be monitored frequently until the patient recovers and is able to be sustained by volitional oral intake.

Adequate protein intake is necessary in renal failure to reduce morbidity. The desire to avoid dialysis should not be a justification to starve patients, particularly because fed patients have better survival rates in acute renal failure. The treatment techniques for renal failure may be used secondarily as a delivery route for nutrients.

Objective To assess the resting energy expenditure of hospitalized patients with pancreatitis. Design Prospective, case-referent study. Setting Nutrition support service in a university tertiary care hospital. Patients Patients referred to the Nutrition Support Service with the diagnosis of pancreatitis. Excluded from study entry included those with cancer, obesity (greater than 150% ideal body weight), those measured within 3 postoperative days, or patients requiring ventilator support with an FIO2 of greater than 0.5. Forty-eight patients with either acute pancreatitis (n = 13), chronic pancreatitis (n = 24), acute pancreatitis with sepsis (n = 7), or chronic pancreatitis with sepsis (n = 7) were studied. The two septic groups were combined into a single pancreatitis-with-sepsis group, since no significant differences among measured variables were observed between individual septic groups. Interventions None. Measurements and main results Resting energy expenditure was measured by indirect calorimetry and compared with the predicted energy expenditure, as determined by the Harris-Benedict equations. Resting energy expenditure (percent of predicted energy expenditure) was significantly (p less than .02) greater for patients with pancreatitis complicated by sepsis (120 +/- 11%) compared with the nonseptic chronic pancreatitis group (105 +/- 14%). Resting energy expenditure for the nonseptic acute pancreatitis patients (112 +/- 17%) was not significantly different from the other groups. The septic pancreatitis group had the largest percentage (82%) of hypermetabolic (resting energy expenditure greater than 110% of predicted energy expenditure) patients, whereas 61% and 33% of the acute and chronic pancreatitis groups were hypermetabolic, respectively (p less than .02). Conclusions Resting energy expenditure is variable in patients with pancreatitis (77% to 139% of predicted energy expenditure). The Harris-Benedict equations are an unreliable estimate of caloric expenditure. Septic complications are associated with hypermetabolism and may be the most important factor influencing resting energy expenditure in pancreatitis patients.

Background We based the Patient Safety Leadership Academy (PSLA) on the premise that improving management skills could improve patient safety and employee satisfaction. Study design Fellows completed baseline surveys on leadership skills knowledge, patient safety knowledge, and program goals. They completed the same surveys 7 months later at the final PSLA session. The fellows also completed a survey assessing how PSLA improved expertise and comparing PSLA to other patient safety learning opportunities. Matched pairs t tests were used to compare baseline and postprogram results. Results Baseline scores indicated appropriateness of focusing on leadership, with average leadership knowledge (2.48) significantly lower than patient safety knowledge (3.22). For patient safety, postprogram results were significant for 8 of 10 questions. All results were significant for leadership. Fellows also rated skills covered by the curriculum on a scale of 1 to 10. For all areas, the median score for knowledge gained was 7. When compared with other patient safety learning experiences, participants rated PSLA as 4 or 5, where 1 indicated the other experience much more valuable and 5 much more valuable. Conclusions PSLA demonstrates that leadership skills are perceived as important by physicians and managers in surgical areas. This study demonstrated that a leadership skills approach to patient safety training could improve knowledge in specific leadership areas and general patient safety.

Introduction The reduction of resident work hours due to the 80-hour workweek has created pressure on academic health-care systems to find “replacement residents.” At the authors’ institution, a group of nurse practitioners (NPs) and physician assistants (PAs), collectively referred to as non-physician practitioners (NPPs), were hired as these reinforcements, such that the number of NPPs (56) was almost twice the number of clinical categorical surgery residents (37). An experienced leader with national credibility was hired to run the NPP program. On each service, the call system was changed to a night float system, whereby residents were pulled from traditional resident teams to serve as nighttime residents during the week. A total of 1-3 NPPs were hired for each team, but whether NPPs worked for the team as a whole, or were assigned to individual attendings, was left to the discretion of the division chiefs. One year after the start of this program, the authors wanted to study the effects it has had on both surgery resident education and NPP job satisfaction. Methods An electronic, anonymous survey was conducted during a monthly surgery resident meeting, and out of 72 categorical and preliminary surgery residents, 50% submitted answers to 12 questions. A similar electronic survey was administered to all 56 NPPs, with 45% responding. Results Overall, 63% of residents believed that lines of communication between surgery team members were clear, and 58% of residents and 71% of NPPs believed that attendings, residents, and NPPs worked together effectively. A total of 91% of residents believed that the addition of NPPs to the teams was positive overall, and 80% of NPPs were satisfied with their positions. Overall, 60% of residents and 50% of NPPs felt that educational goals were being met. Discussion Implementation of the 80-hour workweek and introduction of NPs and PAs onto the inpatient surgical services has altered resident education at the authors’ institution. Although overall most residents view the addition of NPPs to the clinical services as positive, there are concerns about the program. Although hired to fill the void left by decreasing labor hours of residents, NPPs do not necessarily have the same goals as surgery residents and there is confusion about how NPPs fit into the hierarchy of the traditional surgical team.

Academic departments of surgery educate the future leaders of surgery-the major factor differentiating them from community programs. Academic programs are not necessarily more important, but their mission differs. Not everyone completing surgical education desires to become a leader, but the nature of our specialty makes us all leaders. Surgical practice is collaborative, but there is only one person in charge in the operating room. It is from the academic programs that the intellectual leaders of the next generation must emerge. In times of change it becomes even more important to have leaders who are well prepared to face new challenges. Our job as academic surgeons is to equip these leaders with the tools necessary to be successful.

Six patients with acute head injury (initial GCS 4.8 +/- 1.7) were studied to determine the contribution of protein oxidation to resting energy expenditure (REE). Patients were studied on the second or third day post-injury and prior to implementation of nutritional support. Variables measured included REE by indirect calorimetry (normalized to percent predicted energy expenditure calculated from the Harris-Benedict equation). 24-hr urinary nitrogen excretion, calorie, and nitrogen intake. All patients received dexamethasone (39 +/- 2 mg/day) and three received pentobarbital. Mean REE was widely variable, ranging from 43 to 128% of predicted (mean, 90 +/- 31%). Mean 24-hr urinary nitrogen excretion was 16.5 +/- 5.8 g. The contribution of protein oxidation to REE was 30 +/- 4%. The contribution of protein oxidation to REE did not parallel REE (r = -0.237, p = NS) or REE expressed as percent predicted (r = -0.258, p = NS). The contribution of protein oxidation to energy expenditure is greater in acute heat trauma than previously described soft tissue injury and sepsis. The observed excessive nitrogen catabolism and increased contribution of protein oxidation to resting energy expenditure suggest accentuated protein requirements in respect to energy needs in head-injured patients.

We have constructed an automated, eight-cage indirect calorimeter (AIC) for the measurement of energy expenditure in rats. We compared the measurements of resting energy expenditure (REE) in rats during a 30-h fast obtained with the AIC with those obtained with a manual indirect calorimetry (MIC) system. There was both a high degree of correlation between the two techniques during the initial 18 h of the fast (r = 0.90, P0.05) and strong intertechnique agreement. REE (AIC) decreased during the final 12 h of the 30-h fast (79.6 +/- 2.7-72.0 +/- 4.4 kcal.kg-0.75.d-1 [mean +/- SD, P0.01]). REE (MIC) did not show a significant decrease during this part of the fast (79.7 +/- 2.6 - 75.2 +/- 4.7 kcal.kg-0.75.d-1 [P = NS]). During the final 12 h of the fast agreement between the two systems gradually dissipated and correlation was poor (r = 0.375, P0.05). The frequency of animal handling necessitated by MIC may have resulted in a stress-induced increase in metabolic work that would mask the animals' adaptive response to starvation. This investigation demonstrates the advantages of the AIC and calls into question the accuracy of manual methods under long-term starvation conditions.

Six patients with extreme short bowel syndrome (4.2 +/− 4.9 cm of residual small bowel) were provided home parenteral nutrition (HPN) for 14,397 days. The average age at onset of HPN was 38 years (18-64 years). Patients maintained body weight at 97% of ideal (86-112%) with mean serum albumin of 3.7 +/− 0.6 g/dL (normal 3.5-5.8 g/dL), serum transferrin of 341 +/− 104 mg/dL (normal 200-400 mg/dL), and mean serum pre-albumin of 27.5 +/− 12.6 mg/dL (normal 16.6-43 mg/dL). Hospital admission for HPN-related complications was required 10.3 times/patient for a total of 864 hospital days and was catheter related in 71% of episodes. Catheter sepsis occurred once per 436 catheter days and required catheter removal in only 33% of instances. Five patients were able to resume an oral diet, five had returned to work or school, and three were married with family. HPN allowed return to a quality productive life with acceptable morbidity following catastrophic massive bowel resection.

BACKGROUND The purpose of this study was to investigate the prevalence of skeletal muscle atrophy and its relation to exercise intolerance and abnormal muscle metabolism in patients with heart failure (HF). METHODS AND RESULTS Peak VO2, percent ideal body weight (% IBW), 24-hour urine creatinine (Cr), and anthropometrics were measured in 62 ambulatory patients with HF. 31P magnetic resonance spectroscopy (MRS) and imaging (MRI) of the calf were performed in 15 patients with HF and 10 control subjects. Inorganic phosphorus (Pi), phosphocreatine (PCr), and intracellular pH were measured at rest and during exercise. Calf muscle volume was determined from the sum of the integrated area of muscle in 1-cm-thick contiguous axial images from the patella to the calcaneus. A reduced skeletal muscle mass was noted in 68% of patients, as evidenced by a decrease in Cr-to-height ratio of less than 7.4 mg/cm and/or upper arm circumference of less than 5% of normal. Calf muscle volume (MRI) was also reduced in the patients with HF (controls, 675 +/- 84 cm3/m2; HF, 567 +/- 112 cm3/m2; p less than 0.05). Fat stores were largely preserved with triceps skinfold of less than 5% of normal and/or IBW of less than 80% in only 8% of patients. Modest linear correlations were observed between peak VO2 and both calf muscle volume per meter squared (r = 0.48) and midarm muscle area (r = 0.36) (both p less than 0.05). 31P metabolic abnormalities during exercise were observed in the patients with HF, which is consistent with intrinsic oxidative abnormalities. The metabolic changes were weakly correlated with muscle volume (r = -0.42, p less than 0.05). CONCLUSIONS These findings indicate that patients with chronic HF frequently develop significant skeletal muscle atrophy and metabolic abnormalities. Atrophy contributes modestly to both the reduced exercise capacity and altered muscle metabolism.

One hundred patients underwent laparotomy for independent jejunal feeding tube placement. Neurologic disease was present in 50%, and obtundation (28) and oropharyngeal dysmotility (25) were the most common indications for enteral feeding. The post-pyloric route was chosen because of aspiration risk in almost all (94%) patients. Postoperative (30-day) mortality rate was 21%, because of cardiopulmonary failure in most (18). One death resulted directly from aspiration of tube feeds. Two surgical complications required reoperation: one wound dehiscence and one small bowel obstruction. Four wound infections occurred. Two patients underwent reoperation after tube removal, and four tubes required fluoroscopically guided reinsertion for peritubular drainage (2), removal (1), and occlusion (1). Aspiration pneumonia was present in 18 patients preoperatively and in eight postoperatively. None of the patients with feeding-related preoperative aspiration pneumonia (13) had a recurrence while fed by jejunostomy. Three patients developed postoperative aspiration pneumonia before initiation of jejunostomy feedings. Jejunostomy may be performed with low morbidity rate and substantial reduction of feeding-related aspiration pneumonia, and is the feeding route of choice in aspiration risk patients.

As dieting behavior and attempts at weight loss are becoming increasingly common in adolescent girls, we wished to determine whether early-onset repeated dieting influenced the development of obesity and its metabolic correlates. Female rats were fed a high-fat diet and subjected to six cycles of dieting and regain, beginning in the peripubertal period. Although dieted rats weighed less than nondieted high-fat fed controls at the completion of the sixth cycle, body composition analysis revealed that the two groups were equally obese. Cumulative caloric intake was less in dieted rats, suggesting that the pattern of consumption promoted by dieting helped to establish the obesity. Resting metabolic rate did not differ between the two groups. These data suggest that although early-onset repeated dieting may result in reduced body weight the eventual level of adiposity may be unknowingly elevated, potentially leading to long-term health risks.

Single snapshot measurements of resting energy expenditure (REE) suggest that hypermetabolism contributes to cancer cachexia, but tumor impact on total 24-hr energy expenditure (TEE) is unknown. Automated multicage indirect calorimetry was employed to measure daily energy expenditure in adult Buffalo rats (n = 16) randomized to tumor inoculation or controls. Measurements included baseline REE, activity EE (AEE), thermic response to food (TEF), and TEE. Rats (n = 16) were randomized. Metabolic measurements, tumor size, and body weight were recorded weekly. Animals were sacrificed at Week 5 for analysis of host and tumor composition. Significant depletion of total lean body mass occurred in TB rats (greater than 15% wt loss, ANOVA P less than 0.001) which inversely correlated with tumor growth (r = -0.81, P less than 0.001). REE, TEF, AEE, and TEE did not change in controls (ANOVA P = n.s.). In TB rats, a 19.5% increase in REE occurred (119.4 +/- 3.3 to 138.7 +/- 1.8 kcal/kg LBM/day, P less than 0.01). TEE remained unchanged (157.3 +/- 5.6 vs 152.9 +/- 3.6 kcal/kg LBM/day, P = n.s.) due to a 66% decrease in AEE (32.9 +/- 3.1 to 10.5 +/- 1.7 kcal/kg LBM/day, P = 0.01). TEF did not change (4.7 +/- 0.8 vs 5.0 +/- 0.3 kcal/kg LBM/day, P = n.s.). Both TB and controls demonstrated a decreased REE in response to a 24-hr fast (7.9% vs 4.8%, P = n.s.). Respiratory quotient decreased in both groups when comparing fed to fasted values: TB (0.86 to 0.76) and controls (0.86 to 0.71), but the decline was greater in controls (P = 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)

Nineteen ambulatory outpatients requiring a tunneled central venous access device with catheter occlusion were studied. Mean catheter life was 7.9 +/- 8.2 months (range, from 1-36 months) at the time of the occlusion. Urokinase (5000 units/ml) was injected in sufficient amount to fill the internal volume of the catheter and allowed to stay for 5 to 10 min before attempting to aspirate. Repeated aspiration attempts were performed every 5 to 10 min for a maximum of 30 to 60 min or patency. In the event catheter patency was not restored, the thrombolytic solution was aspirated from the catheter and a maximum of two additional trials were instituted. Results included clearance of four out of 15 withdrawal occlusions (27%) and two out of four resistance to infusion occlusions (50%). Overall, successful catheter clearance occurred in six out of 19 occlusions (32%). The efficacy rate of thrombolytic therapy for successfully clearing occluded catheters at our institution using conventional low-dose thrombolytic therapy is markedly lower than previously reported rates of 57 to 100%. The reasons for this discrepancy may reflect differences in dosage of thrombolytic agent, method of administration, frequency of monitoring of catheter patency, and catheter life.

Fifty-eight episodes of catheter-related sepsis in 21 patients receiving home parenteral nutrition were retrospectively studied. Of 81 organisms isolated from the blood, 59% were Gram-positive cocci, 25% were Gram-negative bacilli, and 16% were yeast. Attempts to treat bacterial infections at home with antibiotic therapy while the catheter remained in place were made; fungal isolation resulted in immediate hospitalization and catheter removal. Gram-negative infections more often resulted in eventual hospitalization (92%) and catheter removal (50%) than Gram-positive infections (57% hospitalization and 23% catheter removal). Empiric therapy with 1 g of cefazolin intravenously every 12 hr was successful in only 33% of episodes caused by coagulase-negative staphylococci, whereas vancomycin was successful in 62%. Sensitivity testing was not a reliable guide for antibiotic choice for treatment of these infections. Cefazolin, 1 g, intravenously every 12 hr was successful in only 25% of Gram-negative episodes treated empirically with this regimen. We conclude that our home parenteral nutrition patients should be hospitalized for a few days upon presentation with a catheter infection for clinical evaluation and aggressive antibiotic therapy. Vancomycin is the preferred drug for treatment of catheter-related infections caused by coagulase-negative staphylococcus.

Resting energy expenditure (REE), weight, and body composition were measured up to seven times in 13 obese women during a 24-wk study. Patients were randomly assigned to a very-low-calorie diet (VLCD, 500 kcal/d) or a balanced-deficit diet (BDD, 1200 kcal/d). After 8 wk of supplemented fasting, REE of the VLCD patients decreased by 17% whereas that of the BDD patients was virtually unchanged. REE of the VLCD patients increased during 12 subsequent weeks of realimentation such that differences in REE between the two groups were not statistically significant at week 24 (VLCD = -11%, BDD = -2%). Reductions in weight and fat-free mass (FFM) were 12.1% and 3.6% for the VLCD patients and 10.6% and 4.1% for the BDD patients, respectively. There were no significant differences between the groups in pre- to posttreatment changes in REE normalized to FFM. Results suggest that REE recovers partially after consumption of a VLCD. They also provide evidence of a possible metabolic advantage of weight loss by a more moderate restriction.

Pharmacologic therapy designed to block adrenergic activity or alter hormonal milieu may modulate energy and protein metabolism in stress. The metabolic effects of propranolol (beta adrenergic receptor blocker) in sepsis was investigated in 22 well-nourished rats that underwent superior vena caval cannulation, cecal ligation, and puncture. Animals were randomly assigned to receive either a continuous infusion of 0.7 mg/day of propranolol combined with parenteral nutrition (n = 11) or parenteral nutrition alone (n = 11). Both groups received isocaloric, isonitrogenous, isovolemic, parenteral nutrition post-operatively for 24 hr. Nitrogen balance was better for the propranolol group than for the control group (+743 +/- 84 mg/kg/day versus +300 +/- 63 mg/kg/day, respectively, P less than 0.05). A significant difference between the pharmacologic therapy and control groups was noted for urinary 3-methylhistidine excretion versus control (0.99 +/- 0.08 micrograms/kg/day versus 7.5 +/- 0.37 micrograms/kg/day, respectively, P less than 0.01). Measured energy expenditure was similar for both pharmacologic therapy and control groups (149 +/- 20 kcal/kg/day versus 134 +/- 11 kcal/kg/day, respectively, P = N.S.). No statistically significant difference was demonstrated for 24-hr survival between propranolol and control groups (73 and 64%, respectively). Continuous, low-dose propranolol promotes nitrogen retention and decreases 3-methylhistidine excretion without altering energy expenditure in parenterally fed septic rats.

Resting energy expenditure is abnormal in most patients with cancer and may contribute to cancer cachexia. These metabolic abnormalities may be a direct measure of tumor metabolism, or represent alterations in the size or activity of the body cell mass, or both. To unravel this pathogenesis, we prospectively studied 68 preoperative patients with cancer about to undergo curative resection by measuring resting energy expenditure before and after tumor resection. The preoperative measured resting energy expenditure was compared with expected resting energy expenditure based on Harris-Benedict resting energy expenditure predictions: 10 patients were hypometabolic (less than 90% Harris-Benedict); 35 were normometabolic (90% to 110% Harris-Benedict); and 23 were hypermetabolic (greater than 110% Harris-Benedict). Using each patient as his or her own control, resting energy expenditure normalized or remained normal following curative resection. In contrast, after palliative resection, resting energy expenditure remained hypermetabolic or significantly increased toward hypermetabolism. Tumor induces an abnormal metabolic rate, since tumor removal results in prompt normalization of resting energy expenditure. The abnormal energy expenditure of patients with cancer cannot be solely attributed to abnormal host body composition.

A multidisciplinary group of nutritional care providers was surveyed to assess degree of agreement on the relative importance of various areas of nutrition knowledge. A 35-item nutrition content area survey was mailed to a stratified, random sample (n = 400) of the American Society for Parenteral and Enteral Nutrition (ASPEN) membership representing dietitians, nurses, pharmacists, and physicians. Through the use of modified Delphi survey, respondents rated each content area as 'essential,' 'useful,' or 'nonessential' for inclusion in a proposed test to assess nutrition knowledge. Respondents from all disciplines agreed that they should be knowledgeable in 22 of the 35 content areas. Chi square tests were used to assess significant response differences among disciplines. Systematic differences were primarily between dietitians and pharmacists. The study results provide direction to multidisciplinary continuing nutrition education program planners regarding appropriate content for combined discipline programs as well as for those more discipline-specific.

Isoenzyme V of 5′-nucleotide phosphodiesterase (5′-NPD-V) is present in the peripheral sera of patients with hepatic metastases. A total of 122 patients underwent prospective serologic analysis followed by operation for primary tumors of the gastrointestinal tract and careful evaluation of the liver. A positive 5′-NPD-V assay was found in fifty-nine of sixty patients with liver metastases. A negative 5′-NPD-V assay was found in forty-three of sixty-two patients with no evidence of hepatic metastases. The accuracy of the test was 84 per cent, and the predictive value was 75 per cent. Serum 5′-NPD-V was abnormal significantly more frequently in patients with metastatic liver disease than were liver scans or carcinoembryonic antigen (CEA), alpha fetoprotein, serum glutamic oxalacetic transaminase (SGOT), and total serum bilirubin or serum alkaline phosphatase levels.

The difficulty of maintaining adequate nutritional status in cancer patients is well recognized [I, 181. Recently there has been considerable interest in the clinical use of intravenous diets to support these patients [2, 51. Although present evidence strongly suggests that the cancer patient receiving chemoor radiotherapy is significantly benefited by parenteral nutrition, there exists little information on the metabolic changes induced in tumor and host tissue by parenteral nutrition. Unfortunately, nitrogen balance studies are of little value in the cancer patient for they cannot distinguish between host and tumor utilization of nitrogen intake. The use of labeled amino acids has facilitated the measurement of protein synthesis in viva [3, 9, 151. This study involves the use of [15N]glycine as a nitrogen tracer to examine selective utilization of nutrients by host and tumor tissue. The effects of the presence of a tumor and an acute change in nutrient intake are investigated. We have previously reported preliminary data on protein synthetic rates of tumor host tissues [16]. The present study updates our findings on tissue protein synthesis rates and pursues the intracellular localization of the observed tissue changes.

The relationship between serum transferrin ( TFN ) and serum total iron-binding capacity (TIBC) in a clinical setting was evaluated in two related studies. The initial study evaluated 101 blood samples representing a cross-section of hospitalized adults. The samples were double assayed for TIBC using clinical and research methodologies. TFN was assayed by a commercial radial immunodiffusion method. Clinical laboratory TIBC correlated well with research laboratory TIBC (r = 0.87, slope = 0.97, p less than 0.001, n = 50) and the relationship of TIBC to TFN yielded the following equation: TFN = 0.83 TIBC -5.6 (r = 0.82, p less than 0.001, n = 101) where TFN = mg/100 ml and TIBC = micrograms/100 ml. The second study evaluated a new TIBC assay and its effect on the TIBC/ TFN relationship. Additionally, the TFN -TIBC relationship was evaluated at low normal and abnormal TIBC levels. In this second study, TFN = 1.0 TIBC -18.8 (r = 0.88, p less than 0.01, n = 126). Subsample analysis for specimens with TIBC between 105 and 160 showed a TIBC- TFN regression line that was not significantly different than the entire sample. Inclusion of ancillary patient data such as hemoglobin and hematocrit did not improve the relationship between TFN and TIBC in either study. The relationship was unaffected by age, sex, race, disease, treatment, fever, surgery, degree of nutritional support, blood transfusion, or blood chemistry parameters in either study. Laboratories deriving TFN from measured TIBC as a nutritional status indicator must determine the relationship for the specific procedures being used in their laboratories.

The administration of chemotherapy in clinical situations is limited frequently because of the associated toxicity to normal bone marrow cells, gastrointestinal epithelium, and other host tissues. Although nutritional support has been advocated to reduce chemotherapy-related toxicity in cancer patients, few studies substantiate this clinical impression. The current study was performed to determine the role of nutritional status and enteral nutrient intake as determinants of methotrexate (MTX) toxicity in a well-controlled, tumor-bearing animal model. After subcutaneous mammary tumor (AC-33) inoculation, 56 female Lewis/Wistar rats were assigned randomly to one of the following two nutritional regimens for 14 days: (1) protein-depleted chow (PC) (0.03% protein; 4.27 kcal/g) or (2) standard chow (RC) (22.0% protein; 3.50 kcal/g). After 7 days of dietary control, all animals received one of three weight-adjusted doses of MTX (5, 10, or 20 mg/kg intramuscularly [IM] ) or placebo. All animals received leucovorin rescue (0.6 mg IM) at 6 and 24 hours after MTX injection. Improved nutritional status was associated with a significant reduction in objective measures of MTX-related morbidity and mortality. At low doses of MTX (5 and 10 mg/kg), the mean duration of clinical signs of toxicity (i.e., hair loss, lethargy, and diarrhea) and severity of leukopenia were greater in protein-depleted (PD) animals. With high-dose MTX (20 mg/kg), mortality was increased significantly in PD animals (100%) compared with well-nourished animals (0%). Equivalent tumor response was observed in PD and well-nourished animals. Thus, improved nutritional status by enteral nutrition reduced the morbidity and mortality associated with MTX significantly in this tumor-bearing animal model.

A 52-year-old man developed synchronous squamous-cell carcinoma of the larynx and middle one-third of the esophagus following treatment for Hodgkin disease. This patient fell into the subgroup of patients treated by intensive radiation therapy followed by intensive chemotherapy. The link between the therapy and subsequent carcinoma is suggestive. Long-term follow-up care of patients with Hodgkin disease demands continuing evaluation for this possible complication.

To investigate the effect of stress on the dynamics of serum protein response during starvation, serum albumin, prealbumin, and transferrin changes were studied in six chair-adapted macaques during two separate 7-day test periods: (1) Starvation--NPO + IV D5/W (100 cc/kg/day), and (2) Surgery/starvation--laparotomy and gastrostomy + NPO + IV D5/W (100 cc/kg/day). During the starvation period, transferrin was the only protein that decreased from baseline values and did so at day 7 of the study period. In contrast, during the period of starvation following surgery, both prealbumin and transferrin were significantly decreased at both day 4 and day 7 of the study period, whereas albumin was only decreased at day 7 of this period. These findings indicate that the addition of a surgical stress to starvation results in a depression of serum protein levels that is not only of greater magnitude, but also more rapid in onset than observed with starvation alone. In addition, the differential response of prealbumin and transferrin to starvation and stress may provide a useful indicator of the presence and/or degree of stress in certain situations. The clinical utility of this finding remains to be ascertained.

Malnutrition is common in cancer patients and may be an important determinant of operative morbidity and mortality. To determine whether preoperative nutritional assessment can be used to identify a group of high-risk patients, and whether preoperative TPN decreases morbidity and mortality in this group, retrospective, nonrandomized review of 159 patients who were subjected to major cancer surgery was performed. All patients underwent preoperative multiparameter assessment. A previously developed and validated nutritional assessment model (Prognostic Nutritional Index) was used to evaluate the probability of operative complications. Based on predicted outcome (PNI), patients were assigned to either a high-risk or low-risk group for statistical comparison with actual outcome. The effect of preoperative TPN was then analyzed in both risk groups for determination of efficacy of preoperative nutritional support. Substantial malnutrition was found to exist among patients undergoing major cancer surgery and was closely correlated with subsequent morbidity and mortality. This predictive nutritional assessment model accurately identifies a subset of cancer surgery patients at increased risk of operative morbidity and mortality. In this high risk group (PNI greater than or equal to 40%), preoperative nutritional support significantly reduces operative morbidity.

Tumor-bearing animals provided with intravenous glucose and amino acids (TPN) exhibit enhanced response to S-phase-specific chemotherapeutic agents (H. M. Reynolds, J. M. Daly, B. Rowlands, S. J. Dudrick, and E. M. Copeland. Cancer 45 : 3069, 1980; M. H. Torosian, J. L. Mullen, E. E. Miller, et al. J. Parenter. Enteral Nutr. 7: 337, 1983). To determine the mechanism of this response, DNA synthesis rate during starvation or a 48-hr infusion of glucose/amino acids (Glu/AA) was evaluated in tumor, liver, and terminal ileal cells of 68 rats. Tumor cells exhibited a rapid increase in DNA synthesis following the initiation of an infusion of Glu/AA. This increase was most marked after 2 hr of infusion and returned to control levels within 24 hr. Liver DNA synthesis rate increased in both starved and Glu/AA animals over 48 hr with a larger increase in animals receiving Glu/AA. Ileal DNA synthesis decreased equally in both groups. Short pulse Glu/AA produced transient increases in tumor DNA synthesis. Changes in host tissues occurred but followed a different temporal sequence. This may indicate the existence of a period of time following initiation of metabolic manipulation when tumor susceptibility to phase-specific chemotherapeutic agents will be enhanced while host tissues will be spared from increased toxicity.

A consensus definition of malnutrition does not exist. We define "clinically relevant malnutrition" as the state of altered nutritional status that adversely affects clinical outcome. Over four years we have attempted to delineate a clinically applicable and validated nutritional assessment approach. This was accomplished through multiple clinical studies on a large number of surgical patients many of whom were seriously ill. Although an initial prospective study in 64 patients confirmed the relationship between certain nutritional markers and outcome, we found that 97% of patients had at least one abnormality, while 35% had three or more abnormalities, clearly documenting the imprecision in unselected battery testing. In a subsequent retrospective analysis of 161 patients, serum albumin (Alb), serum transferrin (TFN), triceps skinfold (TSF), and skin test reactivity (DH) proved to be the best markers of clinically relevant malnutrition and their relative quantitative importance is embodied in our Prognostic Nutritional Index (PNI), where PNI (% risk) = 158 - 16.6 (Alb) - 0.78 (TSF) - 0.20 (TFN) - 5.8 (DH). In numerous prospective studies of different patient groups, a large percentage of which were critically ill, the PNI has been shown to be a reliable nutritional assessment tool for diagnosing clinically relevant malnutrition. Furthermore, we have shown that seriously malnourished patients classified by the PNI will clinically benefit from preoperative nutritional support. The relevance of baseline and serial nutritional assessment to the nutritional care of the critically ill patient is discussed.

Cancer cachexia, a common finding in patients with gastrointestinal (GI) malignancy, is frequently attributed to tumor-induced aberrations in host energy expenditure. To characterize the frequency and severity of aberrations in energy expenditure in GI cancer patients, and to identify the potential influence of tumor characteristics in this group, the authors measured resting energy expenditure (REE) by indirect calorimetry in 173 patients and compared REE to predicted-energy expenditure (PEE) from the Harris-Benedict formulae based on current body weight. Fifty-eight percent of patients had abnormal REE (normal REE = +/- 10% PEE); 36% (62 of 173) were hypometabolic (REE less than 90% PEE), and 22% (39 of 173) were hypermetabolic (REE greater than 110% PEE). Host and tumor factors were compared between metabolic groups to identify potential determinants of abnormal energy expenditure. Differences between groups cannot be explained by differences in patient age, sex, body size, nutritional status, tumor burden, or duration of disease. Resting energy expenditure does not correlate with percent of weight loss, serum albumin, or duration of disease. Analysis by tumor site reveals patients with pancreatic or hepatobiliary tumors to be predominantly hypometabolic; gastric cancer patients tend to be hypermetabolic, whereas patients with colorectal or esophageal neoplasms are more evenly distributed across metabolic groups, the largest portion being normometabolic (X2 = 20.7, P less than 0.02). The majority of GI cancer patients have abnormal REE which is unpredictable and not uniformly hypermetabolic. The determinants of these abnormalities do not appear to be age, sex, body size, nutritional status or tumor burden. Primary tumor site is a major determinant of energy expenditure in GI cancer patients.

In the ill hospitalized patient with clinically relevant malnutrition, there is a measurable decrease in the ratio of the total body potassium to total body water (TBK/TBW) and a detectable increase in the ratio of total exchangeable sodium to total exchangeable potassium (Nae/Ke). To evaluate body composition analyses in anorexia nervosa patients with chronic uncomplicated semistarvation, TBK and TBW were measured by whole body K40 counting and deuterium oxide dilution in 10 females with stable anorexia nervosa and 10 age-matched female controls. The ratio of TBK/TBW was significantly (p less than 0.05) higher in anorexia nervosa patients than controls. The close inverse correlation found in published studies between TBK/TBW and Nae/Ke together with our results suggest that in anorexia nervosa, Nae/Ke may be low or normal. A decreased TBK/TBW is not a good indicator of malnutrition in the anorexia nervosa patient. The use of a decreased TBK/TBW ratio or an elevated Nae/Ke ratio as a definition of malnutrition may result in inappropriate nutritional management in the patient with severe nonstressed chronic semistarvation.