Biomedical subjects
Publications and source records attributed to N G Clark.
We present a case of an African-American child with vitamin D-deficient rickets. In addition to being solely breast-fed for the period of 1 year, he resided in New England, where exposure to ultraviolet light is limited owing to its northern latitude and long cold winters. He presented with classical signs of nutritional rickets and was immediately responsive to treatment with vitamin D supplementation.
We present a case of a child with iron-deficiency anemia, folic acid deficiency, and scurvy. His anemia proved refractory to treatment with iron until he received both folic acid and vitamin C supplementation. This case illustrates the importance of the evaluation of ascorbic acid and folate status in treating iron-deficiency anemia initially refractory to iron supplementation, because multiple nutrient deficiencies may coexist.
Among the elderly, those at highest risk are the chronically ill, inactive patients. Assessing macronutrient requirements and outcome depends on longitudinal studies. Seven chronically ill, elderly female patients suffering from persistent infections, were studied monthly, over a 6-month period to determine their protein and energy requirements. Calorie and protein requirements were based on clinical status. The results of the nutrition support program were monitored using: weight change, nitrogen balance, serum albumin levels, alterations in anthropometric measurements (triceps skinfold thickness and arm muscle circumference), and immune function tests. Based on the 6-month study period data, the calculated mean energy requirement for weight maintenance was 98% of calculated basal energy expenditure (BEE) and the mean protein required for nitrogen balance, 0.8 g/kg desired body weight (DBW). Excess caloric administration resulted in weight gain, determined to be fat (and/or fluid) but not lean body mass. When surgery is contemplated, there should be a 30% (factorial) increase over these base-line values. It is inadvisable to allow elderly patients to sustain any starvation, period given their inability to produce increases in body cell mass even in this 6-month period.
Total urinary nitrogen (TUN) and urinary urea nitrogen (UUN) in a 24-hour urine collection were measured under a variety of clinical and nutritional conditions in 81 patients for 564 study days. The difference between TUN and UUN averaged 1.8 +/- 0.9 g/day (range 0.0-5.8 g/day) and was independent of the absolute value for UUN. Since UUN was found to correlate linearly with TUN (R = 0.98) over a wide range of values, it is possible to estimate an approximate TUN excretion by adding a constant to the nitrogen excreted as urea. On the basis of the measured mean difference, we suggest using an estimate of 2 g of nitrogen per day. We feel this will not seriously under- or overestimate urinary nitrogen excretion in the calculation of nitrogen balance for the clinical management of nutritional support therapies. Since all hospitals can perform this routine test, it provides an effective, simple, and rapid method to follow accurately the protein catabolic response during disease and response to nutritional therapy. This method, without the supporting data presented here, has previously been recommended [Blackburn et al, 1977, JPEN 1:11-22] and has become a widely used technique for nutritional assessment.
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The feeding devices and delivery systems are only two aspects of the total picture of ideal nutritional support. One needs to (a) perform a complete nutritional assessment to determine the patient's needs (Blackburn et al. 1977); (b) choose appropriately among the currently available formulas for enteral (Bistrian and Wade 1981) and parenteral use; (c) select the necessary feeding device and delivery system; and (d) administer the solution and monitor the patient's progress. There are many options in meeting the nutritional needs of the elderly patient. One needs to consider the patient's ability to ingest, digest, absorb, and metabolize the various foodstuffs. If the gut is functional, it should be used (Bothe et al. 1981). If it is not, the intravenous route is indicated. In light of the vast advances in technology in this area, there exists no excuse to allow our elderly patients to go undernourished.