The effect of the state of nutrition of 18 children with Stage IV neuroblastoma at diagnosis and during initial therapy, was evaluated with respect to treatment delays, drug dosage alterations, tumor response, days to first event (relapse or death), and survival. All patients received similar therapy (CCSG protocol CCG 371). Based on nutrition staging at diagnosis, nine were classified as malnourished; four were randomized to receive total parenteral nutrition (TPN) and four peripheral parenteral nutrition plus enteral nutrition for 28 days (through 2 chemotherapy courses), and one died before randomization. Nine were nourished at diagnosis; seven received a comprehensive enteral nutrition program and two received TPN. By life‐table analysis, the duration of remission was significantly greater in the nourished than the malnourished (P < 0.01) and a trend towards improved survival was evident at one year (P = 0.08). The median length of survival for children nourished at diagnosis was approximately 12 months, whereas those malnourished had a median survival of only 5 months. Nine children remained nourished or were becoming renourished during the first 21 days of therapy, and one of these had treatment delays and decreased drug dosages. Seven were becoming malnourished or remained malnourished during this period and six had treatment delays (P < 0.01). These data support the idea that nutrition staging at diagnosis and during initial treatment should be an integral part of protocol design and initial evaluation of children with Stage IV neuroblastoma.

Examination of 19 serum biochemical and hematologic parameters in a group of white male runners, ranging in age from 23 to 47 years, just prior to and immediately after a 13-mile "mini-marathon," demonstrated a significant increase, by paired Student t-test, in mean values of: K+, BUN, creatinine, CK, LDH, AST (SGOT), alkaline phosphatase, bilirubin, uric acid and leukocyte counts. Prevailing environmental conditions were such as to produce no significant hemoconcentration. Using this group's statistics and this hospital laboratory's upper limits of normal, the percentage of values above two SDs are, for the resting state: K+ 7%, BUN 7%, creatinine 0%, CK 21%, LDH 21%, AST 0%, alkaline phosphatase 0%, bilirubin 7%, uric acid 7%, and leukocyte count 0%. Post-exertional values above normal limits are: K+ 7%, BUN 21%, creatinine 21%, CK 93%, LDH 86%, AST 0%, alkaline phosphatase 0%, bilirubin 14%, uric acid 36%, and leukocyte 71%. Consequently, abnormally high values for K+, BUN, creatinine, CK, LDH, bilirubin, uric acid, and leukocyte counts can often be expected in some patients who exercise heavily. The degree of the abnormality will depend on the level and length of exercise as well as the elapsed time between exercise and testing.

We report on 2 patients who became deeply comatose after transurethral resection of the prostate. Both patients were severely hyponatremic and hyperammonemic but the course of the comas followed serum ammonia concentrations more closely than serum sodium concentrations. The genitourinary irrigant used in both procedures was a 1.5 per cent glycine solution. Serum amino acid analyses in 1 patient suggested that the postoperative hyperammonemia was due to catabolism of glycine absorbed during surgery. The inadequate activation of normal pathways of ammonia metabolism in this patient may have been caused by a partial deficiency of the urea cycle enzyme argininosuccinate synthetase. We believe that hyperammonemia should be considered as a cause of encephalopathy after transurethral resection of the prostate. The 1.5 per cent glycine genitourinary irrigating solution may not be as nontoxic as generally believed.

The effectiveness of enteral and parenteral nutrition regimens in preventing or reversing protein-energy malnutrition (PEM) and in preventing treatment delays was evaluated in 32 children receiving treatment for newly diagnosed Stage 111 (3 patients) and IV (29 patients) neuroblastoma. Ten of 18 malnourished patients were randomized to central parenteral nutrition (CPN) and 8 to peripheral parenteral nutrition (PPN) plus enteral nutrition for 4 weeks and then received enteral nutrition (EN: intense nutrition counselling, oral foods and supplements) for weeks 5 through 10. Ten of 14 nourished patients received EN and 4 CPN for 4 weeks and EN thereafter. Dietary, anthropometric and biochemical measurements were determined for weeks 0, 1,2,3,4,7, and 10 for 24 patients who completed the protocols. In malnourished patients, both CPN (seven patients) and P P N (seven patients) were effective in reversing P E M in the first 4 weeks; thereafter, EN effectively maintained nutritional gains in both groups. In nourished patients, EN (seven patients) was not as effective as CPN (three patients) in preventing P E M during the first 4 weeks; afterwards, EN maintained gains in the CPN group but did not promote needed increases in weight nor fat reserves in the EN group. Patients supported by parenteral nutrition (PN, weeks 1-4) had fewer treatment delays (2/17, 12%) than EN patients (4/7,57%, P < 0.05). These data indicate that PN reverses or prevents P E M and prevents treatment delays during the first 4 weeks of intense oncologic treatment and provides nutritional benefits which can be maintained with EN thereafter.Cancer 56:2881-2897. 1985.lTHIN the last decade, multimodal treatment has W vastly improved the outcome of many children with cancer. Prognosis for children with advanced neuroblastoma, however, continues to be discouragingly poor.