Each issue of the CoramClick provides an in-depth focus on timely and practical solutions. In this issue of the Click, we are focusing on Oncology and Nutrition. Back issues of the Click are available in the CoramClick archive for easy reference!

	Blood Cell Transplant Predisposes Patients to Malnutrition Patients undergoing blood cell transplant are predisposed to malnutrition for several reasons: their underlying disease, the conditioning regimen, and other treatment-related toxicities. These factors contribute to increased morbidity and mortality.	Infection Risks with Blood Cell Transplant Although the acute care setting has historically been the site of care for the oncology patient, given rising healthcare costs and growing trends of nosocomial infections in the hospital environment, transitioning these patients to a home care environment has become a safe, effective model for healthcare utilization. ICD-9 Codes A list of widely used ICD-9 codes relevant to oncology. Resource Center Helpful resources and information focused on oncology. Subscribe to the CoramClick Please include your email address, first and last name, and company name.
	Home Care for the Oncology Patient While many fungal organisms present an infectious risk, the most commonly encountered in blood cell transplant (BCT) patients are Aspergillus and Candida species at rates of approximately 44 and 29 percent respectively.
	Do You Know? Which patient population has the highest rate of infections caused by resistant pathogens? a) Children   b) Adults   c) Elderly

Blood Cell Transplant Predisposes Patients to Malnutrition

A patient’s nutritional status is often prognostic. Patients undergoing blood cell transplant (BCT) are predisposed to malnutrition for several reasons: their underlying disease, the conditioning regimen, and other treatment-related toxicities. These factors contribute to increased morbidity and mortality. Alterations in nutrition status persist long after transplantation, with as many of 50 percent of patients not returning to pre-transplant weight at one year.¹

When considering nutrition in the BCT patient, it is relevant to discuss it in three phases: pre-transplant/early post-transplant, post-transplant and long-term. In the pre-transplant/early transplant phase, patients typically lose nutritional ground due to the side effects of their disease and/or the pre-transplant conditioning of high dose chemotherapy and/or total body irradiation (TBI). Nutritional challenges can continue into the long-term as patients live longer.

It is common for patients to present for cancer treatment with anorexia, weight loss, and other nutritional problems. Anti-cancer therapies can complicate the cancer patient’s treatment and negatively impact their ability to tolerate their therapeutic regimen, and potentially, to recover. In patients with co-morbidities (e.g.: diabetes), the challenges are even greater.

Treatment Side Effects that Can Affect Nutritional Status

All of the treatment options (e.g.: surgery, chemotherapy, and radiation) can negatively affect nutritional status from a mechanical and/or metabolic perspective. When that pre-cancer treatment regimen is in preparation for BCT, the doses, and therefore the consequences, are magnified. Many of the nutritional challenges of are secondary to intense side effects of the therapy itself.

Many patients experience oral and gastrointestinal sores in the early post-transplant weeks. Because of the cytotoxic effects of chemotherapy and radiation, mucositis — often severe — of the lips, gums, mouth, esophagus, and stomach makes eating and swallowing difficult and painful. Nausea and vomiting are experienced frequently, impacting both intake and absorption. The treatment regimen contributes to fatigue, diminished appetite, and weight loss. Total body irradiation (TBI) can contribute to dryness of the mouth and temporarily alter the taste of food. It can also cause thick saliva to form in the mouth and throat, further impacting intake. Absorption is compromised in patients who develop diarrhea.

Inadequate nutrition can be exacerbated by infection, a significant risk in the early post-transplant phase due to typically severe neutropenia. Infection directly and indirectly affects the body’s nutritional needs and utilization.

Maintaining an Adequate Nutritional Status

Maintenance of an adequate nutritional status, including increased calorie and protein intake, is essential for positive post-transplant outcomes. Patients receiving aggressive conditioning therapies need aggressive nutritional management. Nutritional support must include ongoing assessment and interventions maximized to effectively manage the patient’s true nutritional needs. Total parenteral nutrition (TPN) is often needed until the patient can maintain adequate oral intake.

Mucositis

For mucositis, medications are available to ease the pain. Patients should avoid coarse foods as well as foods and beverages that are acidic, salty, spicy, very hot, or caffeinated. As the patient engrafts and the neutropenia resolves, mouth sores will heal. Oral mucosal dryness may be helped if patients avoid dry foods, very hot foods and beverages, and alcohol. Adding sauces to foods and stimulating saliva production by including citric acids in the diet, or by sucking ice chips or hard candies can also help.

Nausea

Severe nausea may be relieved with medications or dietary changes such as eliminating spicy, sweet, fatty, or strong-smelling foods.

Post-transplant Infection

To reduce the risk of post-transplant infection, transplant center guidelines typically recommend strict dietary guidelines with an emphasis on food safety and sanitation. For example, raw fruits and vegetables (except for ones with thick peelable skins such as bananas and oranges) should be avoided because of their potential to carry a food-borne pathogen. Patients should eat only thoroughly cooked foods. Some patients may be restricted from such foods as aged cheeses, commercially prepared salads, etc. Specific dietary restrictions and their duration depend on the type of transplant, degree of neutropenia, time to engraftment, and other patient-specific factors.

Graft-versus-Host Disease

As the transplant timeline progresses, patients become at-risk for other complications that can affect nutritional status and wellness. A significant risk exists in the allogeneic BCT population for the development of graft-versus-host disease (GVHD), an immune response of the donor cells to the now-appearing foreign recipient tissues. The donor immune cells may attack certain organs, most often the skin, gastrointestinal (GI) tract, and liver — any combination of which can contribute to inadequate nutrition.

Acute GVHD

Acute GVHD develops in 30 to 50 percent of allogeneic BCT recipients, typically within the first two months post-transplant. Symptoms include nausea, vomiting, stomach cramps, diarrhea, loss of appetite, and liver dysfunction. Patients must be nutritionally managed and supported through the GVHD and its treatment in order to minimize complications.

Chronic GVHD

Chronic GVHD can occur anytime after the transplant, typically between three and 18 months. Symptoms often advance gradually. Nutrition-related symptoms include:

Some patients who develop chronic GVHD continue to have mouth sores or oral sensitivity a year or more post-transplant.

Caloric needs in patients with chronic GVHD may be increased by up to 30 percent, particularly in patients who have already experienced significant weight loss. High-protein diets are important to prevent catabolism and to maintain health structure and function. Ongoing weight loss must be addressed early.

TPN, Enteral, and Oral Supplementation

There is no doubt that nutritional monitoring is essential, with support and management as needed. TPN has been a standard component of BCT care for more than 20 years. Protocols, however, vary significantly between transplant programs. For example, in some centers TPN is initiated prior to the pre-transplant conditioning regimen and continued for several weeks post-transplant. Many centers start TPN only in the face of severe mucositis, with length of therapy dependent on the intensity and duration of mucositis. Some centers endorse the addition of glutamine to the TPN, although the impact of glutamine is being questioned. Increasingly, transplant programs are combining TPN with amounts of enteral or oral feedings.

Long-term Nutritional Needs

The good news in BCT is that long-term survival rates continue to improve. Depending on disease state and type of transplant, 10 year success rates range from about 20 to 80 percent. Nutrition remains an important component of self-care and continues to impact morbidity and mortality. Ongoing monitoring is important. The Ancillary Therapy and Supportive Care Working Group of the American Society for Blood and Marrow Transplantation recommends physical exams every one to 12 months, including weight and nutritional assessment. The emphasis is on early intervention as needed.

Home Care for the Oncology Patient

Cancer is the second leading cause of death in the U.S., with an estimated 1.5 million new cancer cases expected in 2010, excluding skin cancer. Cancer accounts for nearly one-quarter of deaths in the U.S. annually, but a 16 percent reduction in death rate has been noted between 1991 and 2006. The current survival expectation greater than five years after diagnosis is 66 percent. This is due in part to earlier detection, advances in treatment, prevention of secondary disease and cancer reoccurrence, and lifestyle changes such as smoking cessation and weight control.² The treatment regimen for oncology is intense and debilitating in many cases. Treatment may encompass surgery, radiation, chemotherapy, immunotherapy and even blood cell transplant. Although the acute care setting has historically been the site of care for these patients, given rising healthcare costs and growing trends of nosocomial infections in the hospital environment, transitioning these patients to a home care environment has become a safe, effective model for healthcare utilization. Home care provides a continuum for oncology patients to return to their homes and families. One such therapy that can be provided effectively throughout the continuum of care is nutrition support.

Nutrition Support

Nutrition care and support is an important adjunctive component of cancer treatment. The incidence of malnutrition ranges from 40 to 80 percent in cancer patients, depending upon the body organ(s) affected and the toxicity or impact of treatment. Contributing factors to malnutrition often seen in this population include type of tumor, stage of disease, type and amount of anti-neoplastic therapy, increased nutrient needs, abnormal nutrient metabolism, adequacy of nutrient intake, and cytokine activity. The impact of malnutrition is profound with protein calorie malnutrition being one of the most common secondary diagnoses in individuals with cancer. Outcomes published in Nutrition in Clinical Practice found that of 81 cancer patients studied, 69 percent lost more than 10 percent of their body weight before nutrition support was initiated.³ Patients who are allowed to lose more than 10 percent of their body weight before starting nutrition support have a lower functional status which can be improved with effective nutrition intervention. In addition to weight loss, malnutrition further delays wound healing, promotes muscle weakness, and impairs immune function that results in increased morbidity and mortality, decreased quality of life, and increased healthcare cost in this population.

Types of Nutrition Therapy

While oral, enteral (tube feeding), or parenteral (intravenous feeding) nutrition support is not an anti-cancer therapy, it is focused on maintaining and/or improving the nutritional status of the person with cancer so that the patient can tolerate the anti-cancer treatments. Marin Caro, et al., suggest that nutritional intervention should be started as early as possible, as this can reduce and even reverse poor nutritional status, improve performance status and, consequently, quality of life.⁴

The application of which nutrition therapy to provide depends upon the extent and site of injury to the gastrointestinal tract. Oral diet is the most acceptable and comfortable means of nutrition intake but frequently is inadequate for a cancer patient. Diet modifications, supplements, and appetite stimulants should be exhausted as a first step approach in the management of oncology patients. However, for patients who are malnourished and cannot consume or absorb adequate nutrients, nutrition support is appropriate during anti-cancer therapy.⁵ Patients who are moderately to severely malnourished may also benefit from 7 to 14 days of preoperative nutrition support to optimize post-surgical outcomes.⁵ When oral intake cannot meet a patient’s needs, the consideration of tube feeding is made to support nutrition needs. Patients who experience anorexia, dysphagia, gastroparesis, and proximal gastrointestinal obstruction are Candidates for tube feeding. Those that exhibit an inability to tolerate tube feeing and are at risk for becoming malnourished (or are already malnourished) such as in the case of bowel obstruction, high output intestinal fistula, severe malabsorption, and enteritis would benefit from parenteral nutrition support.

Studies indicate that home parenteral nutrition (TPN) as an adjunct therapy for cancer patients with nonfunctional gastrointestinal tracts improves quality of life and functional status, and that TPN preserves patients’ nutritional status from progressive deterioration, potentially helping to prolong survival. August, et al., reviewed the use of TPN in patients with inoperable malignant bowel obstruction. Patients and families viewed TPN treatment as “highly beneficial” or “beneficial contributing to improved quality of life.⁶ "

The nutrition implications of each form of anti-neoplastic therapy are significant and must be understood so that appropriate utilization of nutrition support therapies can occur.

Cancer Treatment Options

Surgery is the oldest and most preferred form of treatment for cancer. Approximately 60 percent of patients with cancer have a surgical procedure. For undisseminated cancer, surgery can be curative. Surgery, however, can impact a patient’s ability to tolerate or absorb food. Surgery for resection of head and neck tumors can result in impaired taste and smell, difficulty swallowing, and increased regurgitation. Esophageal resection can result in gastric atony, diarrhea, reflux, and aspiration. Bowel resection may result in dumping syndrome, diarrhea, malabsorption, and vitamin and mineral deficiency. After undergoing a pancreatectomy, a patient may experience diabetes mellitus and enzyme deficiency. Each of these surgical interventions can result in diminishment of a patient’s nutrition status. Without swift intervention, nutrition status can become a significant risk factor in clinical outcome. An opportunity exists in some cases, however, to positively impact clinical outcome and reduce malnutrition related complications by providing peri-operative nutrition support in patients who are determined to be nutritionally debilitated for 7 to 14 days pre-surgery.⁷

Radiation therapy is utilized in approximately 50 percent of cancer patients. Depending on the area radiated, a patient may experience mucositis, ulcerations, fistula, anorexia, bowel strictures, dental carries, enteritis, mucosal atrophy, nausea, and vomiting. Head and neck cancer patients undergoing radiation therapy can benefit from an enteral feeding via a gastrostomy to maintain nutrient intake during treatment and throughout recovery.⁸

Chemotherapy uses chemical agents or medications to interfere with the steps of the cell cycle specifically involved in the synthesis of DNA and the replication of tumor cells. Nutrition-specific side effects of chemotherapy depend upon the drug or drugs and can vary greatly. Side effects may include nausea, vomiting, mucositis, stomatitis, changes in taste and smell, anorexia, food aversions, colitis, and either diarrhea or constipation.

Immunotherapy is used to manipulate the immune system and kill cancer cells. Biological response modifiers (interferon, IL-2, cytokines and monoclonal antibodies) carry cytotoxic drugs to the tumor. Side effects are mild in comparison to other anti-neoplastic agents and include flu-like symptoms.

Nutrition support is occasionally required for blood cell transplant (BCT) patients due to the severe adverse gastrointestinal effects (nausea, vomiting, esophagitis, mucositis, and diarrhea) of the cytoreductive regimen. Oral diet modifications, such as a low bacteria diet which is intended to minimize introduction of pathogens into the sterile post-cytoreductive gastrointestinal tract by food, require comprehensive diet counseling and safe handling of food during preparation. Finally, graft-versus-host-disease (GVHD) occurs in a subset of BCT patients, necessitating nutrition support intervention when the gastrointestinal tract is affected. GVHD is a T-cell mediated immunologic reaction of engrafted lymphoid cells that occurs against host-tissue resulting in destruction of healthy cells in the skin, liver, and gastrointestinal tract. Sloughing of the gastrointestinal mucosa necessitates parenteral nutrition support to promote bowel rest, stabilization of fluid and electrolyte balance, and metabolic support due to maintain nutrition status despite hypermetabolism.

By identifying malnutrition earlier in the cancer patients’ treatment process, cancer survival, healthcare cost, and quality of life can be dramatically impacted. Nutrition support therapies can be transitioned from the hospital to the home setting, or in many cases, can be initiated safely in the home, avoiding hospitalization completely. When specialized nutrition support is needed, the goal for all patients who undergo anti-neoplastic therapy is to support them during treatment and recovery, and to carefully transition the patient back to an oral diet as tolerated.

Infection Risks with Blood Cell Tranplants

Given its typically dramatic clinical course and frequently fatal outcome, fungal infections remain one of the most significantly feared post-transplant complications. Fungal infections occur at a higher than normal rate in transplant recipients. Management continues to be challenging, and the mortality rate, despite the use of newer antifungal agents, remains unacceptably high.

The risk for fungal infection is greatest during the post-transplant period during which the patient is profoundly neutropenic — typically for during the first 100 days post-blood cell transplant (BCT). Risk decreases as the patients engraft and circulating levels of infection fighting cells again become protective. Fungal infections are also frequently seen in patients with graft failure or significant delays in immune reconstitution, such as in recipients with severe graft-versus-host disease.

While many fungal organisms present an infectious risk, the most commonly encountered in BCT patients are Aspergillus and Candida species at rates of approximately 44 and 29 percent respectively. Historically, Candida albicans has been the principal yeast-like fungus isolated. More recently, however, other species such as Candida tropicalis, Candida parapsilosis, Candida guillermondii, Candida krusei, Candida glabrata, and Candida inconspicua have emerged as pathogens in bone marrow transplant patients. Unfortunately, these yeasts are often associated with resistance to antifungal azoles and with higher mortality. Appreciation for associated risk factors and the need for rapid and aggressive treatment are post-transplant mandates.

Aspergillus

Aspergillus is a genus of a nearly 200 different mold species. These fungal organisms are found throughout our natural, oxygen-rich environment. As a result, Aspergillus spores are regularly inhaled by all persons. While most Aspergillus species are innocuous to humans, several are pathogenic. The most common infection-causing species are Aspergillus fumigates, Aspergillus flavus and, less commonly, Aspergillus niger.

Significantly, the mortality rate in transplant recipients with invasive aspergillosis has ranged from 74 to 92 percent and an estimated 9.3 to 16.9 percent of all deaths in transplant recipients in the first year are attributable to invasive aspergillosis.

Aspergillosis refers to the infectious diseases caused by Aspergillus fungal organisms. Some common examples include bronchopulmonary aspergillosis, pulmonary aspergilloma, and invasive aspergillosis. Immunocompromised transplant patients are at great risk for infection. Key risk factors for fungal infection are essentially determined by degree of both immunosuppression and exposure.

Clinically, infection with Aspergillus present a continuum of symptoms and outcomes. For example, a pulmonary fungal abscess may present an absence of symptoms and be discovered only via chest x-ray. Or it may cause repeated hemoptysis and occasionally severe, even fatal, bleeding. A rapidly invasive Aspergillus infection in the lungs may present with cough, fever, chest pain, and difficulty breathing. Aspergillosis affecting the deeper tissues may present with fever, chills, shock, delirium, blood clots, and organ failure with death occurring quickly.

Diagnosis

Early diagnosis remains a major requirement for successful treatment. Sputum cultures are frequently non-diagnostic. While not guaranteed, the bronchio-alveolar lavage (BAL) specimen is positive in 45 to 62 percent of patients with invasive aspergillosis. Patients may have a chest x-ray and/or CT scan to support a suspected diagnosis. Evident will be the classically manifested “air crescent” sign. This finding is due to a lung cavity that is filled with air and shaped like a crescent (see Figure 1). Microscopically, Aspergillus species are demonstrated by silver stain.

Treatment

A number of strategies have been used to reduce the incidence and mortality associated with Aspergillus. Antifungal prophylaxis, frequent bronchoscopic surveillance, and aggressive early empiric therapy are among the common approaches undertaken.

Commonly prescribed prophylactic agents include itraconazole, inhaled/nebulized amphotericin-B, or voriconazole, with an expected course of therapy of three to 18 days. Many transplant programs treat airway colonization as well.

When infection does occur, treatment frequently requires reduction or discontinuation of immunosuppression. The risk, of course, is rejection or graft-versus-host disease as the immune system is no longer weakened. Noting that few patients with invasive Aspergillus amidst persistent neutropenia survive, it is important that recovery of functional neutrophils be rapid and efficient.

Amphotericin B, caspofungin, flucytosine, iatraconazole, and voriconazole are used to treat invasive aspergillosis. For severe cases, combination therapy including voriconazole and caspofungin may be initiated as first line treatment.

Adjunctive immunotherapy comprising gamma interferon has been utilized, although clinical outcomes have yet to demonstrate clear impact. Current research suggests that administration of a granulocyte or granulocyte-macrophage stimulating factor may be useful as immunotherapy against Aspergillus infections. Further study will influence determinative outcomes. Surgical resection of affected areas is also required in certain patients.

Candida

Candida is a genus of yeasts. Similar to Aspergillus, the environment is rife with Candida and most Candida species do not cause disease. Such Candida species as Candida albicans, which is normal flora in the mouth, gastrointestinal (GI) tract, and vagina, can cause infection, particularly in immunocompromised patients. In the stem cell transplant population, invasive Candida infections present at a frequency of approximately 30 percent. Significant predisposing factors in this population include:

• Mucositis and disruption of the oral mucosa
  
• Salivary gland dysfunction, resulting in xerostomia
  
• Changes in the microbial flora of the oral cavity that favor overgrowth of C. albicans
  
• Immunosuppression

The most common sites of infection are the superficial mucosal surface of the oral cavity (thrush), vagina, folds of skin, and nails. Esophageal lesions can provide a point of entry for Candida into the bloodstream and are a source of disseminated infection.

Acute disseminated candidiasis, in which bloodstream infection (candidemia) is accompanied by invasion of deep organs, is a life-threatening complication. The GI tract and indwelling vascular catheters are the principal portals of entry of Candida into the bloodstream. Candida infection of multiple organs is common, particularly the kidney, brain, and lung.

In the GI tract, the esophagus and stomach are most frequently impacted. Mucosal erosion and ulcer-like lesions develop as the organisms invade the submucosa and submucosal blood vessels. Candida can lead to cystitis, ascending pyelonephritis, and papillary necrosis of the kidney. Necrotic “fungal balls” may lead to ureteric obstruction and hydronephrosis. Candida is the most common central nervous system fungal infection, with the development of multiple microabscesses and/or localized meningitis. A fungal pneumonia can develop in the lungs either by inhalation or via hematogenous spread.

Diagnosis

Suspected fungal lesions can be cultured and examined by Gram-stain. For example, Candidal lesions seen on upper GI endoscopy present with characteristic whitish plaques. The plaques are brushed with a cytology brush and identified microscopically. Real-time PCR supports rapid diagnosis.

Treatment

The treatment options for Candida infection are similar to those for Aspergillus. Treatment with anti-fungal agents such as fluconazole, iatraconazole, and voriconazole is used. Caspofungin may also be initiated as first line treatment. Response rates are high, although re-infection can occur and some patients require maintenance therapy.

Common ICD-9 Oncology Codes

The following ICD-9 codes are associated with diagnosing oncology. Please note, this information is not all-inclusive and ICD-9 codes are updated on a regular basis. Always check that you are using the current and correct code by visiting our ICD-9 Code resource page.

Do You Know?

Which patient population has the highest rate of infections caused by resistant pathogens?
a) Children   b) Adults   c) Elderly

Answer: a) Children
Children are at a significant risk for resistant infection because this population has the highest rate of antibiotic use and thus the highest rate of infections caused by resistant pathogens.

Resource Center

The American Society of Clinical Oncology
The American Society of Clinical Oncology (ASCO) is a non-profit organization with overarching goals of improving cancer care and prevention, and ensuring that all patients with cancer receive care of the highest quality. As the world’s leading professional organization representing physicians who treat people with cancer, ASCO is committed to advancing the education of oncologists and other oncology professionals, to advocating for policies that provide access to high-quality cancer care, and to supporting the clinical trials system and the need for increased clinical and translational research. For more information, visit www.asco.org/portal/site/ASCO/.

Antiemetic Guidelines
The Multinational Association of Supportive Care in Cancer has compiled these antiemetic guidelines based on the Perugia Consensus Conference on Antiemetic Therapy. The presentation, updated in 2008, can be found online at:
www.mascc.org/mc/page.do?sitePageId=88041.

CancerIndex
The CancerIndex provides helpful links to cancer-related websites for both adult and pediatric cancers. To access these resources, visit www.cancerindex.org.

CancerCare
CancerCare is a national nonprofit, 501 c(3) organization that provides free, professional support services to anyone affected by cancer. CancerCare programs — including counseling and support groups, education, financial assistance, and practical help — are provided by professional oncology social workers and are completely free of charge. Visit CancerCare at www.cancercare.org.

Fever and Neutropenia Guidelines
The American Cancer Society (ACS) in combination with the National Comprehensive Cancer Network (NCCN) have developed and published treatment guidelines for patients with cancer who experience fever and neutropenia. These guidelines offer a more in-depth discussion of fever and neutropenia along with definitions and treatment algorithms. These guidelines are available in both English and Spanish and are updated as new information becomes available. The guidelines are available online at www.cancer.org or www.nccn.org. You can also call the ACS at 800.ACS.2345 (800.227.2345) or NCCN at 888.909.NCCN (888.909.6226).

References

• ¹August, DA, Huhmann, MB and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors (2009). A.S.P .E.N. Clinical Guidelines: Nutrition Support Therapy During Adult Anticancer Treatment and in Hematopoietic Cell Transplantation. J Parenter Enteral Nutr,33(5), 472-500
• ²American Cancer Society. Cancer Facts and Figures, 2005.
• ³Ireton-Jones C., DeLegge M. Quality of Life Outcomes in Cancer Patients Receiving Home Parenteral Nutrition Support. Nutr Clin Prac 2002.
• ⁴Marin Caro M.M., Laviano A., Pichard C. Nutritional intervention and quality of life in adult oncology patients. Clin Nutr 2007;26:289-301.
• ⁵A.S.P.E.N. Board of Directors and The Clinical Guidelines Task Force. Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients. JPEN 26 (suppl): 82SA-84SA, 2002.
• ⁶August D.A., Thorn D., Fisher R.L., et al. Home Parenteral Nutrition for Patients with Inoperable Malignant Bowel Obstruction. J Paren and Enter Nutr 1991;15:323-327.
• ⁷ Bozzetti F. Perioperative nutrition of patients with gastrointestinal cancer. Br J Surg. 2002;89:1201-1202.
• ⁸Raykher A., Russo L., Schattner M., et al. Enteral nutrition support of head and neck cancer patients. Nutr Clin Prac 2007;22(1):68-73.
• Bechard, LJ, Guinan, EC, Feldman, HA, Tang, V, Duggan, C (2007). Prognostic Factors in the Resumption of Oral Dietary Intake After Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) in Children. Journal of Parenteral and Enteral Nutrition, 31(4), 295-301.
• Bow, EJ (2009). Invasive Fungal Infection in Haematopoietic Stem Cell Transplant Recipients: Epidemiology from the Transplant Physician’s Viewpoint. Published online: 3 April 2009.
• Cohen, J and Maurice, L (2010). Adequacy of Nutritional Support in Pediatric Blood and Marrow Transplantation. Journal of Pediatric Oncology Nursing, 27(1), 40-47.
• Lipkin, AC, Lenssen, P, Dickson, BJ (2005). Nutrition Issues in Hematopoietic Stem Cell Transplantation: State of the Art. Nutrition in Clinical Practice, 20(4), 423-439.
• Thompson, JL and Duffy, J (2008). Nutrition Support Challenges in Hematopoietic Stem Cell Transplant Patients. Nutrition in Clinical Practice, 23, (5), 533-546.
• Singh, N and Paterson, L. (2005). Aspergillus Infections in Transplant Recipients. Clinical Microbiology Reviews, January 2005, p. 44-69, Vol. 18, No. 1.
• Springer Science+Business Media B.V. 2009 Mycopathologia (2009) 168:283–297. Retrieved March 19, 2010.

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