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Skip Navigation LinksHome > August 2012 - Volume 14 - Issue 6 > Management of Anorexia-Cachexia in Late-Stage Lung Cancer Pa...
Journal of Hospice & Palliative Nursing:
doi: 10.1097/NJH.0b013e31825f3470
Symptom Management Series

Management of Anorexia-Cachexia in Late-Stage Lung Cancer Patients

Del Ferraro, Catherine MSN, Ed, BSN, PHN, RN, CCRP; Grant, Marcia DNSc, RN, FAAN; Koczywas, Marianna MD; Dorr-Uyemura, Laura A. RD

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Author Information

Catherine Del Ferraro, MSN, Ed, BSN, PHN, RN, CCRP, is Senior Research Specialist, Department of Population Sciences, Division of Nursing Research and Education, City of Hope, Duarte, CA.

Marcia Grant, DNSc, RN, FAAN, is Director and Professor, Department of Population Sciences, Division of Nursing Research and Education, City of Hope, Duarte, CA.

Marianna Koczywas, MD, is Clinical Professor, Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA.

Laura A. Dorr-Uyemura, RD, is Director, Clinical Nutrition Services, City of Hope, Duarte, CA.

Address correspondence to Catherine Del Ferraro, MSN, Ed, BSN, PHN, RN, CCRP, Division of Nursing Research and Education, City of Hope, 1500 E Duarte Rd, Population Science Bldg #173, Room 169, Duarte, CA 91010 (

The authors have no conflict of interest to disclose.

This work is supported by a grant from the National Cancer Institute (PO1 CA 136396–Palliative Care for Quality of Life and Symptom Concerns in Lung Cancer; B. Ferrell, principal investigator).

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Nutritional deficiencies are experienced by most adults with advanced lung cancer during the course of their disease and treatment. Well-nourished individuals tolerate cancer treatment with less morbidity, mortality, and increased response to treatment as compared with those who are malnourished. Novel anticancer therapies cause many deficits that impact nutritional and functional status during the treatment process. Nutritional deficits include weight loss, malnutrition, and anorexia-cachexia. Anorexia-cachexia is complex, not well understood and seen in many solid tumors in late-stage disease. Assessing adequate nutrition is one of the most challenging problems for nurses, their patients, and patient’s families. The purpose of this review was to define and describe cancer anorexia-cachexia in late-stage lung cancer, through case presentation, and to describe palliative strategies for prevention, assessment, and management in the palliative care setting. Early assessment for nutritional imbalances must be done regularly with reevaluation for intervention effectiveness and should continue throughout the illness trajectory. Management of adverse effects of cancer and cancer-related treatment is critical to improving quality of life. Palliative care and hospice nurses play a critical role in early assessment, education, and prevention to support nutritional needs for patients and their families.

In 2012, it is estimated there will be about 226,000 new cases of lung cancer (non–small cell lung cancer [NSCLC] and small cell lung cancer [SCLC] combined), and more than 160,000 estimated related deaths will occur in the United States.1 About 20% of the deaths will be caused by the effects of cancer-related anorexia-cachexia syndrome.2 Cancer anorexia-cachexia is a wasting syndrome that occurs in 80% of patients with incurable solid tumors.3 This syndrome is common in specific cancer types: gastric, 85%; pancreatic, 83%; non–small cell lung, 61%; small cell lung, 57%; prostate, 57%; and colon, 54%.4 It involves extreme weight loss and malnutrition. According to the data, 60% of patients with lung cancer have already experienced a significant weight loss at diagnosis.3,5 In addition, cancer itself may be complicated with metabolic disorders.6 For example, paraneoplastic syndromes (PNPs) are rare metabolic disorders that are the result of remote clinical effects of cancer.7 They are not due to the physical effects of the cancerous tumors but are caused by substances produced by the tumors acting on tissues in the body.7

Nutritional screening and assessment are recommended at initial diagnosis, before cancer treatment begins, and should continue throughout care.5 Agreement exists among clinicians that cachexia related to cancer occurs in most patients with advanced lung cancer, and cancer anorexia, the loss of appetite, is a common symptom of cachexia.5 Assessing adequate nutrition is one of the most challenging problems for nurses and the interdisciplinary palliative care team. The purpose of this review was to describe cancer-related anorexia-cachexia in late-stage lung cancer, through a case presentation, and describe current and evolving strategies for prevention, assessment, and management. Management strategies presented apply to other cancers and noncancer illnesses in which effective treatment management for anorexia-cachexia is required.

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Mrs A.C. is a 72-year-old elderly Latina woman, who is newly diagnosed with stage IV NSCLC with metastatic disease to the brain and liver. She initially presented when undergoing preoperative workup for bladder reconstruction 1 month ago. Chest x-ray and computed axial tomography scan revealed a 4-cm left upper lobe lung mass. Bronchoscopy with biopsy demonstrated atypical cells highly suggestive of bronchogenic carcinoma. She underwent a left upper lobectomy with lymph node dissection. Pathology confirmed a 4-cm poorly differentiated adenocarcinoma with clear margins and positive lymph nodes, consistent with adenocarcinoma. She was referred to medical oncology for evaluation and an opinion of further treatment and care.

A comprehensive physical evaluation of the patient was done. Mrs A.C. is a thin, elderly bilingual female in no acute distress, alert, and oriented times three. She is 5′4″ tall, weighs 115 lb, with a body mass index (BMI) of 19.7 kg/m2. Her vital signs and oxygen saturation are within normal limits, and Karnofsky Performance Scale (KPS) score is 70. Her comorbidities include osteoporosis, gastroesophageal reflux disease, and urinary incontinence. She is also status-post two bladder resuspension surgeries. Her current medications are risedronate sodium (Actonel) and lansoprazole (Prevacid). Her family cancer history includes a brother who died at age 80 years of lung cancer, with a heavy smoking history. Her social history reveals that she is divorced, self-employed, college educated, and a lifetime nonsmoker. She has three adult children. Mrs A.C. lives at her younger son’s home, and he is her caregiver. She is Catholic and attends church regularly.

A complete blood count and comprehensive metabolic panel are normal. Her current complaints are moderate back pain, mild hoarse voice, mild hand tremors, moderate continual urinary incontinence, mild constipation, mild dyspnea on exertion, 3-lb weight loss within the last month, and mild fatigue.

After discussion of diagnosis, prognosis, treatment options, and goals of care with Mrs A.C. and her family, she agreed to initiate palliative adjuvant therapy of oral erlotinib and whole-brain radiation. Before initiation of treatment, the medical oncologist ordered a comprehensive nutritional screening and assessment based on Mrs A.C.’s complaints and examination noted above. The palliative care nurse conducted a comprehensive nutritional screening and assessment, assessing subjective and objective information. The Functional Assessment of Anorexia/Cachexia Treatment (FAACT) tool version 4 (Figure 1) was utilized to further assess concerns in Mrs A.C.’s appetite. The medical oncologist was notified, and the findings were reviewed with Mrs A.C. and her son.

Figure 1
Figure 1
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A treatment plan was formulated with a multimodal approach consistent with the patient and family goals of care. Appropriate pharmacologic interventions were prescribed by the medical oncologist to stimulate appetite (megestrol acetate), control pain (oxycodone with acetaminophen), and constipation (docusate sodium and sennosides). Nonpharmacologic interventions included referrals to the dietitian for nutritional counseling and education; pulmonary rehabilitation to assess pulmonary function; physical therapy to increase strength, endurance, and mobility; occupational therapy to address energy conservation needs for self-care; palliative care medicine for pain management; and radiation oncology for treatment evaluation. Before adjuvant treatment began, reevaluation of the effectiveness of interventions was scheduled in 1 week. Reevaluation noted a 1-lb increase in weight. Reports by the patient and family included an increased appetite and resolved pain. She continued to have mild constipation and admitted to “forgetting” to take her stool softener. She also stated that food was once again appetizing to eat especially foods she was culturally accustomed to cooking for lent. Treatment was initiated without delay.

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Cancer malnutrition has been described as a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form, function, and clinical outcome.8 Cancer- related anorexia and cancer-related cachexia are distinct syndromes but are often intertwined in progressive disease.9 Cancer cachexia is unique but difficult to distinguish from other causes of weight or muscle loss such as malnutrition related to cancer anorexia or malabsorption related to impaired gastrointestinal function.6 Therefore, because they are so closely related, definitions of cancer-related anorexia and cachexia have been combined and referred to as the “anorexia- cachexia syndrome.”6,10

Anorexia is the loss of appetite or desire to eat.11,12 In acute events, anorexia usually resolves with resolution of the illness, and any weight lost may be replaced with nutritional supplements or increased intake.3,5 In lung cancer patients, anorexia may not be recognized and lead to insufficient caloric intake and protein-calorie malnutrition. Weight loss seen in this starvation phenomenon usually involves loss of fat, rather than muscle tissue.3 The characteristics of anorexia are common among many patients with serious illnesses such as lung cancer, acquired immune deficiency syndrome, and other chronic diseases.3,5 Anorexia is the most common cause of malnutrition in lung cancer patients and is a symptom that is associated with cachexia.5

Agreement exists that cachexia is a complex syndrome and not well understood.3,6,8 Cachexia has been recognized as a frequent problem in lung cancer patients and represents an unmet need.6 Cachexia is a multifactorial syndrome and may or may not be associated with anorexia, along with significant weight loss, loss of muscle tissue as well as adipose tissue, and generalized weakness.6,13 It is often complicated by other food intake problems such as impaired integrity and function of the gastrointestinal tract from mouth to anus and poorly controlled physical and psychosocial symptoms including pain, shortness of breath, depression, or severe fatigue.3,6,13,14

The European Palliative Care Research Collaboration (EPCRC) is currently developing classification systems for pain, depression, and cachexia in patients with advanced cancer.6,15 This process has been comprehensive involving expert and public consultations and literature reviews.6,15 The cachexia guideline expert group identified cancer cachexia as a continuum of three stages of clinical relevance: precachexia, cachexia, and refractory cachexia.6 It was noted that not all patients would move through the entire spectrum.6 The stages of cachexia are defined on the basis of the patient’s characteristics and circumstances.6,15 Diagnostic criteria for end-stage cachexia have been defined by the EPCRC (Figure 2).6,16 In 2010, the cachexia guideline development group published European Clinical Guidelines on the management of cachexia in advanced cancer patients with a focus on refractory cachexia.6

Figure 2
Figure 2
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Refractory cachexia is characterized by a low performance status and life expectancy of less than 3 months.6 Refractory cachexia represents a stage where reversal of weight loss seems no longer possible because of very advanced or rapidly progressive cancer unresponsive to anticancer therapy.6 In this stage, the burden and risks of artificial nutritional support likely outweigh any potential benefit, and therapeutic interventions focus on alleviating the suffering associated with cachexia, such as symptom control with appetite stimulation and treatment of nausea or eating-related distress of patients and families.6 The diagnostic criteria include variable degrees of cachexia, cancer disease both procatabolic and not responsive anticancer treatment, low performance score, and less than 3 months’ expected survival.6

Lung cancer itself may be complicated by the PNPs of cachexia, which are often associated with anorexia.17 Metabolic PNPs such as hypercalcemia or hyponatremia may also cause anorexia or symptoms such as fatigue that contribute to anorexia.9 Overall, PNPs are rare, and only 10% to 20% of the patients with cancer experience metabolic disorders of PNPs over the course of their illness.18 Paraneoplastic syndromes occur more frequently in patients with lung cancer, particularly in SCLC, occurring in 3% to 5% of patients.18 Paraneoplastic syndromes are the result of substances (hormones, growth factors, cytokines, and antibodies) abnormally secreted by the primary tumor and its metastases.19 These substances affect the endocrine, neurologic, hematologic, and musculoskeletal systems of the body.18 The most common and best understood of the PNPs are of the endocrine system.20 Endocrine PNPs seen in patients with lung cancer include humoral hypercalcemia of malignancy, ectopic adrenocorticotropic hormone syndrome (also known as Cushing syndrome), and syndrome of inappropriate antidiuretic hormone.20

Basic etiologies of the anorexia-cachexia syndrome are (1) decreased food intake, (2) metabolic abnormalities, (3) the actions of proinflammatory cytokines, (4) systemic inflammation, (5) neurohormonal dysregulation, (6) tumor by-products, and (7) the catabolic state.21 Some of these mechanisms have a mutually reinforcing aspect; for example, anorexia leads to fatigue, fatigue increases anorexia, anorexia increases fatigue, and so forth.9

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Perhaps, the most important element of assessment involves patient and family goals of care.3,5,6,9,22 Nutritional screening and assessment are done before lung cancer treatment begins.5 Specific recommendations include completing a nutritional screening and assessment within 48 hours of admission or diagnosis of lung cancer, before initiation of cancer therapy, change in therapy, or a weight change of 2% to 5%.6,22,23 A nutritional screening profile is the process of assessing characteristics (early satiety, weight loss, weakness, fatigue, impaired immune function, skeletal muscle wasting, and poor performance status) of malnutrition and risk factors that will predispose a patient to nutritional deficiencies.17 Predisposing risk factors include: weight loss 5% or less in 1 month, 10% or less in 6 months, inadequate oral intake for 7 days or less, serum albumin 3.5 g/dL, recent surgery, severe infection, recent radiation therapy or aggressive chemotherapy, persistent distress lasting more than 2 weeks, pain, nausea, vomiting, dysphagia, diarrhea, mucositis, depression, anorexia, diminished self-care or lack of caregiver, dementia, poverty, and addiction (alcohol and/or dugs).17,22 Currently, there are no clearly accepted diagnostic criteria for identifying the specific cause of anorexia-cachexia seen in lung cancer, but anorexia from some etiologies is treatable, and assessment of the possible presence of causes as mentioned above is vital to quality palliative care.6,9 Early recognition of the etiologies followed by comprehensive assessments is recognized as imperative in the development of assessment guidelines.5,6,22 Other areas of assessment include laboratory values, anthropometric measures (BMI), and tools to assess functioning and performance and prognosis such as the KPS, and the use of multidimensional standardized instruments, such as the FAACT tool (Figure 2).6,8,9

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The best way to treat anorexia-cachexia seen in lung cancer is obviously to cure lung cancer; this will normalize the metabolic abnormalities induced by the tumor and/or tumor host interactions.6,21,24 If cure cannot be achieved, the next option would be to increase nutritional intake by dietary counseling and education and oral nutritional supplements.5,6 Early intervention to try to prevent malnutrition is easier than trying to reverse it after it occurs.25 Therefore, management is multimodal with the focus of stabilizing weight, improving comfort, lowering the risk of infection, keeping up strength and energy, minimizing distress, and improving quality of life (QOL).5,9 As previously stated, management and recommendations for anorexia-cachexia seen in lung cancer apply to other advanced cancers and illnesses.

The National Comprehensive Cancer Network (NCCN) has published Guidelines for Supportive and Palliative Care Symptom Management for anorexia-cachexia (Figure 3).26,27 The NCCN guidelines are a statement of evidence and consensus of the Palliative Care Panel Member authors regarding their views of currently accepted approaches to treatment.26,27 These guidelines are defined as categories to evidence and are based on lower-level evidence where uniform NCCN consensus agrees that the strategies are appropriate.27 These guidelines apply to all cancer diagnoses.26,27 The guidelines are divided for patients whose life expectancy is years to months, months to weeks, and weeks to days (dying patient).26

Figure 3
Figure 3
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When life expectancy is years to months, the NCCN guidelines recommendations include assessments, medications, and nonpharmacologic approaches. These are as follows: evaluate rate and severity of weight loss26; treat readily reversible causes of anorexia, for example, early satiety (eg, metoclopramide 10 mg before meals) and symptoms that interfere with intake such as dysgeusia, xerostomia, oral-pharyngeal candidiasis, mucositis, nausea and/or vomiting, dyspnea, depression, constipation, and pain26; review and/or modify medications that interfere with intake26; evaluate for endocrine abnormalities such as hypogonadism, thyroid dysfunction, and metabolic abnormalities (hypercalcemia and hyponatremia)7,26; consider appetite stimulants, for example, progestational agents (eg, megestrol acetate 160-180 mg BID), corticosteroids (eg, decadron 4 mg/d or prednisone 10-20 mg/d), and cannabinoids (dronabinol 5-20 mg/d)9,12,26; consider an exercise program9,12; assess social and economic factors9,26; consider a nutritional consultation9,26; consider nutrition support, enteral and parental feeding (as appropriate)26; and reassess the effectiveness of intervention and continue to treat and monitor symptoms and QOL to determine whether status warrants change in strategies with ongoing assessments.26 If the patient shows weight stabilization or gain, improvement in symptoms that interfere with intake, improved energy level, and resolution of metabolic/endocrine abnormalities, continue to treat and monitor symptoms and QOL to determine whether status warrants change in management.26 If unacceptable symptoms continue, intensify palliative care interventions, provide dietary consultation, and consider a clinical trial for anorexia-cachexia.26

When life expectancy is months to weeks or weeks to days, the NCCN guidelines are as follows: assess importance of symptoms of anorexia and cachexia to patient and family, and if important consider short course of corticosteroids26; focus on patient goals and preferences9,26; provide family with alternative way of caring for the patient26; provide emotional support and treat for depression (eg, mirtazapine 7.5-30 mg HS), if appropriate26; provide education and support to patient and family regarding emotional aspects of withdrawal of nutritional support26; recognize that discontinuation of nutrition is a value-laden issue and consider consultation with a bioethicist or spiritual counselor9; educate the patient and family of the natural history of end-stage disease including the following points: absence of hunger and thirst is normal in the dying patient, nutritional support may not be metabolized in patients with advanced disease,26 risks associated with artificial nutrition (eg, fluid overload, infection, and hastened death),26 intravenous hydration may increase excretion of drug metabolites providing benefits to the patient,26 symptoms like dry mouth should be treated with local measures (eg, mouth care and small amounts of liquids),26 withholding or withdrawal of enteral or parenteral nutrition is ethically permissible in this setting, and therefore it will not cause exacerbation of symptoms and may improve some symptoms26; and reassess the effectiveness of intervention. If acceptable, continue to monitor, treat, and reassess.26 If unacceptable, intensify palliative care efforts and involve specialized palliative services or hospice.26 These guidelines provide current accepted practical approaches to the treatment and care.3,9,12,26,28 The goal in palliative care is to minimize distress of symptoms and improve QOL.5,6

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Quality of life is influenced by nutritional status.17,27 The anorexia-cachexia syndrome is the most common syndrome experienced by people with advanced stages of disease and seen in a subset of cancers, led by pancreatic and gastric cancer, but also lung, esophageal, colorectal, and head and neck cancer.5,27 The distress and disruption in daily activities caused by anorexia-cachexia leave patients frail and weak, and their emaciated appearance is devastating for patients and their families.5,6,27,28

Quality of life encompasses four dimensions of well-being: physical, psychological, social, and spiritual.5,6,27,28 In some ways, the dimensions are distinct; however, there is tremendous overlap. The impact of anorexia-cachexia on QOL, seen in late-stage lung cancer is illustrated in Figure 4, adapted from the City of Hope Quality of Life Model.28 Whether physical, psychological, social, or spiritual, a deficit that is identified in one domain impacts all other domains of QOL.27,28 The symptoms caused by anorexia-cachexia that impact physical well-being include weight loss, decrease in muscle mass and body in fat, fatigue weakness, and dehydration.5,6,17,27,28 Anorexia-cachexia impacts psychological well-being with symptoms that include anxiety, depression, worry, and fear.5,6,17,27,28 Physical and psychological distress may also impact social well-being for patients and family caregivers.27,28 Often, family caregivers continue to try to help the patient by reminding and pleading with the patient to eat, as eating/feeding has great cultural meanings.5,6,17,27,28 The patient’s inability to eat can lead to irritability and become a source of tension, leading to family conflict and social isolation.5,6,17,27,28 Food we eat is derived from our cultural heritage, and in some cultures, eating provides a way of socialization.5,6,17,27,28 Increasing weight loss may lead to alteration in body image.5,6,17,27,28 Spiritual well-being is impacted by helplessness, hopelessness, and uncertainty and may cause one to reflect on meaning of his/her life and imminence of death.27,28

Figure 4
Figure 4
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Palliative care is an approach that improves the QOL of patients and their families facing the problems associated with advanced illnesses such as lung cancer, through the prevention and relief of suffering by means of early identification and impeccable assessment. Palliative care nurses play a crucial role in ensuring that nutritional screening and assessments are conducted for all patients with lung cancer, regardless of where the patient is in the disease trajectory. It should be done early and should be tailored to the goals of the patient and family. Most importantly, continued reassessment is necessary to evaluate the effectiveness of the response of interventions throughout the care. Management strategies are multimodal; therefore, collaborating with other specialists in the palliative care team is necessary to minimize suffering for patients and their families.

In conclusion, anorexia-cachexia is a challenging syndrome found in many cancers and other diseases. Further research is needed to continue testing of assessment and management approaches. Meanwhile, nursing assessment and reassessment of nutritional status can be used to implement current strategies. Collaborating between palliative care clinicians and researchers will allow the development of effective and practical guidelines, which is long overdue. The European Palliative Research Collaborative currently is the primary source of evidence-based practice guidelines of cancer cachexia with the overall aim of improving the management of pain, depression, and cachexia with translational research.

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1. National Cancer Institute (NCI). Non–small cell lung cancer treatment (PDQ). 2012; Accessed January 25, 2012.

2. Walz DA. Cancer-related anorexia-cachexia syndrome. Clin J Oncol Nurs. 2010; 14 (3): 283–287.

3. Jatoi A. Pharmacologic therapy for the cancer anorexia/weight loss syndrome: a data-driven, practical approach. J Support Oncol. 2006; 4 (10): 499–502.

4. Granda-Cameron C, DeMille D, Lynch MP, et al.. An interdisciplinary approach to manage cancer cachexia. Clin J Oncol Nurs. 2010; 14 (1): 72–80.

5. National Cancer Institute (NCI). Nutrition in Cancer Care (PDQ). 2011; Accessed January 25, 2012.

6. Radbruch L, Elsner F, Trottenberg P, Strasser F, Fearon K. Clinical Practice Guidelines on Cancer Cachexia in Advanced Cancer Patients. Aachen, Germany: Department of Palliative Medicine/European Palliative Care Research Collaborative; 2010.

7. Tyson LB. Paraneoplastic syndromes. In: Houlihan NG, ed. Site-Specific Cancer Series Lung Cancer. Pittsburg, PA: Pennsylvania Oncology Nursing Society; 2004: 57–72.

8. Kravits KG, Grant M. Malnutrition and cachexia. In: Chernecky CC, Murphy-Ende K, eds. Acute Care Oncology Nursing. 2nd ed. St Louis, MO: Saunders Elsevier; 2009: 406–418.

9. Wholihan D, Kemp C. Anorexia and cachexia. In: Ferrll BR, Coyle N, eds. Oxford Textbook of Palliative Nursing. 2nd ed. New York: Oxford University Press; 2010: 211–219.

10. Strasser F. Eating-related disorders in patients with advanced cancer. Support Care Cancer. 2003; 11 (1): 11–20.

11. Benson LM, Cawley KA. Principles of symptom management: anorexia. In: Newton S, Hickey M, Marrs J, eds. Mosby’s Oncology Nursing Advisor A Comprehensive Guide to Clinical Practice. St Louis, MO: Mosby Elsevier; 2009.

12. Becze E. Put evidence into practice to prevent and manage anorexia. ONS Connect. 2009; 24 (3): 14–15.

13. Mantovani G, Madeddu C. Cancer cachexia: medical management. Support Care Cancer. 2010; 18 (1): 1–9.

14. Perboni S, Inui A. Anorexia in cancer: role of feeding—regulatory peptides. Philos Trans R Soc Lond B Biol Sci. 2006; 361 (1471): 1281–1289.

15. Blum D, Omlin A, Baracos VE, et al.. Cancer cachexia: a systematic literature review of items and domains associated with involuntary weight loss in cancer. Crit Rev Oncol Hematol. 2011; 80 (1): 114–144.

16. Blum D, Omlin A, Fearon K, et al.. Evolving classification systems for cancer cachexia: ready for clinical practice? Support Care Cancer. 2010; 18 (3): 273–279.

17. Wilkes GM, Smallcomb KM. Nutritional issues facing lung cancer individuals. In: Haas ML, ed. Contemporary Issues in Lung Cancer A Nursing Perspective. 2nd ed. Sudbury, MA: Jones and Bartlett; 2010: 155–193.

18. Tyson LB, Ginex PK. Paraneoplastic syndromes. In: Houlihan NG, Tyson LB, eds. Site-Specific Cancer Series Lung Cancer. 2nd ed. Pittsburgh, PA: Oncology Nursing Society (ONS) Publications; 2012: 71–85.

19. Mayden KD. Paraneoplastic syndrome. In: Yarbro CH, Wujcik D, Gobel BH, eds. Cancer Nursing: Principles and Practice. 7th ed. Sudbury, MA: Jones and Bartlett; 2011: 845–862.

20. Armstrong TS. Paraneoplastic syndromes. In: Yarbro CH, Frogge MH, Goodman M, eds. Cancer Nursing: Principles and Practice. 6th ed. Sudbury, MA: Jones and Bartlett; 2005: 808–824.

21. Inui A. Cancer anorexia-cachexia syndrome: current issues in research and management. CA Cancer J Clin. 2002; 52 (2): 72–91.

22. Moreland SS. Nutrition screening and counseling in adults with lung cancer: a systematic review of the evidence. Clin J Oncol Nurs. 2010; 14 (5): 609–614.

23. McMahon K, Brown JK. Nutritional screening and assessment. Semin Oncol Nurs. 2000; 16 (2): 106–112.

24. Bosaeus I. Nutritional support in multimodal therapy for cancer cachexia. Support Care Cancer. 2008; 16 (5): 447–451.

25. Ottery FD. Cancer cachexia prevention, early diagnosis, and management. Cancer Pract. 1994; 2 (2): 123–130.

26. National Comprehensive Cancer Network (NCCN) Guidelines. NCCN Guidelines Palliative Care. Anorexia/Cachexia 2011. Accessed April 11, 2012.

27. National Comprehensive Cancer Network (NCCN) Guidelines. NCCN Categories of Evidence and Consensus. 2012; Accessed May 7, 2012.

28. Ferrell BR, Coyle N. The Nature of Suffering and the Goals of Nursing. New York: Oxford University Press; 2008.

anorexia; cachexia; cachexia-anorexia syndrome

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Skip Navigation LinksHome > August 15, 2013 - Volume 38 - Issue 18 > Reduction of Airway Complications With Fluid Management Prot...
doi: 10.1097/BRS.0b013e31829914ed
Cervical Spine

Reduction of Airway Complications With Fluid Management Protocol in Patients Undergoing Cervical Decompression and Fusion Across the Cervicothoracic Junction

Hart, Robert A. MD*; Dupaix, John P. MD; Rusa, Renata MD*; Kane, Marie S. MS*; Volpi, Joseph D. BS1*

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Study Design. Retrospective comparative cohort analysis.

Objective. To evaluate the effect of an intraoperative and intensive care unit protocol on incidence of airway complications for patients undergoing combined anterior-posterior cervical decompression and fusion crossing the cervicothoracic junction (CTAPF).

Summary of Background Data. Airway compromise remains an important potential complication for patients undergoing CTAPF. Volume of intravenous fluid replacement perioperatively has been correlated with risk of airway complications in this patient population.

Methods. A retrospective cohort study was performed comparing airway complications (postoperative airway edema requiring reintubation and/or prolonged need for intubation) in patients undergoing CTAPF prior to and after introduction of a standardized protocol. The protocol required limitation of crystalloid fluid resuscitation intraoperatively, with maintenance of blood pressure using vasopressors. Comparisons between the 2 cohorts included operative time, intraoperative blood loss, volume of IV fluid replacement, and incidence of airway complications and dysphagia.

Results. Among patients operated prior to establishment of the protocol, 45% (9/20) experienced airway edema requiring extended intubation or reintubation. This rate was reduced to zero among 8 patients operated after the adoption of the protocol (P = 0.029). Intraoperative IV fluid volumes were reduced from 6190 mL to 4802 mL after institution of the protocol (P = 0.016). EBL and total surgical time did not differ between the 2 cohorts (1024 mL vs. 869 mL, P = 0.443; and 6.76 hr vs. 7.18 hr, P = 0.460). Incidence of dysphagia was not significantly different between the 2 cohorts.

Conclusion. Establishment of a fluid and airway management protocol for patients undergoing CTAPF reduced the incidence of prolonged intubation or reintubation. Given the potentially life-threatening impact of loss of airway patency, intraoperative restriction of IV fluid while maintaining adequate blood pressure may be helpful in increasing the safety of surgical intervention in this complex patient population.

Level of Evidence: 4

© 2013 by Lippincott Williams & Wilkins

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Sunday, March 29, 2009

Ships Passing in the Night

Go check out Sam's blog and the video he took at one of the exits in my hometown. I almost got to have a short visit with the infamous Sam and Bill, but they had to keep moving on to have some BBQ in Nashville. Their truck was full of perishables to get to Dallas, so no time for visiting. Maybe next time!

Here he is at his award-winning blog!!

This is the tower of sweets he sent me last week. That was soooo sweet and thoughtful of you, and I feel so special!!! :-) Thank you, Tugboat from Burntknees!!
Description: Five boxes tall, elegantly proportioned, this slender new assortment delivers five favorites from our confectionery. Includes our popular Milk Chocolate Moose Munch® Confection, impossibly delicious Chocolate Truffles, cool Mint Chocolates, tangy Crème Chews and tender, tasty Raspberry Cutout Cookies.

Sylvia K said...

Ooooh yummy, yummy! Sounds delightful!

frogponder said...

Mooooooooose munch. Much better than the real thing!

mistress maddie said...

Sam is one hellva guy isn't he? His stories make me laugh so hard and you get to hear all the trucking worlds ins and outs and how things work. He is a real sweetheart!

Dan said...

Fooooooood!!!!! :)

Mark in DE said...

Wow, what did you DO to merit such goodies???


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Flower Show 7

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© Kurien Yohannan
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UploadedFebruary 7, 2011
TakenJanuary 21, 2011
ModelCanon EOS 50D
Exposure1/320 sec at f/8
FlashNo Flash
Focal Length70 mm

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  • Happy Birthday to my sister Bonnie
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Photo license: © All rights reserved

Took this image at the Republic Day Flower Show 2011, Bangalore, India. Read all about it @ http://blackstallionphotography.wordpress.com

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    ComfreyandJoy gave props (7 Feb 2011):

    Beautiful close up. Love the bee at home in the color yellow

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    ilus objekt

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Portrait Of Childhood

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© Franz Malalis
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    Chibelle gave props (2 Mar 2011):

    How does this not have more comments? Just precious - perfectly captured

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Our Newest Yarns on a Rainy Day

26 Jul Winter in August

Oh, alright, maybe not winter, but this chilly, rainy morning has me thinking about yarn! Not our (awesome) summer yarns like Firefly, but something wooly. Luckily, we’ve got a few new yarns that totally fit the bill:

  • Tara Tweed in new colors! This earthy-but-still-soft wool blend would be great for guy’s accessories, or a boyfriend-style sweater.
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  • Liberty Wool Prints are back! We’ve got two classic colors and two brand new colors (including my favorite, Middle Earth) of this worsted weight, color-shifting wool.
  • Learn to knit with a Jil Eaton Kit. This kit has all you need to dip your toe in knitting (or get a friend hooked), including soft Minnow Merino yarn.
  • New, wild yarn: Ringo! This is  super bulky chain-link yarn, perfect for quick gifts and adding texture. We’ve got two colors: a kicky blue and pink multi and a demure white and grey mix.

Come check them out! It won’t be cold and rainy forever, but it’s also never too early to start your next cool-weather project.

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Introvert? Beware the coffee drinkers

Introverts and coffeeThe experience of being introverted is widely misunderstood. I don’t mean to imply that, as individual people, introverts are misunderstood. What I mean is that most people don’t understand what defines an introvert versus an extrovert. Introverts aren’t necessarily anti-social, shy, nerdy or lacking good communication or interpersonal skills. No, no, no. Not at all. I’ve met lots of extroverts with poor communication skills and know some introverts (myself included) who can be the life and soul of the party.

I am not going in to too much detail about the theories of why some people are introverted and others are extroverted, or the Jungian origins of these concepts. But this article in Fast Company is an excellent one to read on the topic if you are interested or, this one in the Atlantic, actually written by a self proclaimed introvert.

Most definitions emphasize some common themes, all of which describe me to a tee:

  • Interacting with a lot of people at once drains their energy
  • They love their own company and can happily spend hours alone
  • Highly stimulating circumstances leave them feeling unfocused and confused
  • They tend to have small groups of very close friends rather than large networks of acquaintances

All of that said, I LOVE parties, dancing, meeting new people, big events, night clubs and music festivals. However, after about 5 or 6 hours of any one of the above I am D.O.N.E. Don’t talk to me, don’t call me and definitely don’t turn up unannounced at my house (unless you desperately need the loo and plan to leave immediately afterwards). It is not uncommon for me to do a disappearing act from a party. When my social energy runs out, there are no reserves.

‘So what has all this got to do with coffee?’ I hear you say. Well, another thing I find particularly hard to deal with as an introvert is being “talked at”. And I’ve noticed that people who love to talk at you, talk at you even more after a couple of cups of coffee. It seems they just can’t stop themselves.

I started to notice this when I worked at Brock Uni. One of the students I worked with used to burn the candle at both ends quite frequently. He’d come in sullen and hung over. However, after a Red Bull for breakfast, an extra large Starbucks mid morning, a Coke at lunch and another bucketful of coffee around 3pm, he perked right up. By 4pm his ability to talk became the equivalent, to me, of Chinese Water Torture. After 45 minutes of listening to his verbal diarrhea I would have done anything to have him stop. ANYTHING.

That is an extreme example. However there are many other occasions this has happened. There I have stood, not able to get a word in edgewise, while the over-caffeinated person in front of me conducted a monologue in my direction. My body language turning in on itself, I become incapable of delivering the placatory nods and smiles that indicate polite interest. Every cell is screaming STOP TALKING PLEASE!

I can’t be the only person who experiences this. Although I read somewhere that only 25% of the US populations have predominantly introverted personalities (like most traits, introversion and extroversion exist on a continuum). So maybe I am in the minority. I guess that if you are naturally extroverted you would find it difficult to conceive the experience of an introvert. Although I have no problems imagining what an extrovert might feel like, and have, in the past, wished to be that way.

So for the benefit of those extroverts out there, I stole the following from the Fast Company article. It is handy guide to caring for your Introvert. It doesn’t include “Don’t drink too much coffee”, but in my opinion, it should.

Introvert Chart

Growth Mindset & the Power of “Not Yet”

Growth MindsetSo, I’ve been learning as much as I can about launching a ‘software as a service’ business. Since I also have a day job, I am doing this by listening to podcasts and audio books (see the page Stuff I Like for a list). Am I an expert?? Er, NOT YET! The amount to learn seems overwhelming. Mail Chimp, Google Analytics, Word Press, SEO, Libsyn. And so the list goes on….

However, a side benefit has been a reminder about something that I fundamentally know to be true, but which I often forget. The powers of a growth mindset. In other words, brains and talent are a good starting point, but dedication and hard work will lead to accomplishment.

A fixed mindset is the opposite to a growth mindset. That is the mindset of people who say things like “I am just no good at xxxx”, or “Oh, I could never do that”. Growth mindset is also the enemy of “all or nothing” thinking. This is when you say “Either I am really good at xxxx, or else I am a failure at it”. As a teenager, I was a master at this line of thought.

The “non-runner” who trains for a marathon is a great example of someone who has a growth mindset.  Or the person with no formal education who decides, midlife, to go back to school to get a post secondary qualification.

In my own life, it is what allowed me to go from a 30 year old smoker who couldn’t jog 1 mile, to a mountain biker who podiumed in a 24 hour, solo mountain bike race at 44.

Anything is possible. That is, if you want it badly enough and are prepared to work for it. You need to have a healthy ego, because the chances are you’ll fail along the way. Oh, and a great sense of humour.  Because, let’s face it, life is a shit show.

Also, you’ll notice that 15 years passed between my first, dreadful, running experience and the longest MTB ride of my life. Progress is about chipping away, little by little, at a goal. I learned to recognize small wins and forgive myself when you I didn’t meet my own (arbitrary) expectations. Out of pure frustration I have thrown my bike in to the bush more times than I care to remember. This didn’t do me (or my bike) much good! Forgive yourself but don’t give up. It’s easier and less damaging to personal property than throwing things.

I’d also suggest that you stay away from the FMP (fixed mindset people). You know, those negative nellies, who constantly wang on about what they can’t do, or worse, tell you what you can’t do. Enough said.

I’ve heard others describe this mind set as “believing in the process”. I have adopted this as a personal mantra for when things get a bit tough.

Recently I watched a great Ted Talk by Carol Dweck. She describes a school in the US that added the grade “not yet” to their marking process. If a child doesn’t pass a subject, they receive a “not yet” grade instead of a failing one.

In this way the message they gave to kids was that, although they hadn’t reached the required standard yet, it wasn’t a permanent situation. The door remained open for them to try a different approach, work harder and, with support, get to where they needed to be. Contrast this with the prevailing trend to give everyone a congratulatory slap on the back and a gold star, regardless of performance*.

One of the things I’ve noticed with a growth mindset is that, sometimes, I apply it to certain aspects of my life, but then not others. This happens with other people too. I know individuals who have achieved remarkable success in their careers, yet shy away from fulfilling their burning ambitions out of a fear of failure.

For me, I have always wanted to start my own online business. I am perfectly placed to do so. My husband is a top notch software developer, I have business experience, a wonderful network of smart people, and a relatively flexible life (read: no kids). But I haven’t done it until now because I didn’t know the first thing about it. I would probably still be thinking about it unless a good friend had asked me to join her. Once she did, and we took the first step, I was hooked.

Who knows where this latest venture will take us. We haven’t bet the farm (yet!), we are learning as we go along, and our progress is slow. However, even if this doesn’t turn in to a viable profit making endeavour, I will benefit in other ways. I always do. I’ll prove I can do it, and so gain self confidence. I’ll learn something new. I’ll meet new people and I’ll have a great story to tell.

So what is your burning ambition? What can you do to take small steps to move towards it? If I can, believe me, you can.

*Full disclosure here – I don’t have kids so this comment is based on my own experience working with undergraduate students for 7 years. Those kids whose parents have used the “everything you do is awesome” approach to parenting have fragile egos and don’t know how to deal with criticism.

Brexit Again

Brexit VoteI have been stewing about the Brexit vote all weekend. However, I’ve had the chance to discuss it with friends, including those who are far better politically informed than I.

Dave, who can always be relied upon to provide a well informed counter-argument, gave me an interesting alternative to consider. Following on from our discussion he sent me this article from The Intercept.

The article blames the vote on arrogant and elitist institutions (including the media). It argues that these institutions have systematically ignored the plight of people who are suffering from a decline in their standard of living. All the while the wealth gap between them and the “elite” gets wider. These people have limited alternative methods to enact change, and the Brexit vote was an opportunity to hit back. Regardless of whether it was the right thing to do or not.

Have a read and keep an open mind.

Dave has long since told me I am an elitist. A claim I have always roundly dismissed. But maybe he is right. Maybe that is why the vote upset me so much; because I identify with the oppressors and not the oppressed.

Major food for thought.

Goat School

Goat SchoolYes, you read that right, Goat School. It’s a thing, and Rob and I were there about four weeks ago.

The King and Queen of Goat School, Janice and Ken Spaulding, have lived off the income from their goat farm in rural Maine for about 25 years. In 2004 they started organising a three day workshop to impart their considerable experience and knowledge on rearing goats. What Ken and Janice don’t know about keeping goats is not worth the knowing. On the weekend Rob and I went, there were 18 attendees. They’ve had up to 100 people at a time in the past. In years gone by they have even taken Goat School on the road to other locations across North America.

Now, if I had a dollar for every time someone raised a doubtful eyebrow when I mentioned Goat School, I could probably have bought my own goat by now. I had even let these people get to me. The first day I worried whether the experience would justify the time off work and the ten hour drive. The doubters could not have been more wrong.

I LOVED IT. The three days went too quickly. I was fascinated and engaged the whole time. I felt like I had found my tribe. Most of the attendees were like Rob and I, curious about what goat keeping entailed. Many were either planning for, or in the early stages of, a lifestyle change. They wanted to back away from the world of working for others, and were trying to define what that would look like for them.

We learned about the 3 different types of goats (dairy, meat and fibre) andButter Cup the goat how to care for each type. We learned about milking, breeding, birthing, shots, food, shearing, castration (gulp), tattooing, licensing, hoof trimming and the importance of a vet that knows about small ruminants. We also learned about “freezer camp” – I’ll leave that one to your imagination. The unsentimental delivery of all this info helped me process some of the aspects of goat farming that I was a bit stuck on (freezer camp being one of them).

All this info was sprinkled with real life stories from Ken and Janice’s own experiences. Their banter reminded me of a comedy double act and our entire group spent most of the weekend laughing. In fact, at the end I really did feel like I’d joined a little community. Both, Janice and Ken said that they hadn’t had so much fun delivering goat school in years. You could tell they enjoyed it as much as we did. On the final day we learned about how to make different kinds of cheese out of goat milk, and also how to make soap. Rob was so excited about making our own cheese, I thought he was going to buy a goat right there and then!

So, what’s next? Well we can’t keep goats in our garden. And, as much as the place in EVL would be absolutely perfect, we don’t plan to live in the US. So we just have to figure out what that looks like for us. I expect that this planning is going to take a few years. It will be a journey for sure. However, I thought that if I started blogging about it, if anyone is reading it they could follow this journey with us.

My 2 Cents on Brexit

Banksy UKIPYou may already have heard enough about Brexit to last you a life time. If so, skip this uncharacteristically long one from me. However, quite a few people have asked my opinion. So I decided I wanted to figure out what my opinion actually was. The way I do that is to write about things, so here goes. I wrote this about 5 days after the vote but have only just had the time to post it now.

I’m Going Under Cover

I think I am going to change my accent. 15 years of living in Canada has already given it a funny lilt. Sometimes I am mistaken for an Auzzie, or a South African. In light of the Brexit vote this isn’t such a bad thing. Moving forward I will play along because, for the first time in my life, I am ashamed to call myself a Brit.

I was 23 when Britain joined the EU. However it was many years before that when I started traveling through Europe with my family. We’d drive south to Dover, cross the channel on a ferry, and then down through France and in to Spain. Armed only with the Relais Routiers we’d stop at little B&B’s, eat local food and hang out at the beach. These are some of the fondest memories from my childhood and have had a huge influence on the person I am today.

These early experiences of “foreignness” (France and Spain are very different today than when I was 7), gave me a curiosity about other cultures. I spent years travelling and working in different countries before settling in Canada. Nonetheless, moving to live and work in Canada was a huge cultural eye opener for me. Canada is truly a multi- cultural country. I interact with a far greater variety of cultures now than at any point in my previous, nomadic, life.

How did I get it so wrong?

Even though I’ve lived in Canada for about 15 years, I stay in constant contact with my immediate family in the UK. But, when the EU referendum in the UK was announced, I barely took any notice. In my mind, who would vote for something so completely regressive? How could anyone possibly understand what leaving would mean? Why (unless you are a white supremacist) would you agree to do anything the UKIP party thought was a good idea? Nigel Farrage is a national joke.

Shows you what I know. Now I am shaking my head in disbelief and trying to figure out what possible reason more than 50% of an entire nation would vote this way. And this is what I’ve found.

The question about the payment thing

According to the Leave campaigners, being an EU member was costing the UK, GBP 350 million a week. British funds that could otherwise be much better spent on funding the National Health Service. That was a hotly disputed number even before the vote. The number ($50 million a day) was plastered all over the “battle bus” that Boris Johnson used during the Brexit campaign. Odd now that the Leave campaigners are distancing themselves from that claim. In fact, Nigel Farrage of UKIP is quite certain that he never said this money would go to the NHS. A quick look at the Brexit campaign’s website now will show you that this is a bit of a trend for the Brexit side. You will in fact see that none of the pre-campaign statements/promises are there anymore. Just a lovely note saying “Thank You”. Accountability, anyone?

The Syrian Refugees are Coming!

Another cornerstone of the Brexit campaign was linked to Turkey’s application to be a member of the EU. The Leave side warned of the terrible dangers this held because of all the Syrian refugees Turkey was harbouring. Refugees who had fled to Turkey in fear for their lives. The story went like this:

  1. Turkey becomes a member of the EU
  2. EU member countries open their borders to Turkey
  3. Syrian refugees FLOOD the EU from Turkey and end up in the UK
  4. Syrian refugees then drain the UK economy and steal British people’s jobs
  5. The UK bursts in to flames and sinks in to the Irish sea.

OK, so I made the last bit up. Fact is, Turkey has been trying to get in to the EU since 1972. They have still only managed to meet 1 of the 25 requirements to do so. One politician I was listening to estimated the process would take until 2030. Hardly an immediate threat is it?

Britain for the British

The argument for the Leave side I found most embarrassing was the “Britain for the British” thing. Meaning, ‘we don’t want any of those non-British people coming in, stealing our jobs and diluting our culture’. Let’s suspend belief for a moment. Let’s say this argument’s appeal has nothing to do with xenophobia, misplaced nationalism or a fear of otherness. I would then admit that, if I were chronically unemployed, I would be angry to be told that immigrants were landing jobs because they were prepared to work for less money. I think that may be oversimplifying the argument, but you get my point.

However, I don’t think that leaving the EU is a solution to that problem. First of all it is a minimum wage issue. I don’t remember reading either side saying minimum wage legislation would be tabled as a result of the vote. I also can’t find (though it may exist) anything to says the EU prevented the UK from passing minimum wage legislation.

Immigration, it’s a thing, people!

The second thing people conveniently overlook is that no-one could or should, actually stop immigration. For our current version of Capitalism to work, countries’ economies need to grow. So in a country where birth rates are not keeping up with the number of people dying off, you NEED immigration. All the Syrians Germany “allowed in” are a drop in the bucket compared to their rapidly declining population. The UK is no different.

Along the same lines, there is a hard fact which seems to have escaped a lot of people’s attention. That is we were all bloody immigrants at one time or another!! A large part of my family ancestry is Irish. Were those immigrants (starving, poverty stricken and poorly educated) any more or less worthy of a new start than those seeking a new life in the UK now? If everyone that was “not from here” left, society would grind to a halt.

What Now?

So, let’s say all the above points were actually valid, what has the Brexit vote done for us so far? Well, let’s think.

First off, if free trade ends, I wonder how much all that administration is going to cost to harden borders. How much time will it take to renegotiate all these free trade agreements, individually, with each nation? Then add the possibility of Ireland and Scotland voting to become independent from the UK. Any English Government is going to be embroiled in all of that business for the near future. I wonder if the cost will be more than the money we have been paying to the EU? What does it mean for the implementation of other, important, social and economic legislation?

UK versus the world

Then there’s the Transatlantic Trade and Investment Partnership (T-TIP). This EU – US trade agreement, which has taken years to negotiate will no longer apply to the UK. An EU free UK will have to negotiate its own arrangements with the US and Canada. Way to go UK, you are now on your own!

There is so much uncertainty around the Brexit decision that the financial markets experienced their biggest drop ever. All the major rating agencies have taken away the UK’s former “triple A” credit rating, and the GBP has even fallen against the Canadian dollar – 30 cents in 5 days – a 15% drop.

Finally I think the free movement of people, ideas, and commerce was what made the UK an amazing place to be. I have always been proud to say that the UK was part of Europe, in my mind that was akin to saying “I am a citizen of the world”. Maybe that won’t change, but something about the protectionist and nationalistic undercurrent to the Brexit campaign makes me think that this won’t be the prevailing sentiment.

Babies and Bath Water

I get that there is this bizarre nostalgia for “what Britain used to be”, but it is simply that, nostalgia. The world has changed, and the UK has had to change along with it, as a part of the EU or not.

The dissatisfaction with the social and economic situation in the UK will not be solved by roundly blaming our relationship with our largest trading partner. It certainly won’t be helped by feeding racist ideology and a fear of foreigners, which I sense was driving much of the vote.

Now in the aftermath of the vote, there is so much hyperbole that it is difficult to sort through for the common sense. So many of the people who voted to leave are now standing up and saying they didn’t know what they were voting for. Seems to me there was some irresponsible campaigning by the Brexit side and I feel as though the UK threw out the baby with the bath water when it voted.

Absolutely Fabulous Movie Almost Here!

Absolutely Fabulous MovieAfter a long day on no sleep (dodgy oyster, don’t ask) I sat down to look at the news. Then BAAAAM! I discover that a US release date for the Absolutely Fabulous Movie has been set for July. Hurrah!!!

Absolutely Fabulous (or”Ab Fab”) represents a slice of 90’s UK culture that I hold dear. It reminds me of my early twenties. As with the sitcom, the movie is written by Jennifer Saunders of French and Saunders and Comic Strip fame. Ab Fab’s main characters are Eddy Monsoon (Jennifer Saunders) and Patsy Stone, her alcoholic, pill popping, side kick, (Joanna Lumley). Each show poked fun at their outrageous, booze fueled, lifestyle and slavish dedication to fashion.

Even 24 years ago Eddy and Patsy were, ahem, “past their prime”. Eddy’s plain but sensible daughter and potty mother constantly frustrated Patsy and Eddy’s champagne soaked capers. The show’s other star is Eddy’s hilarious personal assistant, Bubbles. Played by Jane Horrocks. I still laugh when I think of her impression of a fax machine in an early episode. If you’ve never seen the show, think of a British version of Sex in the City (tough, I know). Then imagine the characters trying to behave the way they did in the first series but now they are 20 years older, drink a lot more, and are considerably funnier. Got it? Well then, you are sort of half way there.

Ab Fab has this mix of slapstick and funny, fast-paced dialogue. I loved watching two older women, dressed like 17 year olds, behaving really badly. It wasn’t just me who found them appealing. An entire generation of TV watchers loved the show. Now, 24 years later, they seemed to have pulled it off again.

The Absolutely Fabulous movie is said to have more than 60 star cameos including Stella McCartney, Kate Moss, Joan Collins, Jerry Hall and Jeremy Paxman. Even better (in my opinion), it features 90 drag queens!! Based on the premise that Eddy and Joanna accidentally push Kate Moss off a balcony into the Thames at a party. To escape the paparazzi, they run, penniless, to the South of France.

Oh how my day just got so much better (darling!).

The Oatmeal Dog and the Joys of Swearing

SwearingThis cartoon on Matthew Inman’s comic/blog page “The Oatmeal” has had me laughing to myself all week. I wish I could embed it in this blog.

I love it for two reasons.

The first is that he has exactly captured the behaviour of our youngest dog, Sprocket who is either in repose Sprocket1 or charging around like a thing possessed.

The second reason is because it introduced me to a new swear word. Even as I type “holy assbutts”, I am smiling.

Yes, I LOVE swear words. I can’t explain it. My Mum, or maybe a teacher, once told me that swearing showed a poor command of the English language and a lack of imagination. In other words, if you have to insert “f**k” or “s**t” in to your sentence it’s because you don’t know enough adjectives. That may well be true. But swearing is so much fun!!! I actually like learning new words, period, and then trying to fit them in to a sentence without sounding like a dork, and I don’t often swear in anger, more just because the words themselves make me laugh.

You’ll notice in a blog post below I start it with “holy shit balls”. That is also a fairly new one to my collection. I had wanted to insert a GIF that showed Tina Fey using it, but WordPress has a thing against GIFs and I couldn’t work out how to get around it.

Other recent favourites from a BuzzFeed article include “Fucktrumpet” and “Assbadger”. They make absolutely no sense, but that is part of their awesomeness.

Apparently the British are particularly good at swearing, so maybe that is where my fascination for the crude comes from. I tried to find swear words that Shakespeare used and came across this wonderful blog post by Marginalia, whose site I will be visiting again. She is obviously a scholar of literature (and a fan of profane language) and points out that while Shakespeare didn’t actually use directly foul language (there were all kind of Christian restrictions in those days about what you could and could not say on stage), he was really good at making rude references in a more subtle way. I won’t repeat the examples Marginalia provides, because you can read them for yourself in her post.

So there you have it.

Please do feel free to share your fave swear words with me, the more unusual, the better!

On Longevity

Old ShoesLast night I attended my organisation’s Annual General Meeting.

Apart from the usual business (approving minutes, electing Board members etc.) this meeting is also the time when employee service awards are given out.

People received awards for 5, 10, 15, 20, 25 and 35 years of service. 35 years!!!! The lady who received her 35 year award started work as a student and has never left. She has fulfilled different roles and responsibilities, and the organisation has grown over time, but essentially she grew up with our organisation. She isn’t the only story like this. In some cases, this is the only work environment people have experienced.

This, to me, is amazing. The only thing I have done consistently for more than 10 years (other than the usual, you know, breathing and stuff) is to be married.

I’ve never stayed at a job that long, I’ve never lived in a house (or even one city) that long, heck, I only need one hand to count the number of friends I see regularly who I’ve known that long!

What is wrong with me???

This is not the first time I’ve wondered about this. Before I left my last job I agonized for weeks over whether it was the right thing to do after 4 years. And maybe it wasn’t. BUT I was working crazy hours, was stressed and miserable and no longer really believed that the work I was doing to support the institution was consistent with my values. I am sure though that I can’t be the only person who has faced those circumstances, and many people, I am sure, would hang in there for much longer than I, in the hopes things would change.

So I decided to do a bit of research and come up with a set of good reasons why someone should stay in their job for years and years, and reasons that would justify my flaky employment history. I expected to come out of this feeling like I was an odd ball, after all, I come from a family of loyal time-served employees (my Dad worked for the same company for more than 30 years and my sister has only ever worked for two companies over the course of her professional life). In fact I found the things I read validated my own behaviour.

The positive arguments for longevity seem to me to be good for the employer and not necessarily for the employee (unless they are somewhere that offers steady increases in responsibility and this is reflected in their salary). Employers who value longevity see the advantages of low turnover (hiring and training are expensive and time consuming) and a more “stable” culture. I put “stable” in quotation marks deliberately. In some cases I honestly think “stable” can become “stagnant” and if there are too many people with endless years of service, change gets harder and harder to implement.

What I was surprised to discover was that the definition of “longevity” is not at all “long” and that attitudes that once might have valued years and years of service, have changed. Longevity, in many articles I read, refers to over 2 years of service. Currently a North American worker stays an average 4.6 years at each job before moving on. In fact a new term for “job hopping” has been developed to name the under 25 year old tendency to move jobs every couple of years. It is now known as “Professional Pivoting”.

Another article I read said that you MUST change jobs every 3-5 years in order to learn and grow and move up in your career. Apparently the concept of loyalty is demonstrated through loyalty to an idea, a project or a group of people, and not by showing up day after day to do the same thing for the same company. I concur with this sentiment (I am, of course, a bit biased). At both the job I am in now, and the one I was in before, I bust my ass to make changes and leave the organization in a better place then when I joined. The reality of both organizations when I joined was that I replaced very long term employees (almost 20 years in both cases). Because of this there had been 20 years of some things being done amazingly well and some things were not done well at all. We all have our strengths and weaknesses, and, over 20 years these become ingrained in to culture and practice, this is not necessarily always for the best. There again, I am taking the organisation’s perspective.

From the employee’s perspective, I completely understand that stability and familiarity are important to people at certain points in their lives. I get that if you are bringing up small children, or going through some personal crisis in your own life, then change in other aspects of your life is not welcome. However these things (one would hope) don’t last forever.

However, I also think that staying too long in one place makes you afraid of taking risks, moving on, becoming adaptable to new circumstances and working styles, and possibly learning new skills. One of the themes that has come up in conversations with individuals who have worked for very long periods of time at the same place, is that they don’t know what else they would do. Surely the point of dedicating all that time and hard work to an organization should allow, at the very least, for you to build a skill set that you could leverage if you ever wanted to change direction? Or, that if an individual feels they have stagnated, isn’t it their responsibility to gain new knowledge and skills for themselves?

I think this explains my “Professional Pivoting”. To use a cliche, I give 110% wherever I work, and I expect, as well as a paycheck, to be given the opportunity to take on new things and continuously learn. However if I hit a wall and I cannot see a way to grow (and by that I mean is skills not necessarily in dollars), and I’m getting no support, then it is time to move on with no regrets.

This is apparently a very Gen X/ Gen Y/Millennial way of looking at the world. They will be loyal to an organization, however they expect that the organization demonstrates some loyalty to them in the form of providing opportunities to learn and grow. As a ‘Gen X’r’ myself, this doesn’t make me all that different to my peers. Just different to a lot of the people I work with! But then again that’s probably why I was hired. So maybe I should just stop fretting and get on with the job at hand.

Rock City MTB, Ellicottville

Rock CityRob, myself and the three tiny terrors were bit pooped today after mountain biking in Holiday Valley on Saturday and Sunday. At one point last night, I had to poke Sprocket to check he was still alive. So the prospect of more climbing (which is pretty much a given when mountain biking in EVL) wasn’t that appealing and instead we opted to ride Rock City.

Rock City, part of a NY state forest, is gorgeous. Riding the trails there feels like you’ve gone back in time to when the dinosaurs roamed. JP & Rock CityHuge rocks covered in moss are everywhere and the trees are large and old, with enormous roots. It’s a fun place to ride when it is dry, although for those who are nervous of rocks and roots, there might be a bit of walking involved. That said, there are worse places to hike a bike.

Looking at WNYMBA‘s review of the trail, it gets five stars and I understand why. I think their review is of a much smaller section than the one I call “Rock City” as they say it is 1 mile long and I clocked about 6km from the entrance to the end where we joined the Tournado ByPass loop and rode out on to the South Pale Ale Trail to the road, making about a 9km loop in total.Rob & Terriers There isn’t a lot of elevation and so if you feel like working on your technical skills without coughing up a lung, this is a great place to do it. You may not ride all the sections, but the sense of achievement for getting through a rock garden that you’ve not managed before is unmistakable.

I’ve included the MTB Projects map of the EVL area below so you can get a sense of where it is if you’re interested in riding there. Or you could go to the MTB Project site and search for Ellicottville for more information.

Back At It Again

Where did the time go?Holy s**t balls – it’s been five years since I wrote a blog post! Where does the time go?

I’ve been writing a blog for a business venture that I am working on with a friend and enjoying it so much that I thought it was time to start my personal blog again. The business blog (check it out at is fun but we are writing for an audience who is interested in getting a job in the food industry, so not much scope for my ramblings on other topics. I am also enjoying learning more about WordPress and I figured this was a good place to play in the WordPress sandbox without any consequences, since I doubt anyone is reading this at the moment!!

I’m not going to do a “catch up” type post since I think it will be really boring, but I may post a few things that relate to stuff that happened in the recent past since so much is going on at the moment. You can expect the usual mix of biking, dogs, and the odd rant. I’ve taken up quilting and sewing since completing my MBA, have this nascent online business going and have developed a bit of an obsession with becoming a goat herd. More about that in another post.

It’s good to be back, and I am making a commitment to myself and anyone else who is interested to post twice a week, even if it’s a few lines. The discipline will be good for me.


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Director - Corporate Responsibility
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Cleveland, OH 44114