Nutritional status is a prognostic factor for survival in ALS patients

OBJECTIVE

To evaluate the occurrence of malnutrition in patients with ALS, to assess the relation of malnutrition to the neurologic deficit, and to determine the impact of nutritional status on patient survival.

BACKGROUND

Although ALS may be associated with significant malnutrition, the relative impact on patient survival has not yet been well established.

METHODS

In a prospective 7-month study of 55 ALS patients in a referral neurology practice, nutritional status was assessed by calculating body mass index. Neurologic evaluation includes four functional scores and identifies the form of disease onset. Slow vital capacity (VC) was also measured.

RESULTS

Occurrence of malnutrition in patients studied was 16.4%. Survival (using the Kaplan-Meier method) was worse for malnourished patients (p < 0.0001), with a 7.7-fold increased risk of death. Using multivariate analysis, only reduced VC (p < 0.0001) and malnutrition (p < 0.01) were found to have significant independent prognostic value. The degree of malnutrition is independent of neurologic scores and of forms of ALS onset.

CONCLUSION

Nutritional surveillance of ALS patients is very important, both in bulbar-onset and spinal-onset patients.

Outcomes of undernutrition in patients in the community with cancer or cardiovascular disease

Public health concern has tended to focus on the dangers of obesity, but there is evidence that undernutrition may also pose a risk to physical and mental well-being, particularly in those who are already ill. Using the General Practice Research Database (see office for Population Censuses and Surveys, 1995), we followed up 10,128 men and women aged 18 years and over who had been diagnosed with cancer or cardiovascular disease to examine whether nutritional status, as indicated by BMI, affected rates of use of health care resources and mortality. In both diagnostic groups, patients with a BMI below 20 kg/m2 had higher rates of consultation with GP, higher rates of prescription and higher death rates during the follow-up period compared with those with a BMI of 20-< 25 kg/m2. In men and women with cardiovascular disease, poor nutritional status was associated with a sharply increased risk of hospital admission. Patients whose BMI was 30-< 40 kg/m2 also tended to have increased rates of GP consultation and prescription, and if they were under the age of 65 years, they had an increased risk of death. The results of the present study suggest that in men and women with cancer or cardiovascular disease, even minor degrees of undernutrition are associated with a marked increase in morbidity and mortality.

Acute diarrhea and malnutrition: lethality risk in hospitalized infants

OBJECTIVES

Acute diarrhea is a very frequent disease in developing countries and is the first cause of death in infants under two years of age. This study was designed to evaluate the clinical and epidemiological factors associated to the death of 17 out of 511 infants hospitalized due to severe acute diarrhea between January 1989 and December 1995.

PATIENTS AND METHODS

The patients were divided into two groups according to their clinical evolution: Group I--Death and Group II--Survival. The following parameters were evaluated: birth weight, gender, age, duration of diarrhea (days) prior to admission, nutritional status, hydration, presence of an enteropathogenic agent in the stools, food intolerance and duration of hospitalization.

RESULTS

The analyzed factors have shown a significant association with death for the following variables: age, relative factor of death (RFD)=4.0 for infants less than six months of age, identification of an enteropathogenic Escherichia coli (EPEC) strain in the stools (RFD=3.3), severe malnutrition at admission to the hospital (RFD=4.5), occurrence of food intolerance during hospitalization (RFD=2.7). Some enteropathogenic agent was identified in the stools of 253 infants (54.9%), among the 461 (90.2%) studied. Group I revealed the presence of an enteropathogenic agent in 75% of the cases. The most frequent agents identified in Group I were: EPEC (56.3%) and Shigella (12.5%), while in Group II EPEC was identified in 26.5% of the patients.

CONCLUSIONS

The association of some factors, such as age less than six months, severe malnutrition, food intolerance and the identification of EPEC strains in the stool culture, indicate a high risk of death in infants hospitalized due to severe acute diarrhea.

Repeated neonatal deaths in families with special reference to causes of death

It is recognized that one infant death in a family indicates an increased risk of death of a subsequent sibling. This study examines which cause of death of a sibling is related to the mortality of the younger sibling and when. Longitudinal vital events data from the maternal and child health and family planning (MCH-FP) project and the comparison areas in Matlab, Bangladesh, were used. Primary causes of 868 neonatal deaths and 624 post-neonatal deaths resulting from 18,865 singleton live births in 1989-92 and those (967 as neonates and 708 as post-neonates) of their immediate elder siblings were categorised into infectious and non-infectious diseases. Multinomial logistic regression was used to estimate the risk of younger siblings dying in each age period from infectious and non-infectious diseases given the age and cause of deaths of older siblings and controlling for other biosocial correlates of infant mortality. A neonatal death of non-infectious causes in a family was twice as likely to be followed by another one occurring at the same age from similar causes compared with a surviving infant followed by a neonatal death from non-infectious causes. The MCH-FP project, though successful in reducing the risk of neonatal and post-neonatal mortality from infectious diseases, did not reduce the risk of dying from non-infectious diseases.

[Evolution of the nutritional status of patients with HIV-AIDS. Effects of socioeconomic situation and dietetic counseling]

OBJECTIVES

To know HIV-AIDS patient's nutritional status in different infection's condition and their relation with the socioeconomic situation and, in that case, the nutritional condition improvement through the dietetic advice appropriated for each patient.

METHODS

Prospective study of 79 patients with HIV-AIDS diagnostic in any illness's condition and recopilation of anthropometrics and biochemical variables. At the beginning of the study we got data about socioeconomic situation of patient with a scale of 1 to 5 points each variable and an score top of 35. In the survivors we checked, after dietetic advice, the variables at 6 and 12 months by sanitary personal (physician and nurse) who weren't implicated in direct assistance. The study was analyzed by Student "T" for matched data and the simple correlation test.

RESULTS

We have objectivated a lost of initial weight over their habitual's with a progressive impairment in different stage of evolution that weren't modified by dietetic advice. We didn't observed significant variations in the biochemical variables included in advances states and in parameters which are usually affected in malnutrition. In the analysis of relation between nutritional condition and socioeconomic factors, it was estimated a lesser score, that was statistically significative, in patients who had a work, family situation and an affective upset positive.

CONCLUSIONS

The results obtained induce to think that the nutritional advices appropriated for each patient are not related, in our series, with progressive deterioration of anthropometrics variables, neither biochemical parameters fluctuations at 6, 12 months of follow-up. The patient's socioeconomic situation is not influenced by nutritional condition except for the work, affectivity and family environment.

A scale without anthropometric measurements can be used to identify low weight-for-age in children less than five years old

Malnutrition and morbidity have a synergistic association that often leads to death. However, malnutrition in children who die is largely underreported, because anthropometry of the deceased child is rarely known. This study had two purposes: i) to develop a scale that would help determine if a child had low weight-for-age (w/a), in the absence of anthropometric measures; and ii) to select an appropriate cut-off that would give the best sensitivity (Se) and specificity (Sp) of the proposed scale when contrasted with actual w/a measurement. The study was designed as a diagnostic test, and carried out in a rural area in central Mexico. We included 132 children under 5 y old with w/a under -2 Z score and 284 children with marginal or no w/a deficit as a control group. The proposed scale included potential predictive variables from clinical, socioeconomic and family factors. The best logistic regression model to predict low w/a included: birth weight less than 2,800 g, introduction of weaning foods after the sixth month of life, introduction of animal protein after the sixth month of life, low socioeconomic status, low w/a in siblings and more than three morbidity episodes in the previous 6 mon. Selecting a cut-off of 4 for this model to identify children with low w/a showed a Se and Sp of 85 and 95%, respectively. We tested the external validity of the scale in a different locale, and included 877 children under 5 y old from 10 rural communities. In this population, the scale showed Se of 84% and Sp of 81% to identify low w/a. Based on these results, we propose that the scale be included as a means of identifying low w/a in children who have died. We believe that this should be done in verbal autopsies, which, based on our previous research, the Ministry of Health adopted as part of the regular activities to monitor problems in the disease to health-seeking to death process.

Relative survival of calves in 16 traditionally managed herds in Bauchi, Nigeria

An actuarial life-table approach was used to study the mortality of 277 calves born alive in 16 traditionally managed herds in Bauchi, Nigeria from 1993 to 1995. The proportion of calves in the herds surviving for the first 12 months was 53.8%. The probability of dying was greatest during the first month of life and decreased with age. The proportion of calves surviving in the herds has been increasing for the last 2 years. We suspect that this is probably due to improvements in management practices. Septicaemia, malnutrition and injury were the common causes of calf mortality. We recommend that more attention be given to improving the management of calves early in life in order to reduce mortality of calves and hence reduce economic losses to the herd owner.

Nutritional status of children admitted to hospital with different diseases and its relationship to outcome in The Gambia, West Africa

Admission records from two paediatric units in The Gambia were used to explore the relationship between admission weight and different diseases. In total 13579 hospitalized children were analysed. For comparison, 7399 children were recruited from several surveys of well subjects to provide anthropometric values for healthy Gambian children. Compared to the control children, mean admission weights were lower for malaria (weight for age z-score: -1.602), cerebral malaria (-1.547), transfused malarial anaemia (-1.764), pneumonia (-1.725), meningitis (-1.362), gastro-enteritis (-2.497) and malnutrition (-3.786). Children with bronchiolitis did not have a significantly different weight for age than the controls. Outcome of the hospital admission was recorded and related to the weight on admission. In all disease categories the death rate rose with decreasing admission weight with the exception of bronchiolitis. For all diseases taken together, case fatality was 7.2% for children with a weight for age z-score above -2 Standard Deviations (SD), 9.3% between -2 and -3 SD, 15.6% between -3 and -4 SD and 22.7% for children with weight for age SD z-scores less than -4. Malnourished children are more susceptible to several infectious diseases frequently seen in developing countries and nutritional interventions, as well as standard treatment, may improve outcome.

Dietary treatment of severe malnutrition in adults

The aim of this study was to compare the effects of two diets, differing primarily in protein content, on the nutritional rehabilitation of severely malnourished adults. The study took place in the Concern Worldwide Adult Therapeutic Feeding Centre in Baidoa, the town at the epicenter of the 1992 famine in Somalia. The response to treatment in 573 patients admitted to the center between November 1992 and March 1993 was studied. Mortality, appetite, rates of edema loss, and weight gain in 2 groups of patients receiving either a higher-protein (16.4% of energy from protein) or lower-protein (8.5% of energy from protein) diet were compared. Among edematous patients, the use of the lower-protein diet during the initial phase of treatment was associated with a threefold decrease in mortality (P < 0.05) and accelerated resolution of edema (P < 0.05). Among marasmic patients, no differences in mortality or rate of weight gain were observed. The large reduction in mortality associated with the use of the lower-protein diet in edematous patients appeared to be due to the lower amount of dietary protein. However, differences in the 2 diets other than or in addition to the protein content may have contributed. Notwithstanding, the data obtained suggest strongly that severely malnourished adults, particularly those with edema, recover more successfully with a diet of lower protein content than usually recommended. The lower-protein diet used in this study was much cheaper and more easily obtained than the conventional higher-protein diets in Baidoa.

Growth, morbidity, and mortality of children in Dhaka after treatment for severe malnutrition: a prospective study

Over 1300 severely malnourished children (< 60% of US National Center for Health Statistics weight-for-height, with edema, or both) are admitted each year to the Children's Nutrition Unit in Dhaka. Fatality during treatment is low and recovery is rapid. Our aim was to determine whether this initial success is sustained when children return home. A previous attempt to address this question was frustrated by the difficulty in tracing children after discharge because most are from slum settlements and families move frequently. This prospective study with fortnightly monitoring was therefore undertaken. The main outcomes of interest were anthropometric status, relapse, morbidity, and mortality. Children (n = 437) who had been treated for severe malnutrition when aged 12-59 mo and had reached the discharge criterion of 80% of weight-for-height, were followed for the next 12 mo. During follow-up, 7.5% were lost without trace, 0.6% relapsed, and 2.3% died. Morbidity was high, with a mean of seven episodes of diarrhea during the year. Outpatient visits for diarrhea occurred for 67% of children, and 58% had pneumonia (10% had pneumonia three times). After 12 mo, mean weight-for-height was 91% (-0.92 z score) but mean height-for-age remained at 84% (-4.14 z score). Weight gain, but not height gain, tended to be lower in children who experienced more diarrhea. Fever and cough were not associated with either weight or height gain. The high prevalence of illness highlights the need for continued accessible health care and for interventions to reduce disease acquisition.

Paediatric admissions to a rural South African hospital: value of hospital data in helping to define intervention priorities and allocate district resources

OBJECTIVE

To audit paediatric medical admissions to a rural district hospital in order to help define intervention priorities and allocate district resources.

DESIGN

Prospective audit of consecutive admissions to the paediatric medical service of Hlabisa Hospital, KwaZulu-Natal, between March 1995 and February 1996.

MAIN OUTCOME MEASURES

Number of admissions, month of admission, age, sex, diagnosis, nutritional status, HIV status, outcome and length of stay.

RESULTS

Of 1,364 children admitted, 995 (73%) were aged under 24 months and 584 (43%) were either underweight for age or severely malnourished. Acute respiratory tract infection (384, 28%), acute diarrhoea (200, 15%), dysentery (168, 12%) and severe malnutrition (149, 11%) were the major causes for admission and were responsible for most deaths (113, 75%). The overall case fatality rate was 11% and most (90, 60%) died within 48 hours of admission. Forty-five per cent of the 332 children tested were HIV-positive.

CONCLUSION

Most severe morbidity and mortality result from four common conditions, reflecting poor socioeconomic conditions in the area. Opportunities for clincial intervention to reduce their impact include identification of 'at risk' children, focusing care early in admissions, use of standardised protocols of care, and integrated management of the sick child.

[Longevity of malnourished rats fed with the regional basic diet (RBD) of the northeast of Brazil]

The effects of a Regional Basic Diet (RBD) on life expectancy and growth were studied in 23 Sprague-Dawley rats from mothers fed RBD since fecundation. These animals were compared with 20 rats from mothers fed the balanced control diet (22% protein). At weaning, the animals were fed their mothers diet and the weight was recorded every week until death. Sex related differences were not detected among RBD-fed animals; the growth curve was similar for both sexes. The critical points of acceleration and deceleration of the growth rate were not defined for these rats. Survival for RBD-groups decreased until 75 d of age and was unchanged between 75 and 450 d of life. From the 459 th d to the 589 th d of life deaths occurred successively. Controls survived until the 860 th d of life. Data point out the need for improving the basic food pattern of the region to prevent, among other things, a low life expectancy for the northeastern population.

[Children in poor countries also have right to good health care. A new care program will reduce child mortality]

According to the WHO (World Health Organization), 12 million children die annually before reaching the age of five. Seventy per cent of the deaths are related to one or more of five common diseases: acute respiratory tract infection, diarrhoea, measles, malaria and malnutrition. Consequently, drawing on international experience and expertise, the WHO and UNICEF (United Nations International Children's Emergency Fund) have compiled and developed guidelines for the primary care of Third World children. This programme, entitled Integrated management of childhood illness (IMCI), is expected to improve the care of children in areas and situations resources are limited.

Relationship of nutritional status to length of stay, hospital costs, and discharge status of patients hospitalized in the medicine service

OBJECTIVE

This study was conducted to determine the relationship, if any, between nutritional status, length of stay (LOS) in hospital, discharge placement, readmission rates, and hospital costs and charges in patients hospitalized in the medicine service.

DESIGN

Data regarding medical diagnosis, LOS, hospital costs, charges, discharge destination, and readmission rates were collected prospectively from medical records and through patient interviews on patients admitted to the medical service who were classified to be at risk or not at risk for malnutrition on the basis of established criteria (weight for height < 75% ideal body weight, admission serum albumin level < 30 g/L, or > or = 10% unintentional weight loss within 1 month before admission).

SUBJECTS

All patients admitted directly to any of three medicine units during December 1994 who met study criteria were included in the study. Off-service patients, transfer patients, and patients discharged before screening (usually admitted and discharged within 72 hours) were excluded. Data were collected on 173 patients.

STATISTICAL ANALYSIS PERFORMED

At-risk and not at-risk patients were compared for LOS, costs and reimbursement, and discharge placement (to home, to home with home health care services, or to another facility for further care). Two sample t tests and alpha survival analysis technique were used to compare continuous variables between the two study cohorts. Nonparametric tests were used for LOS and readmission data. chi 2 Tests were used for categoric variables. An alpha level of .05 was used throughout to determine statistical significance.

RESULTS

Median LOS in the not-at-risk population (n = 56) was significantly greater than in the not-at-risk population (n = 117): 6 days (25th percentile = 4 days, 75th percentile = 8 days) vs 4 days (25th percentile = 3 days, 75th percentile = 7 days) (P < .01). Mean hospitalization cost per patient was also higher in the at-risk group ($6,196 vs $4,563, P < .02). Readmission rate per month of follow-up was not significantly different. At-risk patients were significantly less likely to be discharged home with self-care (23[41%] vs 77 [66%], P < .05). At-risk patients were significantly more likely to use home health care service than not-at-risk patients (17[31%] vs 14 or [12%], P < .001).

APPLICATIONS

Patients at risk for malnutrition had significantly higher LOS, costs, and home health care needs, despite the fact that 51, or 91%, received nutrition intervention while hospitalized. Further research should explore the use of nutrition screening and intervention before, during, and after hospitalization to ensure that appropriate nutrition intervention, as indicated by medical patients' clinical condition and nutritional risk status, is initiated and continued.

Oral rehydration solution in the year 2000: pathophysiology, efficacy and effectiveness

The use of oral rehydration solution (ORS) with early refeeding forms the basis of therapy for dehydration secondary to diarrhoea ORS has produced such positive results in dehydrated patients that no further scientific demonstration is needed to confirm its efficacy. This review presents several issues that remain unsettled or controversial. They include the following. 1. The mechanism of water handling by the intestine is discussed; this is more complex than initially thought, at the epithelial, cellular and molecular level. 2. The composition of ORS which has been successfully adapted for the most frequent conditions, except for severely malnourished children, is described. 3. In contrast to the strong scientific basis and obvious efficacy in rehydration of ORS, its consequences for growth, nutrition and mortality are difficult to demonstrate, unless adequate long-term nutritional support is also provided in addition to ORS. 4. Finally, discrepancies between the recommendations and the practice of oral rehydration therapy are now well documented. Analysis of the causes of these discrepancies may participate in improving public health campaigns.

Emergencies in international child health

Emergencies in the pediatric populations of third world and developing countries are of a much different sort than those to which pediatricians in developing countries are familiar. Many of these emergencies derive from conditions, situations, and etiologies that no longer represent a threat to children in developed countries: malnutrition, immunizable illnesses, infectious diseases from pathogenes easily treated or prevented, urbanization, and armed conflict. Programs directed at improving basic public health, health education, access to basic health care, and immunization have been shown to have a major and positive impact on children's health status in these countries. Because of the vastness of these health problems, a growing number of volunteer organizations offer opportunities for pediatricians to contribute to improvement and they have an impact on the health of children considerably less fortunate than those in developed countries.

Mortality by cause for eight regions of the world: Global Burden of Disease Study

BACKGROUND

Reliable information on causes of death is essential to the development of national and international health policies for prevention and control of disease and injury. Medically certified information is available for less than 30% of the estimated 50.5 million deaths that occur each year worldwide. However, other data sources can be used to develop cause-of-death estimates for populations. To be useful, estimates must be internally consistent, plausible, and reflect epidemiological characteristics suggested by community-level data. The Global Burden of Disease Study (GBD) used various data sources and made corrections for miscoding of important diseases (eg, ischaemic heart disease) to estimate worldwide and regional cause-of-death.patterns in 1990 for 14 age-sex groups in eight regions, for 107 causes.

METHODS

Preliminary estimates were developed with available vital-registration data, sample-registration data for India and China, and small-scale population-study data sources. Registration data were corrected for miscoding, and Lorenz-curve analysis was used to estimate cause-of-death patterns in areas without registration. Preliminary estimates were modified to reflect the epidemiology of selected diseases and injuries. Final estimates were checked to ensure that numbers of deaths in specific age-sex groups did not exceed estimates suggested by independent demographic methods.

FINDINGS

98% of all deaths in children younger than 15 years are in the developing world. 83% and 59% of deaths at 15-59 and 70 years, respectively, are in the developing world. The probability of death between birth and 15 years ranges from 22.0% in sub-Saharan Africa to 1.1% in the established market economies. Probabilities of death between 15 and 60 years range from 7.2% for women in established market economies to 39.1% for men in sub-Saharan Africa. The probability of a man or woman dying from a non-communicable disease is higher in sub-Saharan Africa and other developing regions than in established market economies. Worldwide in 1990, communicable, maternal, perinatal, and nutritional disorders accounted for 17.2 million deaths, non-communicable diseases for 28.1 million deaths and injuries for 5.1 million deaths. The leading causes of death in 1990 were ischaemic heart disease (6.3 million deaths), cerebrovascular accidents (4.4 million deaths), lower respiratory infections (4.3 million), diarrhoeal diseases (2.9 million), perinatal disorders (2.4 million), chronic obstructive pulmonary disease (2.2 million), tuberculosis (2.0 million), measles (1.1 million), road-traffic accidents (1.0 million), and lung cancer (0.9 million).

INTERPRETATION

Five of the ten leading killers are communicable, perinatal, and nutritional disorders largely affecting children. Non-communicable diseases are, however, already major public health challenges in all regions. Injuries, which account for 10% of global mortality, are often ignored as a major cause of death and may require innovative strategies to reduce their toll. The estimates by cause have wide Cls, but provide a foundation for a more informed debate on public-health priorities.

The effect of malnutrition on the risk of diarrheal and respiratory mortality in children < 2 y of age in Cebu, Philippines

The effects of nutritional status on diarrheal and acute lower respiratory infection (ALRI) mortality in children < 2 y of age were examined by using data from a 1988-1991 longitudinal study of 9942 children in Metro Cebu, Philippines. Cox regression methods were used to study the strengths of the associations, possible interactions with birth weight and breast-feeding status, and the effect of additional confounding factors. Nutritional status as measured by weight-for-age was a significant risk factor for both ALRI and diarrheal mortality in the first 2 y of life. Poor nutritional status resulted in a 1.6-fold increased risk of diarrheal mortality for each one-unit decrease in weight-for-age Z score. For ALRI mortality, a one-unit decrease in weight-for-age Z score resulted in a 1.7-fold increase in risk, and for mortality associated with ALRI and diarrhea combined, the relative risk was 2.0. This study provides further evidence that malnutrition is a major determinant of mortality in very young children and it is one of the first longitudinal studies to estimate the magnitude of the effect on cause-specific mortality associated with nutritional status.

A prospective study of malnutrition in relation to child mortality in the Sudan

We examined prospectively the relation between malnutrition and mortality among Sudanese children. A cohort of 28753 children between the ages of 6 mo and 6 y was examined every 6 mo for 18 mo. Two hundred thirty-two children died during 18 mo of follow-up (480624 child-months). Low weight-for-height was associated with an increased risk of mortality (P < 0.0001). Even children with Z scores between -1 and -2 were 50% more likely to die in the following 6 mo than were children with Z scores > -1 (multivariate relative mortality: 1.5; 95% CI: 1.1, 2.2). There was also an inverse relation between height-for-age and mortality (P < 0.0001). Among breast-fed children, the relative mortality associated with a Z score for weight-for-height of < -3 compared with > -2 was 7.3 (95% CI: 3.3, 15.9); among children not breast-fed, it was 26.0 (95% CI: 12.8, 53.0; P for interaction = 0.001). A strong and significant synergy was also found between infection and wasting or stunting as predictors of child mortality (P for interaction = 0.001 and 0.02. respectively). In developing countries, children who are below the customary cutoff point of -2 Z for weight-for-height may be at higher risk of death. Breast-feeding and reduction of morbidity should be advocated in programs designed to reduce malnutrition and mortality among children.