Serum Levels of Albumin and Prealbumin Do Not Correlate With Nutrient Delivery in Surgical Intensive Care Unit Patients

Prevalence of the use of oral nutritional supplements among acute inpatients at risk of malnutrition and associated patient characteristics

AIM

To provide a snapshot of the current use of oral nutritional supplements, its association with inpatient characteristics, and with a focus on the role of nursing monitoring of food intake and implementing nutritional interventions for patients with low intake.

DESIGN

Retrospective cohort study.

METHODS

The study collected data from a hospital database regarding oral nutritional supplement initiation and variables of patients hospitalised in internal medicine departments, who did not receive enteral or parenteral nutrition.

RESULTS

Of the 5155 admissions, 1087 fulfilled the inclusion criteria (47% female; mean age, 72.4 ± 14.6 years; mean length of stay, 14.6 ± 11.4 days). Sufficient food intake reporting was noted in 74.6% of the patients; of these 17% had decreased intake. Oral nutritional supplements and non-oral nutritional supplements groups did not differ in terms of sex, age, length of stay, Charlson Comorbidity Index, proportion of nursing reports, and absence of intake monitoring. Oral nutritional supplements were initiated in 31.9% of patients with a Malnutrition Universal Screening Tool score ≥2 and in 34.6% with decreased food intake. On multivariable analysis, hypoalbuminemia (adjusted odds ratio, 3.70), decreased food intake (adjusted odds ratio, 3.38), Malnutrition Universal Screening Tool score ≥2 (adjusted odds ratio, 2.10), and age <70 years (adjusted odds ratio, 1.56) were significantly associated with oral nutritional supplements use.

CONCLUSION

The prevalence of oral nutritional intervention was suboptimal in patients at risk of malnutrition during acute hospitalisation, although decreased food intake and Malnutrition Universal Screening Tool score ≥2 independently increased the probability of oral nutritional supplements initiation.

RELEVANCE IN CLINICAL PRACTICE

Understanding the clinical practice and nursing impact of care management in relation to nutritional intervention can assist in reviewing and improving patient care. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE IMPACT (ADDRESSING): This study informs clinical management and influences nursing practice standards related to assessing, monitoring, and managing malnutrition risk.

IMPACT

The study impacts the quality of care for patients at risk of malnutrition.

REPORTING METHOD

We adhered to the STROBE Checklist for cohort studies.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Predictive value of postoperative prealbumin levels for detecting early-stage complications following off-pump coronary artery bypass grafting

Background

A pathological decrease in the serum prealbumin level is closely associated with the severity of various diseases and complications after surgery. Many patients suffer from a systemic inflammatory response and local myocardial ischemia after off-pump coronary artery bypass grafting, which is related to an adverse prognosis. This study aimed to explore the relationship between the serum prealbumin level and early complications following off-pump coronary artery bypass grafting, in addition to its predictive value.

Methods

Data were retrospectively collected on patients undergoing off-pump coronary artery bypass grafting from January 2014 to July 2019. The serum prealbumin level was assessed within 6-12 h after the operation. Patients were classified into two groups: the "normal" level group (≥17 mg/dl) and the "low" level group (<17 mg/dl). Univariate and multivariable analyses were performed to evaluate the predictive value of a low serum prealbumin level.

Results

Of the 1,002 patients, 553 (55.2%) had a low serum prealbumin level. The rate of pulmonary infection in the low group was significantly higher than in the normal group. Univariate analysis and multivariable analysis indicated that a low serum prealbumin level was associated with the increased incidence of postoperative pulmonary infection, pleural effusion, and new-onset atrial fibrillation.

Conclusion

The serum prealbumin level following off-pump coronary artery bypass grafting serves as a crucial predictor for early major postoperative complications, such as pulmonary complications and new-onset atrial fibrillation. Early identification of high-risk patients by assessing serum prealbumin levels, in addition to the timely adjustment of treatment and care strategies, can improve patient prognosis, shorten hospital stays, and reduce healthcare expenses.

Nine Myths about Enteral Feeding in Critically Ill Adults: An Expert Perspective

Malnutrition is a well-studied and significant prognostic risk factor for morbidity and mortality in critically ill perioperative patients. Common nutrition myths in the critically ill may prevent early, consistent, and adequate delivery of enteral nutrition. We outlined 9 common intensive care unit (ICU) nutrition misconceptions and our recommendations to optimize enteral nutrition in critically ill patients based on the review of available literature. Our approach is to treat every patient admitted to the ICU as at risk for malnutrition and to initiate enteral nutrition upon admission in the absence of contraindications. Early enteral nutrition via the gastric route is more beneficial than delaying feeding while awaiting small bowel access and daytime-intermittent nutrition support can safely be initiated over continuous feeding. Gastric residual volumes to assess feeding tolerance should no longer be routinely measured. For perioperative nutrition, we recommend continuing enteral nutrition for most patients with secure airways undergoing anesthesia and resuming nutrition within 24 h of abdominal surgery; even patients with open abdomens can be safely fed in the absence of bowel injury. Critically ill patients who are proned, paralyzed, and on vasopressors can usually continue enteral nutrition. Finally, continuing enteral nutrition before extubation may optimize nutrition without compromising extubation success. In this review, we highlight several common misconceptions regarding ICU nutrition that may prevent achieving nutrition goals and subsequently lead to increased malnutrition, morbidity, and mortality. This knowledge may contribute to increased implementation of early and consistent enteral nutrition strategies to improve outcomes in critically ill adult patients.

The correlation of CT-derived muscle density, skeletal muscle index, and visceral adipose tissue with nutritional status in severely injured patients

BACKGROUND

This study explored if computerized tomography-derived body composition parameters (CT-BCPs) are related to malnutrition in severely injured patients admitted to the Intensive Care Unit (ICU).

METHODS

This prospective cohort study included severely injured (Injury Severity Score ≥ 16) patients, admitted to the ICU of three level-1 trauma centers between 2018 and 2022. Abdominal CT scans were retrospectively analyzed to assess the CT-BCPs: muscle density (MD), skeletal muscle index (SMI), and visceral adipose tissue (VAT). The Subjective Global Assessment was used to diagnose malnutrition at ICU admission and on day 5 of admission, and the modified Nutrition Risk in Critically ill at admission was used to assess the nutritional risk.

RESULTS

Seven (11%) of the 65 analyzed patients had malnutrition at ICU admission, increasing to 23 patients (35%) on day 5. Thirteen (20%) patients had high nutritional risk. CT-BCPs were not related to malnutrition at ICU admission and on day 5. Patients with high nutritional risk at admission had lower MD (median (IQR) 32.1 HU (25.8-43.3) vs. 46.9 HU (37.7-53.3); p < 0.01) and higher VAT (median 166.5 cm2 (80.6-342.6) vs. 92.0 cm2 (40.6-148.2); p = 0.01) than patients with low nutritional risk.

CONCLUSION

CT-BCPs do not seem related to malnutrition, but low MD and high VAT may be associated with high nutritional risk. These findings may prove beneficial for clinical practice, as they suggest that CT-derived parameters may provide valuable information on nutritional risk in severely injured patients, in addition to conventional nutritional assessment and screening tools.

LEVEL OF EVIDENCE

Level III, Prognostic/Epidemiological.

Relevance of plasma lipoproteins and small metabolites in assessment of nutritional status among patients with severe injuries

Background

This study aimed to identify plasma lipoproteins and small metabolites associated with high risk of malnutrition during intensive care unit (ICU) stay in patients with severe injuries.

Methods

This observational prospective exploratory study was conducted at two level-1 trauma centers in the Netherlands. Adult patients (aged ≥18 years) who were admitted to the ICU for more than 48 h between July 2018 and April 2022 owing to severe injuries (polytrauma, as defined by Injury Severity Scores of ≥16) caused by blunt trauma were eligible for inclusion. Partial least squares discriminant analysis was used to analyze the relationship of 112 lipoprotein-related components and 23 small metabolites with the risk of malnutrition (modified Nutrition Risk in Critically Ill score). Malnutrition was diagnosed based on Subjective Global Assessment scores. The relationship of lipoprotein properties and small metabolite concentrations with malnutrition (during ICU admission) was evaluated using mixed effects logistic regression.

Results

Overall, 51 patients were included. Lower (very) low-density lipoprotein ([V]LDL) (free) cholesterol and phospholipid levels, low particle number, and higher levels of LDL triglycerides were associated with a higher risk of malnutrition (variable importance in projection [VIP] value >1.5). Low levels of most (V)LDL and intermediate-density lipoprotein subfractions and high levels of high-density lipoprotein Apo-A1 were associated with the diagnosis of malnutrition (VIP value >1.5). Increased levels of dimethyl sulfone, trimethylamine N-oxide, creatinine, N, N-dimethylglycine, and pyruvic acid and decreased levels of creatine, methionine, and acetoacetic acid were also indicative of malnutrition (VIP value >1.5). Overall, 14 lipoproteins and 1 small metabolite were significantly associated with a high risk of malnutrition during ICU admission (P <0.05); however, the association did not persist after correcting the false discovery rate (P=0.35 for all).

Conclusion

Increased triglyceride in several lipoprotein subfractions and decreased levels of other lipoprotein subfraction lipids and several small metabolites (involved in the homocysteine cycle, ketone body formation, and muscle metabolism) may be indicative of malnutrition risk. Following validation in larger cohorts, these indicators may guide institution of preventive nutritional measures in patients admitted to the ICU with severe injuries.

Fat-soluble vitamins as biomarkers of nutritional status and their relation with complications in polytrauma patients

BACKGROUND AND AIMS

This exploratory observational prospective study aimed to evaluate fat-soluble vitamin plasma levels during hospital admission and its relation with the development of malnutrition and complications in polytrauma patients, considering the protocolized multivitamin supplementation during intensive care unit (ICU) admission.

METHODS

In 49 well-nourished polytrauma (injury severity score ≥ 16) patients admitted to the ICU of two level-1 trauma centers, vitamin A, D, and E levels were assessed weekly during hospital stay. All patients received multivitamin supplementation during ICU stay. Linear mixed-effect models were used to assess a trend in vitamin levels over time during hospital stay. Mixed-effects logistic regression analysis was performed to relate vitamin concentrations with malnutrition, defined as a subjective global assessment score ≤5, and complications.

RESULTS

Vitamin A levels increased 0.17 µmol/L per week (95% confidence interval 0.12-0.22, p < 0.001), vitamin D levels increased 1.49 nmol/L per week (95% confidence interval 0.64-2.33, p < 0.01), vitamin E levels increased 1.17 µmol/L per week (95% confidence interval 0.61-1.73, p < 0.001) during hospital stay (29 ± 17 days). Vitamin levels were not related to malnutrition or complications during hospital stay.

CONCLUSION

Vitamin A, D, and E levels increased due to supplementation during hospital admission. Plasma levels of vitamins A, D, and E do not seem to be useful as biomarkers for the nutritional status of polytrauma patients during hospital stay. No correlation with complications could be demonstrated.

Dynamic assessment of prealbumin for nutrition support effectiveness in critically ill patients

BACKGROUND & AIMS

Serum prealbumin is considered to be a sensitive predictor of clinical outcomes and a quality marker for nutrition support. However, its susceptibility to inflammation restricts its usage in critically ill patients according to current guidelines. We assessed the performance of the initial value of prealbumin and dynamic changes for predicting the ICU mortality and the effectiveness of nutrition support in critically ill patients.

METHODS

This monocentric study included patients admitted to the ICU between 2009 and 2016, having at least one initial prealbumin value available. Prospectively recorded data were extracted from the electronic ICU charts. We used both univariable and multivariable logistic regressions to estimate the performance of prealbumin for the prediction of ICU mortality. Additionally, the association between prealbumin dynamic changes and nutrition support was assessed via a multivariable linear mixed-effects model and multivariable linear regression. Performing subgroup analysis assisted in identifying patients for whom prealbumin dynamic assessment holds specific relevance.

RESULTS

We included 3136 patients with a total of 4942 prealbumin levels available. Both prealbumin measured at ICU admission (adjusted odds-ratio (aOR) 0.04, confidence interval (CI) 95% 0.01-0.23) and its change over the first week (aOR 0.02, CI 95 0.00-0.19) were negatively associated with ICU mortality. Throughout the entire ICU stay, prealbumin dynamic changes were associated with both cumulative energy (estimate: 33.2, standard error (SE) 0.001, p < 0.01) and protein intakes (1.39, SE 0.001, p < 0.01). During the first week of stay, prealbumin change was independently associated with mean energy (6.03e-04, SE 2.32e-04, p < 0.01) and protein intakes (1.97e-02, SE 5.91e-03, p < 0.01). Notably, the association between prealbumin and energy intake was strongest among older or malnourished patients, those suffering from increased inflammation and those with high disease severity. Finally, prealbumin changes were associated with a positive mean nitrogen balance at day 7 only in patients with SOFA <4 (p = 0.047).

CONCLUSION

Prealbumin measured at ICU admission and its change during the first-week serve as an accurate predictor of ICU mortality. Prealbumin dynamic assessment may be a reliable tool to estimate the effectiveness of nutrition support in the ICU, especially among high-risk patients.

Association of prealbumin with short-term and long-term outcomes in patients with acute ST-segment elevation myocardial infarction

BACKGROUND

Prealbumin is considered to be a useful indicator of nutritional status. Furthermore, it has been found to be associated with severities and prognosis of a range of diseases. However, limited data on the association of baseline prealbumin level with outcomes of patients with acute ST-segment elevation myocardial infarction (STEMI) are available.

METHODS

We analyzed 2313 patients admitted for acute STEMI between October 2013 and December 2020. In-hospital outcomes and mortality during the 49 months (interquartile range: 26-73 months) follow-up period were compared between patients with the low prealbumin level (< 170 mg/L) and those with the high prealbumin level (≥ 170 mg/L).

RESULTS

A total of 114 patients (4.9%) died during hospitalization. After propensity score matching, patients with the low prealbumin level than those with the high prealbumin level experienced higher incidences of heart failure with Killip class III (9.9% vs. 4.4%, P = 0.034), cardiovascular death (8.4% vs. 3.4%, P = 0.035) and the composite of major adverse cardiovascular events (19.2% vs. 10.3%, P = 0.012). Multivariate logistic regression analysis identified that the low prealbumin level (< 170 mg/L) was an independent predictor of in-hospital major adverse cardiovascular events (odds ratio = 1.918, 95% CI: 1.250-2.942, P = 0.003). The cut-off value of prealbumin level for predicting in-hospital death was 170 mg/L (area under the curve = 0.703, 95% CI: 0.651-0.754, P < 0.001; sensitivity = 0.544, specificity = 0.794). However, after multivariate adjustment of possible confounders, baseline prealbumin level (170 mg/L) was no longer independently associated with 49-month cardiovascular death. After propensity score matching, Kaplan-Meier survival curves revealed consistent results.

CONCLUSIONS

Decreased prealbumin level closely related to unfavorable short-term outcomes. However, after multivariate adjustment and controlling for baseline differences, baseline prealbumin level was not independently associated with an increased risk of long-term cardiovascular mortality in STEMI patients.

Nutritional Support in Critically Ill Trauma Patients

Enteral nutrition should be initiated within 24 to 48 hours of injury, starting at a trophic rate and increasing to goal rate after hemodynamic stability is achieved. The modified Nutritional Risk in the Critically Ill score can help identify patients who will benefit most from aggressive and early nutritional intervention. In the first week of critical illness, the patient should receive only 70% to 80% of estimated calories and protein should be targeted to 1.5 to 2 g/kg. Parenteral nutrition can be provided safely without increased adverse events. Peri-operative (and intra-operative) feeding has been shown to be safe in selected patients.

Clinical practice guidelines for nutritional assessment and monitoring of adult ICU patients in China

The Chinese Society of Critical Care Medicine (CSCCM) has developed clinical practice guidelines for nutrition assessment and monitoring for patients in adult intensive care units (ICUs) in China. This guideline focuses on nutrition evaluation and metabolic monitoring to achieve optimal and personalized nutrition therapy for critically ill patients. This guideline was developed by experts in critical care medicine and evidence-based medicine methodology and was developed after a thorough review of the system and a summary of relevant trials or studies published from 2000 to July 2023. A total of 18 recommendations were formed and consensus was reached through discussions and reviews by expert groups in critical care medicine, parenteral and enteral nutrition, and surgery. The recommendations are based on currently available evidence and cover several key fields, including screening and assessment, evaluation and assessment of enteral feeding intolerance, metabolic and nutritional measurement and monitoring during nutrition therapy, and organ function evaluation related to nutrition supply. Each question was analyzed according to the Population, Intervention, Comparison, and Outcome (PICO) principle. In addition, interpretations were provided for four questions that did not reach a consensus but may have potential clinical and research value. The plan is to update this nutrition assessment and monitoring guideline using the international guideline update method within 3-5 years.

AGA Clinical Practice Update on Diet and Nutritional Therapies in Patients With Inflammatory Bowel Disease: Expert Review

DESCRIPTION

Diet plays a critical role in human health, but especially for patients with inflammatory bowel disease (IBD). Guidance about diet for patients with IBD are often controversial and a source of uncertainty for many physicians and patients. The role of diet has been investigated as a risk factor for IBD etiopathogenesis and as a therapy for active disease. Dietary restrictions, along with the clinical complications of IBD, can result in malnutrition, an underrecognized condition among this patient population. The aim of this American Gastroenterological Association (AGA) Clinical Practice Update (CPU) is to provide best practice advice statements, primarily to clinical gastroenterologists, covering the topics of diet and nutritional therapies in the management of IBD, while emphasizing identification and treatment of malnutrition in these patients. We provide guidance for tailored dietary approaches during IBD remission, active disease, and intestinal failure. A healthy Mediterranean diet will benefit patients with IBD, but may require accommodations for food texture in the setting of intestinal strictures or obstructions. New data in Crohn's disease supports the use of enteral liquid nutrition to help induce remission and correct malnutrition in patients heading for surgery. Parenteral nutrition plays a critical role in patients with IBD facing acute and/or chronic intestinal failure. Registered dietitians are an essential part of the interdisciplinary team approach for optimal nutrition assessment and management in the patient population with IBD.

METHODS

This expert review was commissioned and approved by the AGA Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Gastroenterology. The best practice advice statements were drawn from reviewing existing literature combined with expert opinion to provide practical advice on the role of diet and nutritional therapies in patients with IBD. Because this was not a systematic review, formal rating of the quality of evidence or strength of the presented considerations was not performed. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Unless there is a contraindication, all patients with IBD should be advised to follow a Mediterranean diet rich in a variety of fresh fruits and vegetables, monounsaturated fats, complex carbohydrates, and lean proteins and low in ultraprocessed foods, added sugar, and salt for their overall health and general well-being. No diet has consistently been found to decrease the rate of flares in adults with IBD. A diet low in red and processed meat may reduce ulcerative colitis flares, but has not been found to reduce relapse in Crohn's disease. BEST PRACTICE ADVICE 2: Patients with IBD who have symptomatic intestinal strictures may not tolerate fibrous, plant-based foods (ie, raw fruits and vegetables) due to their texture. An emphasis on careful chewing and cooking and processing of fruits and vegetables to a soft, less fibrinous consistency may help patients with IBD who have concomitant intestinal strictures incorporate a wider variety of plant-based foods and fiber in their diets. BEST PRACTICE ADVICE 3: Exclusive enteral nutrition using liquid nutrition formulations is an effective therapy for induction of clinical remission and endoscopic response in Crohn's disease, with stronger evidence in children than adults. Exclusive enteral nutrition may be considered as a steroid-sparing bridge therapy for patients with Crohn's disease. BEST PRACTICE ADVICE 4: Crohn's disease exclusion diet, a type of partial enteral nutrition therapy, may be an effective therapy for induction of clinical remission and endoscopic response in mild to moderate Crohn's disease of relatively short duration. BEST PRACTICE ADVICE 5: Exclusive enteral nutrition may be an effective therapy in malnourished patients before undergoing elective surgery for Crohn's disease to optimize nutritional status and reduce postoperative complications. BEST PRACTICE ADVICE 6: In patients with IBD who have an intra-abdominal abscess and/or phlegmonous inflammation that limits ability to achieve optimal nutrition via the digestive tract, short-term parenteral nutrition may be used to provide bowel rest in the preoperative phase to decrease infection and inflammation as a bridge to definitive surgical management and to optimize surgical outcomes. BEST PRACTICE ADVICE 7: We suggest the use of parenteral nutrition for high-output gastrointestinal fistula, prolonged ileus, short bowel syndrome, and for patients with IBD with severe malnutrition when oral and enteral nutrition has been trialed and failed or when enteral access is not feasible or contraindicated. BEST PRACTICE ADVICE 8: In patients with IBD and short bowel syndrome, long-term parenteral nutrition should be transitioned to customized hydration management (ie, intravenous electrolyte support and/or oral rehydration solutions) and oral intake whenever possible to decrease the risk of developing long-term complications. Treatment with glucagon-like peptide-2 agonists can facilitate this transition. BEST PRACTICE ADVICE 9: All patients with IBD warrant regular screening for malnutrition by their provider by means of assessing signs and symptoms, including unintended weight loss, edema and fluid retention, and fat and muscle mass loss. When observed, more complete evaluation for malnutrition by a registered dietitian is indicated. Serum proteins are no longer recommended for the identification and diagnosis of malnutrition due to their lack of specificity for nutritional status and high sensitivity to inflammation. BEST PRACTICE ADVICE 10: All patients with IBD should be monitored for vitamin D and iron deficiency. Patients with extensive ileal disease or prior ileal surgery (resection or ileal pouch) should be monitored for vitamin B12 deficiency. BEST PRACTICE ADVICE 11: All outpatients and inpatients with complicated IBD warrant co-management with a registered dietitian, especially those who have malnutrition, short bowel syndrome, enterocutaneous fistula, and/or are requiring more complex nutrition therapies (eg, parenteral nutrition, enteral nutrition, or exclusive enteral nutrition), or those on a Crohn's disease exclusion diet. We suggest that all newly diagnosed patients with IBD have access to a registered dietitian. BEST PRACTICE ADVICE 12: Breastfeeding is associated with a lower risk for diagnosis of IBD during childhood. A healthy, balanced, Mediterranean diet rich in a variety of fruits and vegetables and decreased intake of ultraprocessed foods have been associated with a lower risk of developing IBD.

Serum Albumin as Prognostic Marker for Older Adults in Hospital and Community Settings

Serum albumin, known for its multifaceted role in health, is hypothesized to serve as a prognostic marker for older adults, both in hospital and community settings. Nine studies were included in the review, revealing consistent associations between low serum albumin levels and increased mortality risk in hospitalized older individuals. In community settings, low serum albumin levels were linked to higher mortality rates compared to those with normal levels. The synthesis of evidence underscores the potential of serum albumin as a prognostic marker for older adults, offering valuable insights for risk stratification and targeted interventions. While robust evidence supports its utility in hospital settings, further research is warranted in community settings to address current limitations and enhance the applicability of serum albumin as a prognostic tool. This review merges existing knowledge of the prognostic significance of serum albumin in older adults across hospital and community settings. The findings emphasize the importance of serum albumin as a potential prognostic marker, urging continued research efforts to refine its application in diverse healthcare contexts and improve outcomes for the aging population.

Using three statistical methods to analyze the association between aldehyde exposure and markers of inflammation and oxidative stress

BACKGROUND

Exposure to aldehydes has been linked to adverse health outcomes such as inflammation and oxidative stress, but research on the effects of these compounds is limited. This study is aimed at assessing the association between aldehyde exposure and markers of inflammation and oxidative stress.

METHODS

The study used data from the NHANES 2013-2014 survey (n = 766) and employed multivariate linear models to investigate the relationship between aldehyde compounds and various markers of inflammation (alkaline phosphatase (ALP) level, absolute neutrophil count (ANC), and lymphocyte count) and oxidative stress (bilirubin, albumin, and iron levels) while controlling for other relevant factors. In addition to generalized linear regression, weighted quantile sum (WQS) and Bayesian kernel machine regression (BKMR) analyses were applied to examine the single or overall effect of aldehyde compounds on the outcomes.

RESULTS

In the multivariate linear regression model, each 1 standard deviation (SD) change in propanaldehyde and butyraldehyde was significantly associated with increases in serum iron levels (beta and 95% confidence interval, 3.25 (0.24, 6.27) and 8.40 (0.97, 15.83), respectively) and the lymphocyte count (0.10 (0.04, 0.16) and 0.18 (0.03, 0.34), respectively). In the WQS regression model, a significant association was discovered between the WQS index and both the albumin and iron levels. Furthermore, the results of the BKMR analysis showed that the overall impact of aldehyde compounds was significantly and positively correlated with the lymphocyte count, as well as the levels of albumin and iron, suggesting that these compounds may contribute to increased oxidative stress.

CONCLUSIONS

This study reveals the close association between single or overall aldehyde compounds and markers of chronic inflammation and oxidative stress, which has essential guiding value for exploring the impact of environmental pollutants on population health.

Evaluation of plasma prealbumin as a novel inflammatory biomarker in dogs: a pilot study

Introduction

Prealbumin (PAB) is a plasma protein synthesized in the hepatic parenchymal cells. PAB has a short half-life (~2 days), and its concentration is affected by changes in transcapillary escape. Measurement of PAB is widely used in hospitalized patients in human medicine due to its decreasing concentration in states of inflammation and malnutrition. However, only a few studies are available in dogs. The aim of this study is to determine whether the plasma PAB concentration decreases in dogs with inflammation and to evaluate the relationship between the plasma PAB concentration and inflammation-related parameters in dogs.

Methods

A total of 94 dogs were divided into healthy (n = 33) and diseased (n = 61) groups. These were further divided into group A (n = 24) and group B (n = 37) according to plasma C-reactive protein (CRP) levels. Group A included dogs with a plasma CRP < 10 mg/L, and group B consisted of dogs with a plasma CRP ≥ 10 mg/L. Patient signalment, history, physical examination findings, hematologic and biochemical parameters, various inflammatory markers, and plasma PAB levels were investigated and compared between groups.

Results

The plasma PAB concentration was found to be lower in group B than in the other groups (p < 0.001), but no statistical difference was found when comparing the control group and group A (p > 0.05). A plasma PAB < 6.3 mg/dL predicted an increased CRP level (10 mg/L or greater) with a sensitivity of 89.5% and a specificity of 86.5%. Receiver operating characteristic curve analysis revealed that the area under the curve for PAB was higher than that for the white blood cell count, neutrophil count, albumin level, lactate level, neutrophil-to-lymphocyte ratio, and neutrophil percentage-to-albumin ratio. In addition, the PAB concentration was significantly negatively correlated with the CRP concentration (r = -0.670, p < 0.001).

Conclusion

In conclusion, this is the first study to demonstrate the clinical usefulness of the plasma PAB concentration as an inflammatory marker in dogs. These findings suggest that measuring the plasma PAB concentration along with the CRP concentration may be more useful for evaluating inflammation than measuring CRP alone in canine patients.

Prognostic nutritional index value in the prognosis of Kawasaki disease with coronary artery lesions

Objectives

The prognostic nutritional index (PNI) is a purported predictor of intravenous immunoglobulin (IVIG) resistance and coronary artery aneurysm (CAA) development in patients with Kawasaki disease (KD). However, limited data exist on CAA regression. This study aimed to confirm whether the PNI is a predictor for CAA persistency in patients with KD.

Methods

This retrospective study grouped 341 patients with KD based on the coronary artery status and time of aneurysm persistence. The clinical and laboratory parameters were compared, and multivariate logistic regression analysis was performed to identify the independent risk factors for persistent CAA. The receiver operating characteristic (ROC) curve was further used to assess the predictive values of the PNI in persistent CAA.

Results

Among the study patients, 80 (23.5%) presented with CAA, including CAA persisting for 2 years in 17 patients (5.0%). Patients with CAA were more frequently treated with corticosteroids (p < 0.016). No statistically significant differences were found in the nutritional status and PNI among patients with or without coronary artery lesions, regardless of injury severity. Patients in the persistent CAA group presented with higher rates of overnutrition and showed lower PNI values and a higher incidence of thrombosis than those in the normal group (p < 0.05). The PNI and the maximum Z-score at 1 month of onset were significantly associated with CAA persisting for 2 years and may be used as predictors of persistent CAA. The area under the ROC curve was 0.708 (95% confidence interval, 0.569-0.847), and a 40.2 PNI cutoff yielded a sensitivity and specificity of 41 and 92%, respectively, for predicting CAA persisting for 2 years. Kaplan-Meier survival analysis revealed that the estimated median time of aneurysm persistence was significantly higher in patients with PNI values of ≤40 than in those with PNI values of >40 (hazard ratio, 2.958; 95% confidence interval, 1.601-5.464; p = 0.007). After sampling-time stratification, the PNI differed significantly between patients with and without persistent CAA when sampled on the second (p = 0.040), third (p = 0.028), and fourth days (p = 0.041) following disease onset.

Conclusion

A lower PNI value is an independent risk factor for CAA persisting for 2 years in patients with KD, besides the maximum Z-score at 1 month after onset. Furthermore, the PNI obtained within 4 days from fever onset may possess greater predictive power for patients with persistent CAA.

Associations of albumin and nutritional index factors with delirium in patients admitted to the cardiac intensive care unit

Background

Limited data are available on the association of malnutrition with the occurrence of delirium in the cardiac intensive care unit (CICU). Thus, we aimed to analyze whether nutritional indices and their components can predict the development of delirium in CICU.

Methods

We enrolled 2,783 patients admitted to the CICU of Samsung Medical Center for more than 24 h between September 2012 and December 2018. We assessed the nutritional status at admission using three indices, the Prognostic Nutrition Index (PNI), the Geriatric Nutritional Risk Index (GNRI), and the Controlling Nutritional Status (CONUT). Then, we compared predictive performances for the occurrence of delirium among nutritional indices using Delong's test.

Results

Delirium developed in 678 patients (24.3%) assessed three times daily for 7 days of CICU stay. Nutritional indices had fair predictive performance for development of delirium in critically ill cardiac patients using the area under the receiver-operating characteristic curve (AUROC: 0.729 for the GNRI, 0.728 for PNI, and 0.762 for CONUT). Furthermore, the AUROC of albumin alone (0.77, 95% CI, 0.75-0.79) was significantly greater than that of either GNRI (p < 0.001) or PNI (p < 0.001). In a multivariable analysis including each component of nutritional indices, albumin was a significant predictor for delirium but not absolute lymphocyte count, bodyweight/ideal bodyweight, or total cholesterol level as a component of nutritional indices.

Conclusion

Predictive performances of nutritional indices for the occurrence of delirium were acceptable in patients admitted to CICU. Albumin alone might be a helpful and straightforward indicator for the occurrence of delirium.

Prediction of Prognosis in Geriatric Palliative Care Patients with Diagnosed Malnutrition: A Comparison of Nutritional Assessment Parameters

Objective

Malnutrition is very commonly encountered in palliative care centers (PCC), especially in geriatric patients. It is known that development of malnutrition increases morbidity and mortality. In this study, we aimed to investigate the effectiveness of commonly used nutritional assessment parameters in predicting prognosis in geriatric patients diagnosed in PCC with malnutrition.

Methods

Our study included 1451 patients aged ≥65 years, who were diagnosed with malnutrition in PCC between 2016-2020 and did not yet start receiving nutritional support. Demographic data, comorbidities, The Nutritional Risk Screening 2002 (NRS-2002), body mass index (BMI), albumin, prealbumin and C-reactive protein (CRP) values of the patients were recorded. Prognostic course was evaluated by dividing the patients into 3 groups, namely mortal patients during PCC follow-up, patients transferred from PCC to Intensive Care (ICU) and patients discharged to home from PCC.

Results

Logistic Regression analysis showed that low albumin levels affected transfer to ICU (P<0.05). Elevated NRS-2002 and low albumin and prealbumin levels were found to be factors affecting mortality (P<0.05). Areas under the ROC Curve were calculated to attain patients' differential diagnosis. The area under the ROC Curve of low albumin in patients transferred to ICU was found to be significant (P<0.05). In the differential diagnosis of patients with mortal course, the area under the ROC Curve of low albumin and prealbumin and high CRP was found to be significant (P<0.05).

Conclusion

We found that BMI had no prognostic predictive effects in geriatric PCC patients with malnutrition. We concluded that NRS-2002 and high CRP and low albumin and prealbumin can be used to predict mortality. In addition, we found that low albumin indicates a poor prognosis and predicts patients to be transferred to ICU.

The effects of selenium supplementation on inflammatory markers in critically ill patients

Abstract

Low serum selenium (Se) levels have been shown in critical illness, which is associated with poor clinical outcomes and a higher mortality rate. Se plays an important role in inflammation and oxidative stress. Since the overproduction of inflammatory cytokines and increased oxidative stress is a major component of critical illnesses, its supplementation has been demonstrated to have promising effects on critically ill patients. This study aims to review the evidence regarding the effects of Se supplementation on inflammatory and oxidative markers in critically ill patients. The literature review highlights alterations of inflammatory markers, including procalcitonin, leukocyte count, albumin, prealbumin, C-reactive protein (CRP), inflammatory cytokines, and cholesterol following Se supplementation in critically ill patients. Besides, the antioxidant properties of Se due to its presence in the structure of several selenoenzymes have been reported.

Article highlights

Low serum Se level have been shown in critical illness, which is associated with poor clinical outcome and higher mortality rate.

Se plays an important role in inflammation and oxidative stress.

Se supplementation can have promising effects by alterations of inflammatory markers and its antioxidant properties for critically ill patients.

Absence of oral nutritional support in low food intake inpatients is associated with an increased risk of hospital-acquired pressure injury

BACKGROUND & AIMS

Hospital-acquired pressure injury (HAPI) incidence is a common burden in hospitals. Decreased food intake leading to malnutrition compromises body tissues involved in pressure injury occurrence. However, most tools for predicting pressure injuries do not include daily food intake monitoring nor consider further nutritional interventions. This study aimed to investigate clinical practices for food intake monitoring and its association with predicting HAPI risk, together with Norton Scale use, and whether the initiation or absence of oral nutritional supplements (ONS), separately from other nutritional interventions, was associated with HAPI incidence in low food intake inpatients, who consumed less than 50% of requirements.

METHODS

This observational cohort study covered a one-year period (08/2018-07/2019). Demographic and clinical data were extracted from computerized files of patients hospitalized ≥7 days, aged ≥60 years, and who ate orally. Patients receiving enteral or parenteral nutrition were excluded. Differences were studied between groups without and with HAPI grade ≥2. Subgroups divided by Norton Scale and intake, Norton Scale and albumin levels, food intake and initiation (or not) of any nutritional intervention versus ONS only, were examined for the consistency of association with HAPI.

RESULTS

Of the 5155 admissions during the study period, 895 patients fulfilled the inclusion criteria: 48% female, mean age 77.6 ± 9.1 years, 11% with MUST score ≥2. Nutritional intake was reported in 76% of patients, of them 22% had low food intake, and 9% of the study group developed HAPI grade ≥2. Regarding HAPI incidence, no differences were found between groups divided by MUST scores. Independent risk factors significantly associated with HAPI were Norton <14, albumin levels <3 g/dl, and low food intake. Not providing ONS in low food intake patients had an adjusted 3.49-fold (95%CI 1.57-7.75) increase in HAPI risk (6-fold for non-adjusted relative risk).

CONCLUSION

Failure to initiate ONS as part of nutritional support in low food intake patients is associated with high HAPI risk in these patients. Consequently, monitoring of daily food intake for identifying low intake patients should be integrated into routinely used tools such as the Norton Scale, and adherence to nutritional protocols should be addressed.

Serum albumin was negatively associated with diabetic peripheral neuropathy in Chinese population: a cross-sectional study

BACKGROUND

Previous studies that explored the relationship of serum albumin with diabetic peripheral neuropathy (DPN) have indicated inconsistent results. Thus, the present study aimed to evaluated the association between serum albumin and DPN, defined as vibration perception threshold (VPT) values ≥ 25 V and/or inability to feel the monofilament, in Chinese patients with type 2 diabetes mellitus (T2DM).

METHODS

1465 T2DM patients aged ≥ 16 years, who completed the measurement of serum albumin and DPN screening between 2012 and 2015, were included in the cross-sectional study. Correlation and multivariate logistic regression analysis models were used to evaluate the possible relationship between serum albumin and DPN.

RESULTS

Patients with higher quartiles of serum albumin had significantly lower VPT values and prevalence of DPN compared with those with lower quartiles (P for trend < 0.01), and there was an inverse relationship between serum albumin and VPT values and prevalence of DPN (all P < 0.01). Multivariate logistic regression analysis demonstrated that the risk of DPN was progressively decreased across serum albumin quartiles (P for trend < 0.01), and participants in the highest quartile of serum albumin were at a significantly decreased risk of DPN compared to those in the lowest quartile (odds rate: 0.311, 95% confidence intervals 0.134-0.724, P < 0.01). ROC analysis revealed that the optimal cutoff point of serum albumin for the prevalence of DPN was 39.95 g/L in patients with T2DM, with a sensitivity of 65.88% and a specificity of 66.7%.

CONCLUSIONS

Decreased levels of serum albumin might be correlated with increased risk of DPN in Chinese patients with T2DM. Future longitudinal studies with large samples are warranted to confirm our findings, and elucidate putative mechanisms for the association.

Association between low serum prealbumin levels and carpal tunnel syndrome in maintenance hemodialysis patients

Aims

Carpal tunnel syndrome (CTS) and low serum prealbumin concentration are common in maintenance hemodialysis patients. In this study, we focused on the association between low serum prealbumin levels and carpal tunnel syndrome in maintenance hemodialysis (MHD) patients using low-flux dialysis reuse.

Materials and methods

Serum prealbumin levels were assessed to determine the association between low serum prealbumin levels and CTS in 373 prevalent MHD patients (the mean age was 45 years old, hemodialysis duration was 46 months). The patients were divided into 2 groups: the CTS group with 44 patients and the non-CTS group with 329 patients.

Results

The prevalence of CTS was 11.8%. Serum prealbumin showed a good prognostic value to predict CTS in MHD patients using low-flux dialysis reuse (the Area Under the Curve = 0.841, p < .001; cutoff value: 26.5 mg/dL with sensitivity = 72.7% and specificity = 79.9%).

Conclusions

Serum prealbumin was a good prognostic biomarker of CTS in MHD patients using low-flux dialysis reuse.

Target Calorie Intake Achievements for Patients Treated in the Surgical Intensive Care Unit

Adequate nutritional support in critically ill patients is important, however, sometimes it has been neglected in perioperative period of patients at surgical intensive care units (SICU). The aim of this study was to investigate whether approaching target calorie intake of surgical patients influences on their clinical outcomes. A total of 279 patients who admitted at SICU in perioperative period from August 2014 to July 2016 at our hospital were analyzed. Demographics, supplied calorie amount and its method, lengths of SICU and hospital stay, and mortality of study population were collected. Among 279 patients, 103 patietns (36.9%) approached target calorie intake during SICU stay. Patients who approached target calorie intake had significantly decreased length of stay in SICU (10.78 ± 11.5 vs. 15.3 ± 9.9, p = 0.001) and hospital (54.52 ± 40.6 vs. 77.72±62.2, p < 0.001), than those did not, however there was no significant difference of mortality (9.7% vs. 8.5%, p = 0.829). Enteral feeding was a significant factor for target calorie achievement (odd ratio [OR], 2.029; 95% confidence interval [CI], 1.096–3.758; p = 0.024) and especially in patients with ≤ 7 days of SICU stay (OR, 4.13; 95% CI, 1.505–11.328; p = 0.006). Target calorie achievement in surgical patients improves clinical outcomes and enteral feeding, especially in early postoperative period would be an effective route of nutrition.

Semi-elemental versus polymeric formula for enteral nutrition in brain-injured critically ill patients: a randomized trial

Background

The properties of semi-elemental enteral nutrition might theoretically improve gastrointestinal tolerance in brain-injured patients, known to suffer gastroparesis. The purpose of this study was to compare the efficacy and tolerance of a semi-elemental versus a polymeric formula for enteral nutrition (EN) in brain-injured critically ill patients.

Methods

Prospective, randomized study including brain-injured adult patients [Glasgow Coma Scale (GCS) ≤ 8] with an expected duration of mechanical ventilation > 48 h. Intervention: an enteral semi-elemental (SE group) or polymeric (P group) formula. EN was started within 36 h after admission to the intensive care unit and was delivered according to a standardized nurse-driven protocol. The primary endpoint was the percentage of patients who received both 60% of the daily energy goal at 3 days and 100% of the daily energy goal at 5 days after inclusion. Tolerance of EN was assessed by the rate of gastroparesis, vomiting and diarrhea.

Results

Respectively, 100 and 95 patients were analyzed in the SE and P groups: Age (57[44–65] versus 55[40–65] years) and GCS (6[3–7] versus 5[3–7]) did not differ between groups. The percentage of patients achieving the primary endpoint was similar (46% and 48%, respectively; relative risk (RR) [95% confidence interval (CI)] = 1.05 (0.78–1.42); p = 0.73). The mean daily energy intake was, respectively, 20.2 ± 6.3 versus 21.0 ± 6.5 kcal/kg/day (p = 0.42). Protein intakes were 1.3 ± 0.4 versus 1.1 ± 0.3 g/kg/day (p < 0.0001). Respectively, 18% versus 12% patients presented gastroparesis (p = 0.21), and 16% versus 8% patients suffered from diarrhea (p = 0.11). No patient presented vomiting in either group.

Conclusion

Semi-elemental compared to polymeric formula did not improve daily energy intake or gastrointestinal tolerance of enteral nutrition.

Trial registration

EudraCT/ID-RCB 2012-A00078-35 (registered January 17, 2012).

Dynamic prediction for clinically relevant pancreatic fistula: a novel prediction model for laparoscopic pancreaticoduodenectomy

Background

With the recent emerge of dynamic prediction model on the use of diabetes, cardiovascular diseases and renal failure, and its advantage of providing timely predicted results according to the fluctuation of the condition of the patients, we aim to develop a dynamic prediction model with its corresponding risk assessment chart for clinically relevant postoperative pancreatic fistula after laparoscopic pancreaticoduodenectomy by combining baseline factors and postoperative time-relevant drainage fluid amylase level and C-reactive protein-to-albumin ratio.

Methods

We collected data of 251 patients undergoing LPD at West China Hospital of Sichuan University from January 2016 to April 2019. We extracted preoperative and intraoperative baseline factors and time-window of postoperative drainage fluid amylase and C-reactive protein-to-albumin ratio relevant to clinically relevant pancreatic fistula by performing univariate and multivariate analyses, developing a time-relevant logistic model with the evaluation of its discrimination ability. We also established a risk assessment chart in each time-point.

Results

The proportion of the patients who developed clinically relevant postoperative pancreatic fistula after laparoscopic pancreaticoduodenectomy was 7.6% (19/251); preoperative albumin and creatine levels, as well as drainage fluid amylase and C-reactive protein-to-albumin ratio on postoperative days 2, 3, and 5, were the independent risk factors for clinically relevant postoperative pancreatic fistula. The cut-off points of the prediction value of each time-relevant logistic model were 14.0% (sensitivity: 81.9%, specificity: 86.5%), 8.3% (sensitivity: 85.7%, specificity: 79.1%), and 7.4% (sensitivity: 76.9%, specificity: 85.9%) on postoperative days 2, 3, and 5, respectively, the area under the receiver operating characteristic curve was 0.866 (95% CI 0.737–0.996), 0.896 (95% CI 0.814–0.978), and 0.888 (95% CI 0.806–0.971), respectively.

Conclusions

The dynamic prediction model for clinically relevant postoperative pancreatic fistula has a good to very good discriminative ability and predictive accuracy. Patients whose predictive values were above 14.0%, 8.3%, and 7.5% on postoperative days 2, 3, and 5 would be very likely to develop clinically relevant postoperative pancreatic fistula after laparoscopic pancreaticoduodenectomy.

Review of evolution and current status of protein requirements and provision in acute illness and critical care

Nutrition therapy, by enteral, parenteral, or both routes combined, is a key component of the management of critically ill, surgical, burns, and oncology patients. Established evidence indicates overfeeding (provision of excessive calories) results in increased risk of infection, morbidity, and mortality. This has led to the practice of "permissive underfeeding" of calories; however, this can often lead to inadequate provision of guideline-recommended protein intakes. Acutely ill patients requiring nutritional therapy have high protein requirements, and studies demonstrate that provision of adequate protein can result in reduced mortality and improvement in quality of life. However, a significant challenge to adequate protein delivery is the current lack of concentrated protein solutions. Patients often have fluid administration restrictions and existing protein solutions are frequently not sufficiently concentrated to deliver a patient's protein requirements. This has led to the development of new enteral and parenteral nutrition solutions incorporating higher levels of protein in smaller volumes. This review article summarizes current evidence supporting the role of higher protein intakes, especially during the early phases of nutrition therapy in acute illness, methods for assessing protein requirements, as well as, the currently available high-protein enteral and parenteral nutrition solutions. There is sufficient evidence (albeit limited from true randomized, controlled studies) to indicate that earlier provision of guideline-recommended protein intakes may be key to improving patient outcomes and that nutritional therapy that tailors caloric and protein intake to the patients' needs should be considered a desired standard of care.

The Use of Visceral Proteins as Nutrition Markers: An ASPEN Position Paper

Serum albumin and prealbumin, well-known visceral proteins, have traditionally been considered useful biochemical laboratory values in a nutrition assessment. However, recent literature disputes this contention. The aim of this document is to clarify that these proteins characterize inflammation rather than describe nutrition status or protein-energy malnutrition. Both critical illness and chronic illness are characterized by inflammation and, as such, hepatic reprioritization of protein synthesis occurs, resulting in lower serum concentrations of albumin and prealbumin. In addition, the redistribution of serum proteins occurs because of an increase in capillary permeability. There is an association between inflammation and malnutrition, however, not between malnutrition and visceral-protein levels. These proteins correlate well with patients' risk for adverse outcomes rather than with protein-energy malnutrition. Therefore, serum albumin and prealbumin should not serve as proxy measures of total body protein or total muscle mass and should not be used as nutrition markers. This paper has been approved by the American Society for Parenteral and Enteral Nutrition Board of Directors.

Failure of Healing in Chronic Diabetic Wounds: A Case Report

Stalled healing in chronic wounds is a challenging problem for providers and remains multifactorial in etiology. Older adults with insulin-dependent diabetes are at very high risk. In this case report, two patients with large nonhealing wounds were considered for treatment with daily jet lavage irrigation in an attempt to remove the inflammatory products of their respective chronic wounds and eliminate the persisting biofilm bacteria. Several attempts were made to reduce treatments to two to three times per week, and negative-pressure wound therapy was initiated in both cases only to see the return of inflammation and necrosis of the wound bed. In both cases, the daily jet lavage irrigation was successful in creating a granulating wound bed that slowly healed over many months. One patient died with an open sacral pressure injury, and the other patient died 4 months after complete healing of a large heel pressure injury. The interesting observation is the necessity of daily high-intensity wound irrigation to correct the chronic infectious process. Diabetic chronic wounds in high-risk older adults are recalcitrant to standard wound treatments, and providers should consider daily jet lavage wound irrigation to deal with this problem.

Protein-Energy Wasting Assessment and Clinical Outcomes in Patients with Acute Kidney Injury: A Systematic Review with Meta-Analysis

Nutritional assessment is essential to identify patients with acute kidney injury (AKI) who are protein-energy wasting (PEW) and at risk of poor clinical outcomes. This systematic review aimed to investigate the relationship of nutritional assessments for PEW with clinical outcomes in patients with AKI. A systematic search was performed in PubMed, Scopus, and Cochrane Library databases using search terms related to PEW, nutrition assessment, and AKI to identify prospective cohort studies that involved AKI adult patients with at least one nutritional assessment performed and reported relevant clinical outcomes, such as mortality, length of stay, and renal outcomes associated with the nutritional parameters. Seventeen studies reporting eight nutritional parameters for PEW assessment were identified and mortality was the main clinical outcome reported. A meta-analysis showed that PEW assessed using subjective global assessment (SGA) was associated with greater mortality risk (RR: 1.99, 95% CI: 1.36–2.91). Individual nutrition parameters, such as serum chemistry, body mass, muscle mass, and dietary intakes, were not consistently associated with mortality. In conclusion, SGA is a valid tool for PEW assessment in patients with AKI, while other nutrition parameters in isolation had limited validity for PEW assessment.

Anthropometric, Biochemical, and Food Consumption Parameters are Associated with Venous Leg Ulcer Area and Duration

OBJECTIVE

To describe the dietary habits and anthropometric and biochemical parameters of patients with active venous leg ulcers and to verify the association of these variables with wound duration and area.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study conducted with 33 participants diagnosed with venous leg ulcers in outpatient care.

MAIN OUTCOME MEASURES

Socioeconomic data, anthropometric parameters, biochemical parameters, food consumption, and wound characteristics were analyzed by an interprofessional team.

MAIN RESULTS

Participants were an average of 58 ± 13 years, 57.6% women, 84.8% overweight, and had a median wound duration of 10 months (range, 1-192 months) and an average wound area of 5 cm (range, 0.22-61.1 cm). Diets were typically hypocaloric and hypoproteic, with a low amount of vitamin A and magnesium. Wound duration was negatively associated with polyunsaturated fat intake (P = .032), whereas wound area was significantly associated with lipid intake (P = .002) and C-reactive protein (P = .040).

CONCLUSIONS

Patients with active venous leg ulcers were overweight (leading to systemic inflammation) and had low consumption of calories, protein, and micronutrients that could support cicatrization. Wound area was associated with a high-fat diet, whereas wound duration was negatively associated with polyunsaturated fat intake.

Prealbumin: The clinical utility and analytical methodologies

Prealbumin is a small protein which has been widely evaluated as a nutritional and a prognostic marker. The small size and concentration of prealbumin in blood proposes challenges on measuring it with high sensitivity and specificity. Over the years, a number of analytical methodologies have been developed, which may help establish prealbumin as a useful biomarker in routine clinical practice. The aim of the short review was to explore the current literature on the clinical utility of prealbumin and the advances made in the analytical methodologies of prealbumin. We searched MEDLINE, EMBASE and the Cochrane Library for articles published between January 1980 and July 2019, with the general search terms of 'prealbumin', 'prognostic marker', 'nutritional marker', 'analytical methodologies' and 'malnutrition'. Additionally, we selected relevant articles and comprehensive overviews from reference lists of identified studies. The routine use of prealbumin in clinical practice remains debatable; however; it can complement clinical history, anthropometric assessment and physical examination to assess malnutrition with more certainty. Consensus on the clinical applications of prealbumin in the management of malnutrition is warranted.

Soluble Dietary Fiber Reduces Feeding Intolerance in Severe Acute Pancreatitis: A Randomized Study

BACKGROUND

Feeding intolerance of enteral nutrition (EN) frequently occurs in patients with severe acute pancreatitis (SAP) because of intestinal motility disorders. Soluble dietary fiber (SDF) modulates the intestinal motility. The present study examined whether SDF can improve intestinal motility and permeability, and thereby reduce feeding intolerance, in patients with SAP.

METHODS

This study was a single-blind, randomized, controlled, single-center trial. Forty-nine patients with SAP were included. The control and SDF groups received the same EN solution via a nasojejunal tube. The SDF group additionally received 20-g/d polydextrose. The primary outcome was the time to reach the energy goal. Follow-up was continued for 28 days after admission or until discharge from the hospital.

RESULTS

Among 49 randomized patients, 46 patients (n = 22, control group; n = 24, SDF group) were included in the intent-to-treat analysis. The time to reach the energy goal was 7.00 (6.00, 8.25) days and 5.00 (4.25, 6.00) days in the control and SDF groups, respectively (P < 0.001). The rates of feeding intolerance were significantly reduced in the SDF group (59.09% vs 25.00%, P < .05). SDF was associated with decreases in the incidence of abdominal distension (72.73% vs 29.17%, P < .01), diarrhea (40.91% vs 8.33%, P < .05), and constipation (72.73% vs 12.50%, P < .001). The time to first flatus and first defecation were significantly shorter in the SDF group (P < .001). The intestinal mucosal barrier function and levels of gastrointestinal hormone were improved by SDF, as evidenced by significantly reduced blood levels of diamine oxidase, D-lactic acid, endotoxin, and vasoactive intestinal peptide (P < .05).

CONCLUSIONS

SDF shortens the time to reach the energy goal during EN and improves intestinal permeability and motility disorders, thus reducing the incidence of feeding intolerance in SAP patients.

Malnutrition and its effects in severely injured trauma patients

Purpose

In hospitalized patients, malnutrition is associated with adverse outcomes. However, the consequences of malnutrition in trauma patients are still poorly understood. This study aims to review the current knowledge about the pathophysiology, prevalence, and effects of malnutrition in severely injured patients.

Methods

A systematic literature review in PubMed and Embase was conducted according to PRISMA-guidelines.

Results

Nine review articles discussed the hypermetabolic state in severely injured patients in relation to malnutrition. In these patients, malnutrition negatively influenced the metabolic response, and vice versa, thereby rendering them susceptible to adverse outcomes and further deterioration of nutritional status. Thirteen cohort studies reported on prevalences of malnutrition in severely injured patients; ten reported clinical outcomes. In severely injured patients, the prevalence of malnutrition ranged from 7 to 76%, depending upon setting, population, and nutritional assessment tool used. In the geriatric trauma population, 7–62.5% were malnourished at admission and 35.6–60% were at risk for malnutrition. Malnutrition was an independent risk factor for complications, mortality, prolonged hospital length of stay, and declined quality of life.

Conclusions

Despite widespread belief about the importance of nutrition in severely injured patients, the quantity and quality of available evidence is surprisingly sparse, frequently of low-quality, and outdated. Based on the malnutrition-associated adverse outcomes, the nutritional status of trauma patients should be routinely and carefully monitored. Trials are required to better define the optimal nutritional treatment of trauma patients, but a standardized data dictionary and reasonable outcome measures are required for meaningful interpretation and application of results.

Electronic supplementary material

The online version of this article (10.1007/s00068-020-01304-5) contains supplementary material, which is available to authorized users.

The Preoperative Prognostic Nutritional Index in Hepatocellular Carcinoma After Curative Hepatectomy: A Retrospective Cohort Study and Meta-Analysis

OBJECTIVE

Conflicting results existed about the role of prognostic nutritional index (PNI) for hepatocellular carcinoma (HCC) patients who received curative hepatectomy. The aim of this study is to identify the predictive capacity of PNI for survival after hepatectomy.

METHODS

Preoperative PNI, neutrophil-to-lymphocyte ratio (NLR), tumor feature and clinical information of 187 patients with HCC from Sir Run Run Shaw hospital were evaluated. We also conducted a meta-analysis of seven cohort studies.

RESULTS

Our study showed that HCC patients with a low PNI of <45 had a poor recurrence-free survival (RFS) rate (hazard ratio [HR] 1.762, 95% confidence interval [CI] 1.066-2.911, p = 0.027, respectively). The 5-year OS and RFS rates of the high PNI (≥45) vs low PNI (<45) were 76.7% vs 50.1% (p = 0.001) and 47.0% vs 28.9% (p = 0.001), respectively. In HCC TNM I patients (n = 144), a low PNI remained an independent prognostic factor of OS and RFS (HR 2.305, 95% CI 1.008-5.268, p = 0.048; HR 2.122, 95% CI 1.149-3.920, p = 0.016). The 5-year OS and RFS rates of the high PNI vs low PNI were 81.3% vs 62.4% (p = 0.041) and 53.4% vs 45.6% (p = 0.013), respectively. In the pooled analysis, the data showed that a low PNI was significantly associated with poor OS and RFS (HR 2.27, 95% CI 1.03-4.07, p < 0.001 and HR 1.68, 95% CI 1.45-1.94, p < 0.001, respectively).

CONCLUSIONS

The preoperative PNI was an independent prognostic factor for OS and RFS rates in HCC patients who received hepatectomy.

The malnutrition in polytrauma patients (MaPP) study: Research protocol

BACKGROUND

Polytrauma patients are at risk of considerable harm from malnutrition due to the metabolic response to trauma. However, there is little knowledge of (the risk of) malnutrition and its consequences in these patients. Recognition of sub-optimally nourished polytrauma patients and their nutritional needs is crucial to prevent complications and optimize their clinical outcomes.

AIM

The primary objective is to investigate whether polytrauma patients admitted to the Intensive Care Unit (ICU) who have or develop malnutrition have a higher complication rate than patients who are and remain well nourished. Secondary objectives are to determine the prevalence of pre-existent and in-hospital acquired malnutrition in these patients, to assess the association between malnutrition and long-term outcomes, and to determine the association between serum biomarkers (albumin and pre-albumin) and malnutrition.

METHODS

This international observational prospective cohort study will be performed at three Level-1 trauma centers in the United States and two Level-1 centers in the Netherlands. Adult polytrauma patients (Injury Severity Score ≥16) admitted to the ICU of one of the participating centers directly from the Emergency Department are eligible for inclusion. Nutritional status and risk of malnutrition will be assessed using the Subjective Global Assessment (SGA) scale and Nutritional Risk in Critically Ill (NUTRIC) score, respectively. Nutritional intake, biomarkers and complications will be collected daily. Patients will be followed up to one year after discharge for long-term outcomes.

CONCLUSIONS

This international prospective cohort study aims to gain more insight into the effect and consequences of malnutrition in polytrauma patients admitted to the ICU.

Oxaliplatin-Fluoropyrimidine Combination (XELOX) Therapy Does Not Affect Plasma Amino Acid Levels and Plasma Markers of Oxidative Stress in Colorectal Cancer Surgery Patients: A Pilot Study

Chemotherapy for colorectal cancer may lower muscle protein synthesis and increase oxidative stress. We hypothesize that chemotherapy may worsen plasma amino acids (AAs) and markers of oxidative stress (MOS). Therefore, this study aimed to document plasma AAs and MOS before, during and after chemotherapy in colorectal cancer (CRC) surgery patients. Fourteen normal-weight CRC patients were enrolled one month after surgery and scheduled for oxaliplatin-fluoropyrimidine combination (XELOX) therapy. Venous blood samples for AA and MOS (malondialdehyde, MDA; 8-hydroxy-2’-deoxyguanosine, 8-OHdG) measurements were drawn in fasting patients before each oxaliplatin infusion at initiation (A), 1 month (B) and 3 months (C) of the therapy, and after XELOX had finished (6 months, D). The results showed that during XELOX therapy (from phase B to phase D), in comparison to baseline (phase A), the branched chain amino acid/essential amino acid ratio, branched chain amino acids expressed as a percentage of total AAs, and arginine expressed as a percentage of total AAs significantly decreased (p = 0.017, p = 0.028, p = 0.028, respectively). Plasma levels of MOS did not change significantly. This study indicates that XELOX therapy does not affect plasma AA levels or worsen oxidative stress.

Identifying Critically Ill Patients at Risk of Malnutrition and Underfeeding: A Prospective Study at an Academic Hospital

Purpose: Malnutrition is highly prevalent in critically ill patients and is associated with the increased healthcare-related cost and poor patient outcomes. Identifying the factors associated with undernutrition may assist nutritional care. Therefore, this study was designed to identify factors associated with malnutrition and inadequate energy intake to improve nutritional support in intensive care unit (ICU).

Methods: This prospective study was conducted on 285 random samples of ICU patients. We reported time to initiate the enteral nutrition, percent of the adequately received nutrition, and development of malnutrition during the follow-up period. Moreover, variables and clinical outcomes associated with calories underfeeding and malnutrition were reported.

Results: In 28.6% of samples, enteral feeding was initiated greater than 48 hours after ICU admission. During follow-up, 87.4% and 83.3% of patients failed to receive at least 80% of protein and energy target, and malnutrition developed in 84% of study population. Moreover, surgical and medical patients compared to trauma patients were associated with underfeeding. However, only nutrition risk in the critically ill score (NUTRIC) score ≥5 could predict malnutrition development in our study. Finally, underfeeding contributed significantly to a more mortality rate both in ICU and hospital.

Conclusion: Our findings revealed that the majority of nutritionally high-risk patients failed to receive adequate calories and subsequently developed malnutrition. The present study added valuable information to the small body of literature about the factors affecting nutritional decline and malnutrition during the ICU stay.

Malnutrition definitions in clinical practice: To be E43 or not to be?

Malnutrition is a disease that imposes a significant healthcare cost burden in the United States, especially when left undiagnosed and untreated for an extended period of time. This article discusses traditional malnutrition diagnostic criteria for adults and why registered dietitian nutritionists and physicians should no longer use these criteria to determine nutrition status. It concludes with the malnutrition clinical characteristics currently accepted in the United States and globally, with implications for practice. Clinical documentation specialists and medical coders can use this information to better interpret medical record documentation and assign the correct International Classification of Diseases, 10th Revision, Clinical Modification codes to the coding abstract.

PEP uP (Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol) in Surgical Patients-A Multicenter Pilot Randomized Controlled Trial

BACKGROUND

The Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol (PEP uP) has been shown to be feasible, safe, and effective in delivering significantly more energy/protein, though it has not been well studied in surgical/trauma patients. We hypothesized that PEP uP will effectively increase energy/protein delivery to critically ill surgical/trauma patients.

METHODS

This multicenter, prospective, randomized pilot study included adult patients admitted to surgical service who were expected to require mechanical ventilation for >24 hours and intensive care unit (ICU) care for >72 hours. Subjects were randomized to PEP uP or standard care. The PEP uP protocol includes initiation at goal rate, semi-elemental formula, prophylactic prokinetic agents, 24-hour volume-based goals, and modular protein supplementation. The primary outcome was nutrition adequacy over the first 12 ICU days.

RESULTS

Thirty-six subjects were enrolled. Slow recruitment resulted in early trial termination by the sponsor. There were no baseline differences between groups. PEP uP patients received more protein (106.8 ± 37.0 vs 78.5 ± 30.3 g/d, P = 0.02). Energy delivery was not significantly different (1400.0 ± 409.5 vs 1237.9 ± 459.1 kcal, P = 0.25). Vomiting was more common in the PEP uP patients (32% vs 12%, P = 0.03). PEP uP protocol violations included 2 patients (15.4%) not receiving pro-motility medications, 3 (23.1%) not receiving volume-based feeds as ordered, and 4 (30.8%) not receiving supplemental protein.

CONCLUSIONS

In surgical/trauma patients, PEPuP seemed to improve protein delivery but was difficult to implement successfully and may increase vomiting rates.