The role of visceral proteins in the nutritional assessment of intensive care unit patients

Efficacy of early enteral feeding with supplemented mother's milk on postoperative outcomes of cardiac surgical infants: A randomized controlled trial

Introduction

Congenital heart disease (CHD)-associated malnutrition is a systemic consequence of CHD. Dietary recommendations to fulfill nutritional requirements are lacking. This randomized controlled trial (RCT) was conducted to determine the efficacy of early enteral feeding with supplemented expressed breast milk (suppl-EBM) versus expressed breast milk (EBM) in improving the weight of postoperative cardiac surgical infants.

Objective

The primary objective was the weight change between the EBM group and the suppl-EBM group at the 15th postoperative day (POD) or intensive care unit (ICU) discharge. The secondary objectives were to compare the ventilation duration (VD), length of ICU stay (LOICUS), length of hospital stay (LOHS), macronutrient consumption, adverse events, sepsis, and mortality between the two groups.

Materials and Methods

This study was a parallel-group, open-labeled, single-blinded, variable block size RCT conducted at a tertiary care teaching hospital in northern India. Full-term breastfed infants ≤6 months, weighing ≥2.5 kg at birth, and undergoing congenital cardiac repair were enrolled in this study. The infants were fed either EBM or supplemented EBM in control and intervention groups, respectively. Weight and length were measured at baseline and 15th POD or at ICU discharge. Biochemical parameters at baseline and every alternate day, sepsis parameters every third POD and VD, LOICUS, LOHS, macronutrient consumption, and adverse events were assessed daily.

Results

The mean weight, weight change percentage, and weight for age z score were significantly higher in the supplemented EBM group (P < 0.05). The macronutrient consumption was significantly higher in the intervention group (P < 0.05). No significant difference was found between the two groups for VD, LOICUS, and LOHS (P > 0.05). The sepsis was higher in the EBM group. However, the mortality rate did not differ between the two groups (P > 0.05).

Conclusion

Supplemented feeding may improve the weight of postoperative cardiac infants with no serious adverse events.

Comprehensive evaluation of serum hepatic proteins in predicting prognosis among cancer patients with cachexia: an observational cohort study

BACKGROUND

Hepatic proteins, including albumin, prealbumin, and transferrin have been confirmed to be prognostic predictors in various cancers. This study aimed to comprehensively assess the prognostic value of these three serum markers in patients with cancer cachexia.

METHODS

This multicenter prospective cohort study included 1303 cancer cachexia patients, among whom 592 deaths occurred during a median follow-up of 20.23 months. The definition of cachexia was based on the 2011 international consensus. Concordance index (C-index) and receiver operating characteristic (ROC) curves were applied to compare the prognostic performance. The primary outcome was overall survival, which was calculated using the Kaplan-Meier method generated by log-rank test. A Cox proportional hazard regression model was used to identify independent predictors associated with survival. The secondary outcomes included 90-days mortality and quality of life (QoL).

RESULTS

C-index and ROC curves showed that albumin had the most accurate predictive capacity for survival, followed by transferrin and prealbumin. Multivariate Cox analysis confirmed that low albumin (hazard ratio [HR] = 1.51, 95% confidence interval [95%CI] = 1.28-1.80, P < 0.001), prealbumin (HR = 1.42, 95%CI = 1.19-1.69, P < 0.001), and transferrin (HR = 1.50, 95%CI = 1.25-1.80, P < 0.001) were independent risk factors for long-term survival in cancer patients with cachexia. In subgroup analysis, the prognostic value of low albumin was significant in patients with upper gastrointestinal, hepatobiliary and pancreatic, and colorectal cancers; low prealbumin was significant in colorectal cancer; and low transferrin was significant in patients with upper gastrointestinal and colorectal cancer. All three hepatic proteins were valuable as prognostic predictors for patients with advanced (Stage III and IV) cancer with cachexia. The risks of 90-days mortality and impaired QoL were higher in cachexia patients with low albumin, prealbumin, and transferrin levels.

CONCLUSION

Low albumin, prealbumin, and transferrin levels were all independent prognostic factors affecting patients with cancer cachexia, especially in patients in the advanced stages. These results highlight the value of routinely checking serum hepatic proteins in clinical practice to predict the prognosis of patients with cancer cachexia.

Prognostic value of the combined effect of nutritional status and body water component in patients with colorectal cancer

The aim of this study was to explore the impact of Geriatric Nutritional Risk Index (GNRI) and body water component (BWC) on the survival of colorectal cancer (CRC) patients and whether the combined effect had a potential prognostic and predictive efficacy. We evaluated the accuracy of GNRI for malnutrition and estimated the predictive capacity of BWC for survival. Kaplan-Meier survival curves and cox regression analyses were used to examine the prognostic effects. A nutrition-water score (NWS) model was developed and evaluated the survival predictive power. GNRI and extracellular water-to-intracellular water ratio (ECW/ICW) were integrated, with the cut-off values of 103.5 and 63.7%. Lower GNRI and higher ECW/ICW were independent risk factors for poor prognosis in CRC patients. The combination of the two into the NWS model demonstrated a higher risk of death for patients with NWS ≥ 1 compared to those with NWS of 0. NWS showed a better predictive capability compared to GNRI and ECW/ICW, with the concordance index of 0.681. Our study demonstrates GNRI and ECW/ICW's prognostic utility in CRC, with their combination improving survival prediction to help guide patient-centered treatment.

Altered levels of transthyretin in human cerebral microdialysate after subarachnoid haemorrhage using proteomics; a descriptive pilot study

BACKGROUND

Subarachnoid haemorrhage (SAH) is one of the most severe forms of stroke in which delayed cerebral ischemia is one of the major complications. Neurointensive care aims at preventing and treating such complications and identification of biomarkers of early signs of ischemia might therefore be helpful.

METHODS

We aimed at describing proteome profile in cerebral microdialysate in four patients with aneurysmal SAH using two dimensional gel electrophoresis in combination with mass spectrometry in search for new biomarkers for delayed cerebral ischemia and to investigate if there were temporal fluctuations in those biomarkers over time after aneurysmal bleed.

RESULTS

The results showed transthyretin in nine different proteoforms (1001, 1102, 2101, 3101, 4101, 4102, 5001, 5101, 6101) in cerebral microdialysate samples from four patients having sustained SAH. Several proteoforms show highly differing levels and pooled analysis of all samples showed varying optical density related to time from aneurysmal bleed, indicating a temporal evolution.

CONCLUSIONS

Transthyretin proteoforms have not earlier been shown in cerebral microdialysate after SAH and we describe differing levels based on proteoform as well as time from subarachnoid bleed. Transthyretin is well known to be synthetized in choroid plexus, whilst intraparenchymal synthesis remains controversial. The results need to be confirmed in larger studies in order to further describe transthyretin.

Pathogenesis, diagnosis, and treatment of malnutrition in patients with chronic pancreatitis

Chronic pancreatitis (CP) is a persistent and progressive pancreatic inflammatory disease. Malnutrition is a common clinical manifestation in CP patients, which is mainly caused by pancreatic exocrine insufficiency but may also be related to pancreatic endocrine insufficiency and changes of living habit. At present, there is still a lack of gold standard for the diagnosis of malnutrition in patients with CP. Clinicians should comprehensively evaluate such patients through anthropometric parameters, test parameters, imaging diagnosis, pancreatic exocrine function detection, etc., detect malnutrition early, and take timely intervention measures, including improving diet and living habits, enteral/parenteral nutrition, pancreatic enzyme replacement therapy, acid suppressant adjuvant therapy, regulating intestinal flora, and administration of Chinese medicine. And endoscopic and surgical treatment should be used when necessary.

The Effect of a Compound Protein on Wound Healing and Nutritional Status

Proteins provide the main building blocks for tissue growth, cell renewal, and repair during wound healing. We aimed to examine the effect of a compound protein on wound healing, nutritional status, and underlying mechanisms. We first performed a preliminary experiment to identify the appropriate wound healing assessment points. In the formal experiment, there were five groups (control group: 8.3750 g/kg/day saline solution; model group: 8.3750 g/kg/day saline solution; whey protein group: 8.3750 g/kg/day whey protein; low-dose compound protein group: 4.1875 g/kg/day compound protein; and high-dose compound protein group: 8.3750 g/kg/day compound protein) with eight rats in each group. At each turning point, we observed the wound healing rate and nutritional status of the different groups of rats. In addition, biochemical assays were used to determine the mechanisms underlying the effects of the compound protein. In the preliminary experiment, the third day after modeling was the turning point between the inflammatory and proliferation phases, and the eighth day was the turning point between the proliferation and remodeling phases. The formal experiment evaluated wound healing condition, inflammatory response, angiogenesis, collagen deposition, and nutritional status. A pathological report showed increased vascularization, collagen deposition, and epithelialization in compound protein-treated groups. Protein-treated mice showed decreased interleukin (IL)-6, IL-8, neutrophils, and lymphocytes and increased IL-10, albumin, prealbumin, total protein levels, insulin-like growth factor 1 (IGF-1), fibroblast growth factor 2 (FGF-2), and vascular endothelial growth factor (VEGF) expressions. All parameters were significant (p < 0.05) compared to the model group. There was a dose-dependent effect of the compound protein. The accelerated wound healing mechanism may be that the compound protein accelerates the whole wound healing process, making wounds transition from the inflammatory phase to the proliferation phase faster, entering the remodeling phase earlier. Administration of a compound protein can accelerate wound healing and improve the nutritional status.

The Associations Between Preoperative Anthropometry and Postoperative Outcomes in Infants Undergoing Congenital Heart Surgery

Aim:

We explored the association between preoperative anthropometry and biochemistry, and postoperative outcomes in infants with CHD after cardiac surgery, as infants with congenital heart disease (CHD) often have feeding difficulties and malnutrition.

Methodology

This was a retrospective review of infants (≤ 1-year-old) who underwent congenital heart surgery. Preoperative anthropometryin terms of preoperative weight-for-age z-score (WAZ), length-for-age z-score (LAZ), as well as preoperative serum albumin and hemoglobin concentrations, were evaluated against 6-month mortality, and morbidity outcomes including postoperative complications, vasoactive inotrope score, duration of mechanical ventilation, length of stay in the pediatric intensive care unit and in hospital, using the logistic regression or median regression models accounting for infant-level clustering.

Results

One hundred and ninety-nine operations were performed in 167 infants. Mean gestational age at birth was 38.0 (SD 2.2) weeks (range 26 to 41 weeks). Thirty (18.0%) infants were born preterm (<37 weeks). The commonest acyanotic and cyanotic lesions were ventricular septal defect (26.3%, 44/167), and tetralogy of Fallot (13.8%, 23/167), respectively. Mean age at cardiac surgery was 94 (SD 95) days. Feeding difficulties, including increased work of breathing during feeding, diaphoresis, choking or coughing during feeding, and inability to complete feeds, was present in 54.3% (108/199) of infants prior to surgery, of which 21.6% (43/199) required tube feeding. The mean preoperative WAZ was−1.31 (SD 1.79). Logistic regression models showed that low preoperative WAZ was associated with increased risk of postoperative complications (odds ratio 1.82; p = 0.02), and 6-month mortality (odds ratio 2.38; p = 0.008) following CHD surgery. There was no meaningful association between the other preoperative variables and other outcomes.

Conclusion

More than 50% of infants with CHD undergoing cardiac surgery within the first year of life have feeding difficulties, of which 22% require to be tube-fed. Low preoperative WAZ is associated with increased postoperative complications and 6-month mortality.

Time course of the Bioelectrical Impedance Vector Analysis and muscular ultrasound in critically ill patients

PURPOSE

Several different tools have been developed to integrate the clinical and biochemical nutritional evaluations in critical care patients. Aims of this study were to evaluate the changes in the Bioelectrical Impedance Vector Analysis (BIVA) and ultrasonographic features of the diaphragm (DTee) and rectus femoris (RFCSA) during the first week of ICU stay.

MATERIALS AND METHODS

Ninety-six adult mechanically ventilated patients enrolled within 24 h after the admission to the ICU (T1). RFCSA and diaphragm end-expiratory thickness were measured, as well as BIVA parameters. Anthropometric data and biochemical parameters were collected. The measurements were repeated on the 3rd (T3) and 7th (T7) days of ICU stay.

RESULTS

During the study period, the phase angle significantly decreased by 21%, reactance by 27%, and resistance by 11%. Both RFCSA and DTee significantly decreased, while neither were correlated to any BIVA parameter. DTee was considerably higher in survivors vs. non-survivors.

CONCLUSIONS

Body composition is significantly modified after one week of ICU stay. BIVA may be useful in the definition of hydration state, while it does not seem to track muscle mass. Different temporal trends of specific BIVA and muscle ultrasound parameters were found in patients with high or low severity of illness.

Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: children and adolescents

The Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: Children and Adolescents was developed by dietitians, physicians, and pediatric hematologists from 10 Brazilian reference centers in hematopoietic stem cell transplantation. The aim was to emphasize the importance of nutritional status and body composition during treatment, as well as the main characteristics related to patient´s nutritional assessment. This consensus is intended to improve and standardize nutrition therapy during hematopoietic stem cell transplantation. The consensus was approved by the Brazilian Society of Bone Marrow Transplantation.

Predictive value of hypoalbuminemia and severe hypoalbuminemia in oncologic spine surgery

STUDY DESIGN

Retrospective review of a prospectively collected national database.

OBJECTIVE

To evaluate the predictive value of hypoalbuminemia on outcomes in surgical spine oncology patients.

SUMMARY OF BACKGROUND DATA

It is well documented that patients with hypoalbuminemia (albumin <3.5) have significantly higher rates of surgical morbidity and mortality than patients with normal albumin (>3.5 g/dl). We evaluated outcomes for metastatic oncologic spine surgery patients based on pre-operative albumin levels.

MATERIALS AND METHODS

Patients who underwent surgery for metastatic spine disease were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2006 to 2016. Three groups were established: patients with normal albumin (>3.5 g/dl), mild hypoalbuminemia (2.6 g/dl - 3.4 g/dl), and severe hypoalbuminemia (<=2.5 g/dl). A multivariate analysis was used to assess the association between albumin levels and mortality within 30 days of surgical intervention.

RESULTS

A total of 700 patients who underwent surgery for metastatic spinal disease and had pre-operative albumin levels available were identified; 64.0% had normal albumin (>3.5 g/dl), 29.6% had mild hypoalbuminemia, and 6.4% had severe hypoalbuminemia. The overall 30-day mortality was 7.6% for patients with normal albumin, 15.9% for patients with mild hypoalbuminemia, and 44.4% for patients with severe hypoalbuminemia. On multivariate analysis, patients with mild hypoalbuminemia (OR 1.7 95% CI: 1.0-3.0 p = 0.05) and severe hypoalbuminemia (OR 6.2 95% CI: 2.8-13.5 p < 0.001) were more likely to expire within 30 days compared to patients with preoperative albumin above 3.5 g/dl.

CONCLUSION

In this study, albumin level was found to be an independent predictor of 30-day mortality in patients who underwent operative intervention for metastatic spinal disease. Patients with severe hypoalbuminemia had a 7-fold increased risk when compared with those who had normal albumin. While these findings need to be validated by future studies, we believe they will prove useful for preoperative risk stratification and surgical decision-making.

How Have Nutrition Practices in the ICU Changed in the Last Decade (2011-2020): A Scoping Review

Malnutrition is more prevalent in the critically ill than ambulatory patients due to a variety of factors. Strategies employed in the optimization of nutrition practices rely largely on the review of published literature and guidelines. While the last decade was marked by some landmark large randomized controlled trials taking place and some high-quality systematic reviews, it still has left us with many unanswered questions. The evidence generated by these trials can, to a good extent, extrapolate to the developed countries. However, its implementation in developing and third-world countries needs further elaboration and logistical considerations. With this scoping review, we attempt to provide insights into the landmark developments in the decade 2011-2020. Solutions to employ and implement the results of these developments and ways for their corroboration into a larger population are also discussed.

Perioperative Albumin Supplementation is Associated With Decreased Risk of Complications Following Microvascular Head and Neck Reconstruction

PURPOSE

Studies have demonstrated that low serum albumin levels are associated with a high postoperative complication rate after microvascular free flap reconstruction. The aim of this study was to investigate whether perioperative albumin supplementation reduced the postoperative complications of microvascular free flap reconstruction in oral and maxillofacial tumor resections.

PATIENTS AND METHODS

Patients who underwent microvascular free flap reconstruction during oral and maxillofacial tumor resections from January 2012 to December 2017 were enrolled in this retrospective study. The predictor variable was perioperative albumin supplementation. The primary outcome variables were surgery-associated postoperative complications, including local and systemic complications. The secondary outcome variables were the total duration of hospital stay, postoperative ICU admission rate, duration of ICU stay, and mortality during hospitalization.

RESULTS

In total, 315 patients met the criteria. Patients with serum albumin supplementation showed a lower rate of surgery-associated local complications (6.5 vs 21.6%) with an adjusted odds ratio (OR) of 0.24 (95% confidence interval (CI), 0.12 to 0.49, P < .001). The average postoperative hospital stay was significantly shortened for patients with albumin supplementation (12.56 ± 4.23 vs 15.34 ± 5.24 days, P < .001). However, albumin supplementation had no effect on systemic complications.

CONCLUSIONS

The results of this study suggest that perioperative albumin supplementation is associated with a decreased risk of local complications, shortened hospital stay, and decreased need for crystalloid infusion in patients who underwent oral and maxillofacial tumor resections with microvascular free flap reconstruction.

Modified geriatric nutrition risk index as a prognostic predictor of esophageal cancer

BACKGROUND

This study aimed to establish a simple and useful prognostic indicator for elderly esophageal cancer patients. We designed the modified geriatric nutrition risk index (mGNRI) using the inverse of C-reactive protein (CRP) instead of albumin and compared its prognostic value with those of the GNRI and other indices.

METHODS

We included 128 patients aged > 65 years who underwent esophagectomy for esophageal cancer. We defined mGNRI as (1.489/CRP in mg/dL) + (41.7 × present/ideal body weight) and divided patients into two groups: the low-mGNRI (mGNRI < 70, n = 50) and high-mGNRI (mGNRI ≥ 70, n = 78) groups. We retrospectively examined the relationship between mGNRI and long-term prognosis.

RESULTS

The low-mGNRI group had more advanced cancer by stage, higher rates of recurrence, and earlier recurrence than the high-mGNRI group. Univariate analysis identified the following factors as significantly associated with poor overall survival (OS): a lower American society of anesthesiologist performance status (ASA-PS), male gender, CRP-albumin ratio ≥ 0.1, CRP ≥ 1.0, low-mGNRI, tumor depth ≥ T3, Charlson comorbidity index ≥ 2, tumor size ≥ 40 mm, and age > 75 years. A low-mGNRI, ASA-PS 3, age > 75 years, and tumor depth ≥ T3 were independent unfavorable prognostic factors for OS. A low-mGNRI was an independent poor prognostic factor for relapse-free survival. We performed model selection analysis to identify the most clinically useful indices; mGNRI was the best predictive model.

CONCLUSION

mGNRI in patients with esophageal cancer correlated with early recurrence and was a useful independent prognostic factor.

Application effect of initiation of enteral nutrition at different time periods after surgery in neonates with complex congenital heart disease: A retrospective analysis

Early enteral nutrition (EN) promotes the recovery of critically ill patients, but the initiation time for EN in neonates after cardiac surgery remains unclear.This study aimed to investigate the effect of initiation time of EN after cardiac surgery in neonates with complex congenital heart disease (CHD).Neonates with complex CHD admitted to the CICU from January 2015 to December 2017 were retrospectively analyzed. Patients were divided into the 24-hour Group (initiated at 24 hours after surgery in 2015) (n = 32) and 6-hour Group (initiated at 6 hours after surgery in 2016 and 2017) (n = 66). Data on the postoperative feeding intolerance, nutrition-related laboratory tests (albumin, prealbumin, retinol binding protein), and clinical outcomes (including duration of mechanical ventilation, CICU stay, and postoperative hospital stay) were collected.The incidence of feeding intolerance was 56.3% in 24-hour Group and 39.4%, respectively (P = .116). As compared to 24-hour Group, prealbumin and retinol binding protein levels were higher (160.7 ± 64.3 vs 135.2 ± 28.9 mg/L, P = .043 for prealbumin; 30.7 ± 17.7 vs 23.0 ± 14.1 g/L P = .054 for retinol-binding protein). The duration of CICU stay (9.4 ± 4.5 vs 13.3 ± 10.4 day, P = .049) and hospital stay (11.6 ± 3.0 vs 15.8 ± 10.3 day, P = .028) were shorter in 6-hour Group.Early EN improves nutritional status and clinical outcomes in neonates with complex CHD undergoing cardiac surgery, without significant feeding intolerance.

Transthyretin at Admission and Over Time as a Marker for Clinical Outcomes in Critically Ill Trauma Patients: A Prospective Single-Center Study

Background

Transthyretin (TTR) has been described as a predictor for outcomes in medical and surgical patients. However, the association of TTR on admission and over time on outcomes has not yet been prospectively assessed in trauma patients.

Methods

This is a prospective observational study including trauma patients admitted to the intensive care unit (ICU) of a large Level I trauma center 05/2014–05/2015. TTR levels at ICU admission and all subsequent values over time were recorded. Patients were observed for 28 days or until hospital discharge. The association of outcomes and TTR levels at admission and over time was assessed using multivariable regression and generalized estimating equation (GEE) analysis, respectively.

Results

A total of 237 patients with TTR obtained at admission were included, 69 of whom had repeated TTR measurements. Median age was 40.0 years and median ISS 16.0; 83.1% were male. Below-normal TTR levels at admission (41.8%) were independently associated with higher in-hospital mortality (p = 0.042), more infectious complications (p = 0.032), longer total hospital length of stay (LOS) (p = 0.013), and ICU LOS (p = 0.041). Higher TTR levels over time were independently associated with lower in-hospital mortality (p = 0.015), fewer infections complications (p = 0.028), shorter total hospital and ICU LOS (both p < 0.001), and fewer ventilator days (0.004).

Conclusions

In critically ill trauma patients, below-normal TTR levels at admission were independently associated with worse outcomes and higher TTR levels over time with better outcomes, including lower in-hospital mortality, less infectious complications, shorter total hospital and ICU LOS, and fewer ventilator days. Based on these results, TTR may be considered as a prognostic marker in this patient population.

Relationship between nutritional status on admission to the intensive care unit and clinical outcomes

AIM

To determine the prevalence of malnutrition on admission to the intensive care unit (ICU) and the relationship between nutritional status on admission and clinical outcomes in adult critically ill patients.

METHODS

This was a prospective study in an adult ICU. Patients with expected length of stay (LOS) >48 hours in ICU were assessed for nutritional status using the patient generated-subjective global assessment (PG-SGA) within 48 hours of admission to ICU.

RESULTS

Primary outcomes were ICU and hospital mortality, ICU and hospital LOS and length of mechanical ventilation. A total of 166 patients were enrolled in this study. Patients were aged 59 ± 17 years on average with a mean BMI of 29 ± 7 kg/m² and a mean Acute Physiology and Chronic Health Evaluation II score of 19 ± 7. The prevalence of malnutrition in critically ill patients was 36% (n = 60). Mortality rate of malnourished patients was 9% (n = 15) compared to 7.8% (n = 13) in well-nourished patients (adjusted odds ratio, 2.17; 95% confidence interval, 0.9-5.03, P = .069). There was no difference in hospital mortality between malnourished patients and well-nourished patients (10.2% vs 10.2% adjusted odds ratio, 1.93; 95% confidence interval, 0.89-4.19, P = .096). There was no relationship between nutritional status and length of mechanical ventilation (3.0 vs 1.0 days, P = .382)or ICU LOS (4.7 vs 4.8 days, P = .59). Malnourished patients had a longer LOS in hospital than well-nourished patients (24 vs 17 days, P = .03).

CONCLUSION

Malnutrition is an independent risk factor for increased hospital LOS.

Malnutrition in Chronic Pancreatitis: Causes, Assessment Methods, and Therapeutic Management

PURPOSE

In recent years, more and more emphasis has been placed on early diagnosis and adequate treatment of malnutrition in the course of chronic diseases (CP). One of these diseases is chronic pancreatitis in which malnutrition may develop as a consequence of abdominal pain, vomiting, diarrhea, and alcohol abuse. The aim of this review paper is recognized if we can improve the nutritional status of patients with CP.

METHODS

This paper is based on systematic literature review according to the PubMed.

RESULTS

One of the most important problems is lack of "gold standard" in screening of nutritional status in patients with CP, especially in outpatient clinics. Another problem is preventing malnutrition in these patients and beginning treatment already at significant stages of disease. To prevent malnutrition you must first recognize the causes of malnutrition in CP, adequately assess its severity using one of available questionnaires and then apply the appropriate therapeutic management. At each visit, remember to assess the nutritional status of the patient, including laboratory markers and anthropometric measurements. Patients should be advised to stop smoking and drinking alcohol and to use adequate enzyme supplementation.

CONCLUSION

Patients with CP should be led by a team of gastroenterologist, diabetologist, and psychologist and consulted by a dietitian, specialist of pain treatment, and surgeon.

Risk prediction models for the development of oral-mucosal pressure injuries in intubated patients in intensive care units: A prospective observational study

PURPOSE

Oral-mucosal pressure injury (PI) is the most commonly encountered medical device-related PIs. This study was performed to identify risk factors and construct a risk prediction model for oral-mucosal PI development in intubated patients in the intensive care unit.

METHODS

The study design was prospective, observational with medical record review. The inclusion criteria stipulated that 1) participants should be > 18 years of age, 2) there should be ETT use with holding methods including adhesive tape, gauze tying, and commercial devices. Data of 194 patient-days were analysed. The identification and validation of risk model development was performed using SPSS and the SciKit learn platform.

RESULTS

The risk prediction logistic models were composed of three factors (bite-block/airway, commercial ETT holder, and corticosteroid use) for lower oral-mucosal PI development and four factors (commercial ETT holder, vasopressor use, haematocrit, and serum albumin level) for upper oral-mucosal PI development among 10 significant input variables. The sensitivity and specificity for lower oral-mucosal PI development were 85.2% and 76.0%, respectively, and those for upper oral-mucosal PI development were 60.0% and 89.1%, respectively. Based on the results of the machine learning, the upper oral-mucosal PI development model had an accuracy of 79%, F1 score of 88%, precision of 86%, and recall of 91%.

CONCLUSIONS

The development of lower oral-mucosal PIs is affected by immobility-related factors and corticosteroid use, and that of upper oral-mucosal PIs by undernutrition-related factors and ETT holder use. The high sensitivities of the two logit models comprise important minimum data for positively predicting oral-mucosal PIs.

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.

Nutritional assessment of Oraons of West Bengal: a comparison between biochemical and anthropometric methods

Comprehensive nutritional assessment is the basis of nutritional diagnosis and necessary to identify the individual or the population at a risk of dietary deficiencies. However, there is no specific and confirmatory method to measure nutritional status. Present study tried to find out the efficacy of two nutritional assessment method (1) biochemical test like Total serum protein (TSP) and (2) anthropological measurements like body mass index (BMI) and mid-upper-arm-circumference (MUAC). Later, three methods were tested and compared for the strength of assessing the nutritional status. Study was conducted among 198 adult Oraon, 84 male, 114 female individuals of Madarihat and Falakata police station area, Alipurduar district, West Bengal. Selected blood parameters such as total serum protein (TSP), serum albumin and haemoglobin and anthropometric measurements (height, weight, mid-upper arm circumference, waist circumference, hip circumference, calf circumference, biceps skinfold, triceps skinfold, and calf skinfold) were obtained following standard instruments and protocols. Nutritional status of all individuals was assessed by TSP, BMI and MUAC classification methods. Comparison between/among three classification methods (TSP, BMI and MUAC) was done and discriminant function analysis was adopted to find out the percentage of correct classification by each methods. It was found that prevalence of undernutrition using TSP classification was 38.1% male and 43.0% female; using BMI was 34.5% male and 53.5% female; using MUAC was 45.2% male and 64.9% female. Discriminant function analysis showed that BMI (97.0%) had the highest capability of correct classification followed by MUAC (84.80%) and TSP (63.60%). Results indicate that however, TSP is an objective way of nutritional assessment, but BMI had the highest capability of correct classification of nutritional status. It may be pointed out that the evaluation with TSP was expensive and invasive whereas BMI is non-expensive and completely a non-invasive way of evaluation. Therefore, BMI may widely be used for nutritional assessment.

Prognostic Value of Pretreatment Serum Transthyretin Level in Patients with Gastrointestinal Cancers

Background

Many studies have shown the link between the pretreatment serum transthyretin and prognosis in gastrointestinal (GI) cancers. However, based on the conclusion, the initial findings were inconsistent. Hence, this meta-analysis was performed to identify the prognostic values of the pretreatment serum transthyretin in GI cancers.

Methods

Previous studies published before November 2018 were collected from a comprehensive literature search of several databases. The pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were applied in the assessment of the intensity of associations. Also, the publication bias and the robustness of merged data were assessed. All statistical analyses were undertaken using STATA/SE 14.1.

Results

The combined data indicated that the pretreatment serum transthyretin level was related to the prognosis in GI cancers. The group with reduced pretreatment transthyretin had a significantly worse overall survival (OS) (HR = 1.71, 95% CI: 1.37-2.05). The subgroup analysis for OS further showed the predictive value of transthyretin. In addition, the low serum transthyretin level could be an unfavorable factor for recurrence-free survival (RFS) or progression-free survival (PFS) (HR = 1.66, 95% CI: 1.14-2.18) in GI cancers.

Conclusion

The low pretreatment serum transthyretin level implies an unfavorable prognosis for patients with GI cancers. The monitoring of pretreatment transthyretin level could contribute to the risk stratification and individualized therapy in GI cancers.

Sarcopenia Index Is a Simple Objective Screening Tool for Malnutrition in the Critically Ill

BACKGROUND

Reliable and valid tools to screen for malnutrition in the intensive care unit (ICU) remain elusive. The sarcopenia index (SI) [(serum creatinine/serum cystatin C) × 100], could be an inexpensive, objective tool to predict malnutrition. We evaluated the SI as a screening tool for malnutrition in the ICU and compared it with the modified-NUTRIC score.

MATERIALS AND METHODS

This was a historical cohort study of ICU patients with stable kidney function admitted to Mayo Clinic ICUs between 2008 and 2015. Malnutrition was defined by the Subjective Global Assessment. Diagnostic performance was evaluated with the area under the receiver operating characteristic curve (AUC) and multivariable logistic regression.

RESULTS

Of the 398 included patients, 181 (45%) had malnutrition, with 34 (9%) scored as severely malnourished. The SI was significantly lower in malnourished patients than in well-nourished patients (64 ± 27 vs 72 ± 25; P = 0.002), and reductions in SI corresponded to increased malnutrition severity (P = 0.001). As a screening tool, the SI was an indicator of malnutrition risk (AUC 0.61) and performed slightly better than the more complex modified-NUTRIC score (AUC = 0.57). SI cutoffs of 101 and 43 had >90% sensitivity and >90% specificity, respectively, for the prediction of malnutrition. Patients with a low SI (≤43) had a significantly higher risk of mortality (HR = 2.61, 95% CI 1.06-6.48, P = 0.038).

CONCLUSION

The frequency of malnutrition was high in this critically ill population, and it was associated with a poor prognosis. The SI could be used to assess nutrition risk in ICU patients.

Effects of Parenteral Amino Acid Administration on the Postoperative Nutritional Status and Wound Healing of Protein-Malnourished Rats

In Japan, parenteral nutrition (PN) solutions are frequently administered to patients in the postoperative short-term period. In these cases, amino acid-containing peripheral parenteral nutrition (PPN) solutions, amino acid-free maintenance solutions or combinations of the two are used. However, consensus regarding the most beneficial solution for these patients is lacking. Here, we examined the nutritional status and wound healing outcomes in protein-malnourished rats receiving postoperative administrations of PPN solution, maintenance solution or combinations of the two solutions. Protein malnutrition was induced in Sprague-Dawley rats by feeding an AIN-93G-based low-protein diet (5% casein) for 2 wk. After laparotomy, dorsal skin incision, and placement of a jugular vein catheter, the rats were divided into 3 groups. Each group was administered 113 kcal/kg/d, with group A receiving maintenance solutions without amino acid, group B receiving PPN with 1.5% amino acid, and group C receiving PPN with 3% amino acid. After 5 d post-operative administration, we measured the tensile strength of the wound area, skeletal muscle weights, and nutritional parameters. Significantly higher plasma nutritional parameters and gastrocnemius and extensor digitorum longus (EDL) muscle weights were observed in groups B and C than in group A. Group C exhibited significantly elevated tensile strength of the wound area along with up-regulation of type I collagen mRNA expression compared to group A. These findings demonstrate the nutritional status and wound healing benefits of short-term postoperative administration of PPN solutions containing amino acids in protein-malnourished rats.

Transthyretin for the routine assessment of malnutrition: A clinical dilemma highlighted by an international survey of experts in the field

The value of transthyretin (TTR) measurement for assessing malnutrition is under debate due to its sensitivity to inflammation and frequent confusion over its meaning (i.e. as a marker of diagnosis, prognosis, or efficacy of refeeding). Moreover, there is still no ESPEN/ASPEN guideline on its use and cut-off values. Here the aim was to evaluate the overall perception of the value of this parameter and its utilization worldwide. A panel of international experts in the field were surveyed on the use of TTR in clinical practice in their country, on the guidelines issued by their national health authorities, and on the cut-off values used to diagnose malnutrition. A total of 31 experts (nutrition [n = 9], surgery [n = 8], critical care [n = 4], geriatrics [n = 4], biology [n = 3], pediatrics [n = 1], internal medicine [n = 1] and gastroenterology [n = 1]) from 16 countries participated. TTR only appears in Italian, Polish, British and French national guidelines giving cut-off values for mild/moderate/severe malnutrition. TTR is frequently used in research yet rarely if ever in clinical practice in most countries, the reasons cited being lack of evidence for its usefulness, lack of specificity, or its high cost/effectiveness ratio. Given the difficulty of finding a consensus tool for the diagnosis of malnutrition, there is every reason to consider such a simple and inexpensive marker as TTR. However, further studies are needed to define and unify international guidelines on the use of TTR in terms of inflammation level and the associated cut-off values.

Assessing the influence of acute kidney injury on the mortality in patients with acute myocardial infarction: a clinical trail

Objectives: Acute kidney injury (AKI) increases the risk of death following acute myocardial infarction (AMI). In this current study, we tried to understand the role of newly KDIGO defined AKI in AMI-induced early and late mortality.

Methods: We retrospectively analyzed the clinical data of AMI patients (totaling 1371 cases) from the hospital’s computer database. And AKI was defined based on the KDIGO criteria but GFR or urinary output assessment was not used. Subsequently, we compared the association of AKI with 30-day and 30-day to 5-year all-cause mortality, using multivariate COX regression analysis with two models.

Results: We observed the development of AKI in 410 (29.9%) patients during the hospital stay. The 30-day and 30-day to 5-year mortality rates were 5.6% and 11.3%, respectively, in 1371 AMI patients. Further, adjusted Cox regression analysis based on model 1 revealed that AKI severity was an independent risk factor of 30-day mortality, while AKI Stage 3 was an independent predictor of 30-day to 5-year mortality. Adjusted Cox regression analysis based on model 2 revealed that normal baseline renal function with AKI and impaired renal function with AKI were independent risk factors of 30-day mortality, while normal baseline renal function with AKI and impaired renal function with AKI were identified to be independent predictors of 30-day to 5-year mortality.

Conclusions: Whether the baseline renal function decreased or not, AKI strongly correlated with short- and long-term all-cause mortality in patients with AMI. Specifically, the short-term mortality of AMI patients increased with more severe AKI.

Biochemical Markers of Nutrition Support in Critically Ill Trauma Victims

BACKGROUND

In critically ill patients, plasma serum albumin and transthyretin concentrations are thought to reflect the effects of acute illness, including resuscitation and inflammation. Their use as markers for preexisting nutrition status is, therefore, not recommended. Whether they can be used to assess subsequent effectiveness of artificial nutrition support is unclear. We sought to determine if these biomarkers are associated with enteral caloric intake in critically ill trauma patients.

MATERIALS AND METHODS

We analyzed data from adult trauma victims who required ≥2 days of mechanical ventilation and ≥7 days of intensive care. We categorized patients into low, middle, or high enteral calorie delivery groups (2, 9, or 17 kcal/kg/d during the first week). We compared serial concentrations of serum albumin, transthyretin, and C-reactive protein. Multiple linear and Poisson regression were used to determine relationships between calorie intake and nutrition biomarkers.

RESULTS

In total, 1056 patients were analyzed. Their median age was 44 (interquartile range [IQR], 28-57) years, and median injury severity score was 34 (IQR, 26-41). Calorie intake during the first week was not related to biomarkers during the first or second week. However, by the beginning of the third week, the highest calorie group showed greater changes in concentrations of transthyretin (+3.0 mg/dL relative to initial concentration, P = .01) and serum albumin (+0.17 g/dL, P = .05) compared with the lowest calorie group.

CONCLUSIONS

In trauma patients requiring 1 or more weeks of intensive care, changes in transthyretin were associated with enteral caloric intake. Our data suggest that transthyretin could be used to monitor nutrition support after 2 weeks in intensive care.

The Retinol Circulating Complex Releases Hormonal Ligands During Acute Stress Disorders

Intensive care workers actively participate in very hot debates aiming at defining the true metabolic, hormonal and nutritional requirements of critically ill patients, the contributory roles played by thyroid and retinoid ligands being largely underestimated. The present article makes up for redressing the balance on behalf of these last hormonal compounds. The retinol circulating complex is transported in the bloodstream in the form of a trimolecular edifice made up of transthyretin (TTR), retinol-binding protein (RBP) and its retinol ligand. TTR reflects the size of the lean body mass (LBM) and is one of the 3 carrier-proteins of thyroid hormones whereas RBP is the sole conveyor of retinol in human plasma. In acute inflammatory disorders, both TTR and RBP analytes experience abrupt cytokine-induced suppressed hepatic synthesis whose amplitude is dependent on the duration and severity of the inflammatory burden. The steep drop in TTR and RBP plasma values releases thyroxine and retinol ligands in their physiologically active forms, creating free pools estimated to be 10-20 times larger than those described in healthy subjects. The peak endocrine influence is reached on day 4 and the freed ligands undergo instant cellular overconsumption and urinary leakage of unmetabolized fractions. As a result of these transient hyperthyroid and hyperretinoid states, helpful stimulatory and/or inhibitory processes are set in motion, operating as second frontlines fine-tuning the impulses primarily initiated by cytokines. The data explain why preexisting protein malnutrition, as assessed by subnormal LBM and TTR values, impairs the development of appropriate recovery processes in critically ill patients. These findings have survival implications, emphasizing the need for more adapted therapeutic strategies in intensive care units.

Multiple reaction monitoring mass spectrometry to identify novel plasma protein biomarkers of treatment response in cystic fibrosis pulmonary exacerbations

BACKGROUND

Systemic inflammation decreases with IV antibiotics during the treatment of CF pulmonary exacerbations (PEx). We used multiple reaction monitoring mass spectrometry and immunoassays to monitor blood proteins during PEx treatment to determine if early changes could be used to predict PEx outcomes following treatment.

METHODS

Blood samples from 25 PEx (22 unique adults) were collected within 24h of admission, day 5, day 10, and at IV antibiotic completion. Ninety-two blood proteins involved in host immunity and inflammation were measured.

RESULTS

Levels of several blood proteins changed from admission to end of IV antibiotics, most increasing with treatment. Early changes (admission to day 5) in fibrinogen levels had the strongest correlation with overall improvement in CFRSD-CRISS and FEV₁% predicted by the end of treatment.

CONCLUSIONS

Several plasma proteins changed significantly with IV antibiotics. Future studies will evaluate fibrinogen as an early biomarker of PEx treatment response in CF.

Efficacy, Safety, and Preparation of Standardized Parenteral Nutrition Regimens: Three-Chamber Bags vs Compounded Monobags-A Prospective, Multicenter, Randomized, Single-Blind Clinical Trial

Background: Parenteral nutrition (PN) covering the need for carbohydrates, amino acids, and lipids can either be compounded from single nutrients or purchased as an industrially manufactured ready-to-use regimen. This study compares a commercially available 3-chamber bag (study group) with a conventionally compounded monobag regarding nutrition efficacy, safety, and regimen preparation time. Materials and Methods: This prospective, randomized, single-blind study was conducted at 5 Chinese hospitals from October 2010–October 2011. Postsurgical patients requiring PN for at least 6 days were randomly assigned to receive the study or control regimen. Plasma concentrations of prealbumin and C-reactive protein (CRP), regimen preparation time, length of hospital stay (LOS), 30-day mortality, safety laboratory parameters, and adverse events (AEs) were recorded. Results: In total, 240 patients (121 vs 119 in study and control groups) participated in this study. Changes in prealbumin concentrations during nutrition support (Δ_{Prealb(StudyGroup)} = 2.65 mg/dL, P < .001 vs Δ_{Prealb(ControlGroup)} = 0.27 mg/dL, P = .606) and CRP values were comparable. Regimen preparation time was significantly reduced in the study group by the use of 3-chamber bags (t_(StudyGroup) = 4.90 ± 4.41 minutes vs t_{(ControlGroup)} = 12.13 ± 5.62 minutes, P < .001). No differences were detected for LOS, 30-day mortality, safety laboratory parameters, and postoperative AEs (37 vs 38 in study and control groups). Conclusion: The PN regimen provided by the 3-chamber bag was comparable to the compounded regimen and safe in use. Time savings during regimen preparation indicates that use of 3-chamber bags simplifies the process of regimen preparation.

Transthyretin Concentrations in Acute Stroke Patients Predict Convalescent Rehabilitation

OBJECTIVE

For stroke patients, intensive nutritional management is an important and effective component of inpatient rehabilitation. Accordingly, acute care hospitals must detect and prevent malnutrition at an early stage. Blood transthyretin levels are widely used as a nutritional monitoring index in critically ill patients. Here, we had analyzed the relationship between the transthyretin levels during the acute phase and Functional Independence Measure in stroke patients undergoing convalescent rehabilitation.

METHODS

We investigated 117 patients who were admitted to our hospital with acute ischemic or hemorrhagic stroke from February 2013 to October 2015 and subsequently transferred to convalescent hospitals after receiving acute treatment. Transthyretin concentrations were evaluated at 3 time points as follows: at admission, and 5 and 10 days after admission. After categorizing patients into 3 groups according to the minimum transthyretin level, we analyzed the association between transthyretin and Functional Independence Measure.

RESULTS

In our patients, transthyretin levels decreased during the first 5 days after admission and recovered slightly during the subsequent 5 days. Notably, Functional Independence Measure efficiency was significantly associated with the decrease in transthyretin levels during the 5 days after admission. Patients with lower transthyretin levels had poorer Functional Independence Measure outcomes and tended not to be discharged to their own homes.

DISCUSSION

A minimal transthyretin concentration (<10 mg/dL) is predictive of a poor outcome in stroke patients undergoing convalescent rehabilitation. In particular, an early decrease in transthyretin levels suggests restricted rehabilitation efficiency. Accordingly, transthyretin levels should be monitored in acute stroke patients to indicate mid-term rehabilitation prospects.

Does the Subjective Global Assessment Predict Outcome in Critically Ill Medical Patients?

Background:

The Subjective Global Assessment (SGA) is a validated nutrition assessment tool that is not commonly used to evaluate the nutritional status of patients admitted to the intensive care unit (ICU).

Objectives:

The aims of this study were to determine the prevalence of malnutrition in critically ill medical patients using the SGA and to determine whether the SGA was predictive of patient outcome.

Materials and Methods:

A retrospective chart review was performed on 57 consecutive patients admitted to a single tertiary care medical ICU and requiring mechanical ventilation over a 6-month time period. All SGA assessments were performed by a single dietitian trained in this assessment technique. Multiple factors including patient demographics, severity of illness, length of mechanical ventilation, length of ICU stay, and mortality were abstracted from the charts.

Results:

The prevalence of malnutrition on admission as assessed by the SGA was 35%. Severity of illness as determined by Acute Physiology and Chronic Health Evaluation II (APACHE II) score was not different between the SGA groups. Mortality rates were significantly higher in the moderately (45.5%) and severely malnourished (55.6%) groups than in the well-nourished group (10.8%; P = .004).

Conclusion:

Malnutrition on admission is common in critically ill medical patients. Malnutrition, as assessed by SGA at admission to ICU, is associated with increased mortality and thus can serve as a valuable prognostic tool in the assessment of critically ill patients. Given that that the SGA is a simple bedside assessment, it should be considered for routine use in assessing critically ill patients.

Malnutrition: laboratory markers vs nutritional assessment

Malnutrition is an independent risk factor for patient morbidity and mortality and is associated with increased healthcare-related costs. However, a major dilemma exists due to lack of a unified definition for the term. Furthermore, there are no standard methods for screening and diagnosing patients with malnutrition, leading to confusion and varying practices among physicians across the world. The role of inflammation as a risk factor for malnutrition has also been recently recognized. Historically, serum proteins such as albumin and prealbumin (PAB) have been widely used by physicians to determine patient nutritional status. However, recent focus has been on an appropriate nutrition-focused physical examination (NFPE) for diagnosing malnutrition. The current consensus is that laboratory markers are not reliable by themselves but could be used as a complement to a thorough physical examination. Future studies are needed to identify serum biomarkers in order to diagnose malnutrition unaffected by inflammatory states and have the advantage of being noninvasive and relatively cost-effective. However, a thorough NFPE has an unprecedented role in diagnosing malnutrition.

Plasma Transthyretin as a Biomarker of Lean Body Mass and Catabolic States

Plasma transthyretin (TTR) is a plasma protein secreted by the liver that circulates bound to retinol-binding protein 4 (RBP4) and its retinol ligand. TTR is the sole plasma protein that reveals from birth to old age evolutionary patterns that are closely superimposable to those of lean body mass (LBM) and thus works as the best surrogate analyte of LBM. Any alteration in energy-to-protein balance impairs the accretion of LBM reserves and causes early depression of TTR production. In acute inflammatory states, cytokines induce urinary leakage of nitrogenous catabolites, deplete LBM stores, and cause an abrupt decrease in TTR and RBP4 concentrations. As a result, thyroxine and retinol ligands are released in free form, creating a second frontline that strengthens that primarily initiated by cytokines. Malnutrition and inflammation thus keep in check TTR and RBP4 secretion by using distinct and unrelated physiologic pathways, but they operate in concert to downregulate LBM stores. The biomarker complex integrates these opposite mechanisms at any time and thereby constitutes an ideally suited tool to determine residual LBM resources still available for metabolic responses, hence predicting outcomes of the most interwoven disease conditions.