Validation of a Screening Tool to Identify Undernutrition in Ambulatory Patients With Liver Cirrhosis

BACKGROUND

The prevalence of chronic liver disease is increasing in the United States. Malnutrition is common as liver disease progresses. However, an accepted method to screen these patients for malnutrition is lacking. The 6-question undernutrition screening tool was developed for professionals without nutrition training to identify a decline in the nutrition status of patients with liver cirrhosis. A 3-phase validation study was completed to assess face, content, and clinical validity of the screening tool in ambulatory patients with liver cirrhosis.

METHODS

In phase I, face validity was determined by surveying 13 liver disease professionals. In phase II, content validity was assessed by surveying 12 registered dietitians who specialize in liver disease. In phase III, a cross-sectional investigation was completed to compare the agreement between the undernutrition screening tool and nutrition assessment by a registered dietitian (RD).

RESULTS

Twenty-two patients with a diagnosis of liver cirrhosis participated in phase III of the investigation. The RD assessment identified undernutrition in 82% of patients (95% CI, 60%-95%). The κ statistic indicated a fair agreement between the screening tool and RD assessment. Sensitivity and specificity of the tool were 72% and 75%, respectively, and positive predictive value was 93%.

CONCLUSIONS

Feedback from phase I, II, and III indicate that the undernutrition screening tool is simple, is easy to use, and measures the constructs that have the strongest link with undernutrition in liver disease. Additional minor adjustments to the screening tool and a multicenter investigation are indicated to confirm clinical effectiveness and cross-validity of the tool.

Outcome of Patients Discharged From a Heart Failure Disease Management Program following Their Clinical and Echocardiographic Recovery

<b><i>Objectives:</i></b> Heart failure (HF) is associated with high mortality and frequent hospitalizations. Disease management programs (DMPs) have a favorable impact on patients with HF. No data exist regarding the outcomes of patients discharged from such a program. <b><i>Methods:</i></b> We examined the outcome of patients with severe systolic HF who were discharged from a DMP following full clinical and echocardiographic recovery. Data were reviewed for mortality, emergency room visits, hospitalizations, medication adherence and left ventricular ejection fraction (EF). <b><i>Results:</i></b> At enrollment and discharge, the mean EF was 19 and 53%, respectively. At follow-up 46.2 months after discharge, 56% of patients had been to the emergency room, 34% were hospitalized a total of 41 times and 20% had died. In the patients who required hospitalization for HF, the mean EF upon rehospitalization had dropped to 23.4%. <b><i>Conclusions:</i></b> Many patients with initially severe systolic HF who had an almost full recovery in a multidisciplinary DMP had very poor outcomes once they were discharged from the program. It may be appropriate to revisit the practice of discharging patients from DMPs once they have reached a specific clinical target.

A randomized, prospective study comparing once-daily gentamicin versus thrice-daily gentamicin in the treatment of puerperal infection

OBJECTIVE

The efficacy, safety, and antibiotic-related charges for once-daily gentamicin with twice-daily clindamycin were compared with those of thrice-daily dosing of these antibiotics.

STUDY DESIGN

Patients with puerperal endometritis or with chorioamnionitis in labor assessed to be at risk for endometritis were randomized to receive gentamicin 4 mg/kg intravenously every 24 hours with clindamycin 1200 mg intravenously every 12 hours (experimental arm) or gentamicin 1.33 mg/kg intravenously and clindamycin 800 mg intravenously every 8 hours (conventional dosing interval arm). Primary outcomes included cure rates, mean length of treatment, antibiotic-related charges, and nephrotoxicity. Multiple logistic regression analysis was used to control for confounding variables.

RESULTS

There were 135 and 137 patients randomized to the experimental and conventional interval arms, respectively. Cures were obtained in 94.1% and 87.6% of patients in the experimental and conventional arms, respectively (p = 0.06). The experimental arm had mean antibiotic charges of $250.79 versus $442.49 in the conventional arm (p < 0.0001). There was no permanent nephrotoxicity in either group.

CONCLUSIONS

Once-daily gentamicin dosing with twice-daily clindamycin dosing is as efficacious and safe as the thrice-daily dosing of gentamicin and clindamycin for peripartum uterine infection. The experimental regimen results in substantial cost savings. The incidence of nephrotoxicity is low.

First-trimester growth patterns of aneuploid fetuses

First-trimester growth restriction has been reported in certain aneuploid pregnancies. The purpose of this study was to evaluate this association further by comparing the crown-rump lengths (CRLs) and growth rates from 196 chromosomally abnormal fetuses with a control population of 1929 euploid fetuses. The mean CRLs and growth rates were significantly reduced (P < 0.05) in the groups of fetuses with trisomy 18 (n = 49), trisomy 13 (n = 19), and triploidy (n = 8). Using a fifth percentile cut-off, growth rate was a better discriminator than a single CRL in identifying fetuses affected with these aneuploidies. These growth parameters were not significantly reduced in fetuses with trisomy 21 (n = 92), sex chromosome trisomies (n = 20), or 45,X (n = 8). We conclude that fetal growth restriction associated with an underlying chromosome abnormality can occur as early as the first trimester. This phenomenon results from intrinsic fetal factors and not delayed ovulation. Such information is important to establish as first-trimester serum screening evolves.

Responsibility of the educator

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Calibration of Voltage Transformers and High- Voltage Capacitors at NIST

The National Institute of Standards and Technology (NIST) calibration service for voltage transformers and high-voltage capacitors is described. The service for voltage transformers provides measurements of ratio correction factors and phase angles at primary voltages up to 170 kV and secondary voltages as low as 10 V at 60 Hz. Calibrations at frequencies from 50-400 Hz are available over a more limited voltage range. The service for high-voltage capacitors provides measurements of capacitance and dissipation factor at applied voltages ranging from 100 V to 170 kV at 60 Hz depending on the nominal capacitance. Calibrations over a reduced voltage range at other frequencies are also available. As in the case with voltage transformers, these voltage constraints are determined by the facilities at NIST.

Spontaneous bilateral quadriceps tendon rupture in a patient on hemodialysis

Since the initiation of maintenance dialysis and renal transplantation, the course of patients with chronic renal disease has been altered. One of the frequent complications found in such patients is the development of secondary hyperparathyroidism, which is commonly associated with metastatic calcification and a variety of bone lesions collectively referred to as renal osteodystrophy. Bilateral rupture of the quadriceps tendon is a rare complication and previous reports have prescribed surgical correction of the ruptured tendon. The present case is that of a patient on chronic hemodialysis with secondary hyperparathyroidism and bilateral spontaneous rupture of the quadriceps tendon who was treated successfully without surgery.

Post-fracture avascular necrosis of the femoral head: correlation of experimental and clinical studies

Both extraosseous and intraosseous blood supply of the femoral head are susceptible to injury in patients with femoral neck fractures. The injury to the extraosseous vessels is proportional to the amount of displacement at the time of fracture. The major intraosseous vessels are damaged if the fracture extends through the superior lateral portion of the neck or head. There is no apparent significant age difference in adults who develop avascular necrosis following a femoral neck fracture that unites compared with those who do not develop avascular necrosis. The difference in reported incidence of avascular necrosis following femoral neck fracture is probably due to several factors. Impacted and nondisplaced fractures should be reported separately from displaced fractures. Avascular necrosis should be reported following united fractures to avoid the confusion in diagnosis when associated with nonunion. At least two years of follow-up are necessary to diagnose 80% of patients who develop avascular necrosis. The type of internal fixation used does not significantly alter the incidence of avascular necrosis. The amount of vascular damage produced at the time of fracture predetermines which patient will develop avascular necrosis. Additional vascular damage may be produced at the time of internal fixation, especially malrotation of the head. The arthritic changes seen in some patients three or more years after femoral neck fracture seem to be initiated by collapse and fragmentation of small areas of avascular necrosis in or near the weight-bearing portion of the head. The various methods currently available for predicting the vascularity of the head at the time of fracture are not sufficiently quantitative to be used on a routine clinical basis. Biologic factors may explain the difference in the incidence of avascular necrosis in the adult femoral head epiphysis compared with that in the metaphysis and explain why the area of revascularization and reossification of avascular bone is so limited.