Serum Albumin and Prealbumin in Calorically Restricted, Nondiseased Individuals: A Systematic Review

Association of albumin to urea nitrogen ratio with 30-day mortality in adult hemophagocytic lymphohistiocytosis: a retrospective cohort study

Hemophagocytic lymphohistiocytosis (HLH) is a severe disease with a grim prognosis. This study aims to investigate the potential role of albumin to urea nitrogen ratio (AUR) as a predictor of 30-day mortality in adult HLH patients. This retrospective analysis involved patients admitted to the hospital with a first-time diagnosis of HLH between January 2015 and September 2021. The primary outcome was defined as 30-day all-cause mortality. Patients were categorized as survivors and non-survivors, as well as test and validation cohorts. Clinical signs and laboratory biomarkers on admission were picked up. A total of 467 patients were included in the study, with a 30-day mortality rate of 31.0% (n = 145). There were no significant differences observed between the test and validation cohorts. Surviving patients exhibited significantly higher levels of AUR. Multivariate analysis indicated that an AUR < 3.40 was deemed to be an independent risk factor (test cohort: HR: 3.663, P < 0.001; validation cohort: 2.475, P = 0.013; total cohort: 2.976, P < 0.001). The area under the receiver operating characteristic curve (AUC) values were 0.734 in the test cohort, 0.690 in the validation cohort, and 0.711 in the total cohort. AUR emerged as an independent and reliable risk indicator for 30-day mortality in adults with HLH, offering clinicians a tool to identify high-risk patients efficiently.

Low transthyretin concentration linked to adverse prognosis in elderly inpatients

BACKGROUND

To investigate the association between low transthyretin (prealbumin) concentration and mortality or readmission for all causes in elderly inpatients.

METHODS

This analysis is based on a prospective cohort study conducted from September 2018 to April 2019 in ten wards of three tertiary referral hospitals in Beijing. Patients aged 65 years or older were enrolled, and their clinical data, laboratory test results, and auxiliary test results for patients were collected. A three-year follow-up was conducted with patients. Based on the 5th and 95th percentiles of transthyretin concentration, patients were split into three groups. The correlation between transthyretin concentration and the outcome of elderly hospitalized patients was investigated. The primary outcome of the research was death or readmission from all causes within three years.

RESULTS

Among the 636 individuals in the study, 335 (52.7%) were males, with a median age of 74.7 years (interquartile range [IQR]: 69.3-80.1). During a median follow-up period of 1,099.0 days (IQR: 1,016.3-1,135.0), 363 individuals (57.0%) experienced all-cause mortality or readmission events. Patients with transthyretin concentrations at or below the 5th percentile had a significantly increased risk of all-cause mortality or readmission compared to those with concentrations between the 5th and 95th percentiles (hazard ratio [HR]: 2.25; 95% confidence interval [CI]: 1.55-3.26). Even after adjusting for potential confounders, low transthyretin concentration remained an independent risk factor for poor prognosis in elderly inpatients (HR: 1.84; 95% CI: 1.03-3.28). Since women have consistently lower baseline transthyretin levels than men, we performed gender-specific analysis. We found that low transthyretin concentration is an independent risk factor for adverse prognosis in elderly male inpatients (HR: 2.99; 95% CI: 1.35-6.62) but not in females.

CONCLUSIONS

Low transthyretin concentrations are associated with increased all-cause mortality or readmission in elderly inpatients, particularly among male patients.

Development and Validation of a Scoring System (SAGA Score) to Predict Weight Loss in Community-Dwelling, Self-Supported Older Adults

This retrospective cohort study explored the prevalence of substantial weight loss (≥10% per year) in independent older individuals in order to develop and validate a scoring system for high-risk group identification and targeted intervention against malnutrition. We used insurance claims and the Kokuho Database (KDB), a nationwide repository of Japanese-specific health checkups and health assessments for the older people. The study included 12,882 community-dwelling individuals aged 75 years and older who were self-supported in their activities of daily living in Saga Prefecture, Japan. Health evaluations and questionnaires categorized weight-loss factors into organic, physiological, psychological, and non-medical domains. The resulting scoring system (SAGA score), incorporating logistic regression models, predicted ≥ 10% annual weight-loss risk. The results revealed a 1.7% rate of annual substantial weight loss, with the SAGA score effectively stratifying the participants into low-, intermediate-, and high-risk categories. The high-risk category exhibited a weight-loss rate of 17.6%, highlighting the utility of this scoring system for targeted prevention. In conclusion, the validated SAGA score is a crucial tool for identifying individuals at high risk of significant weight loss, enabling tailored interventions and social support benefiting both older individuals and their relatives.

Characteristics and outcome of patients referred to a specialized outpatient clinic for the management of malnutrition: A retrospective audit

BACKGROUND & AIMS

Insufficient screening and management of malnutrition leads to increase morbidity and mortality.

AIMS

to evaluate the characteristics and clinical outcomes of malnourished patients referred to a specialized outpatient clinic for the management of malnutrition (primary); to compare the latter according to malnutrition severity; to determine the factors associated with severe malnutrition and mortality; to compare the consistency of the decided medical nutrition therapy with the European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines (secondary).

METHODS

This retrospective, observational study included malnourished adults referred for the first time to the specialized nutrition consultation of a teaching University Hospital during 50 months. Malnutrition was diagnosed according to the Global Leadership Initiative on Malnutrition criteria, including body composition assessment by bioimpedance analysis.

STATISTICS

Chi2 or Fisher, Student or Wilcoxon rank-sum tests; multivariable logistic regression to assess the factors associated with severe malnutrition and mortality.

RESULTS

108 malnourished adults were included: 74% had severe malnutrition. The main secondary diagnosis was digestive cancer (48.2%). During the follow-up (median = 70 days) after the first nutritional consultation, 11% of patients were admitted at hospital, 19% had infections and 23.1% died, without any difference according to malnutrition severity. Severely malnourished patients had lower body mass index, a smaller fat mass index (FMI) (4.6 ± 1.8 vs 6.0 ± 2.5 kg/m2; p = 0.01), and a higher level of total body water (64.7 ± 7.1 vs 60.6 ± 5.4%; p = 0.02), compared to moderately malnourished individuals. A low FMI (odds ratio = 0.72 [0.54-0.96]) was the only factor significantly associated with severe malnutrition. We did not find any factor associated with mortality. There was a moderate consistency (47.1%) between the decided medical nutrition therapy and the ESPEN guidelines of nutritional care.

CONCLUSIONS

Adults referred for the first time to a specialized nutritional consultation present mostly with severe malnutrition and are at risk for significant complications, leading to a high mortality rate. In this population, a low FMI is associated with severe malnutrition. An earlier diagnosis and care of malnutrition and an earlier referral to clinical nutrition units would improve outcomes.

Bioelectrical Impedance Vector Analysis, Nutritional Ultrasound®, and Handgrip Strength as Innovative Methods for Monitoring Critical Anorexia Nervosa Physical Recovery: A Pilot Study

Eating disorders (EDs) manifest as persistent disruptions in eating habits or related behaviors, significantly impacting physical health and psychosocial well-being. Nutritional assessment in ED patients is crucial for monitoring treatment efficacy. While dual-energy X-ray absorptiometry (DEXA) remains standard, interest in alternative methods such as bioelectrical impedance vector analysis (BIVA) and Nutritional Ultrasound® (NU) has risen due to their affordability and portability. Additionally, hand dynamometry offers a user-friendly approach to assessing grip strength (HGS), indicative of nutritional status. A prospective study was carried out to evaluate the utility of BIVA, NU®, and HGS in 43 female AN patients. Measurements were taken at baseline and hospital discharge. A total of 41 patients completed the study. After the intervention, numerous BIVA-related parameters such as fat (3.5 ± 2 kg vs. 5.3 ± 2.7 kg, p < 0.001) and free fat mass (33.9 ± 3.8 kg vs. 37.5 ± 4.1 kg, p < 0.001) were partially restored. Similarly, Nutritional Ultrasound® showed promising results in assessing body composition changes such as total abdominal fat tissue (0.5 ± 0.3 cm vs. 0.9 ± 0.3 cm, p < 0.05). In the same way, rectus femoris cross-sectional area values correlated with clinical outcomes such as free fat mass (0.883, p < 0.05) and appendicular muscle mass (0.965, p < 0.001). HGS reached the normality percentile after the intervention (21.6 ± 9.1 kg vs. 25.9 ± 12.3 kg, p < 0.05), demonstrating a significant association between grip strength and body composition parameters such as free fat mass (0.658, p < 0.001) and appendicular muscle mass (0.482, p < 0.001). Incorporating BIVA-, NU®-, and HGS-enhanced nutritional assessment into the treatment of AN patients offers cost-effective, portable, and non-invasive alternatives to DEXA. These techniques offer valuable insights into changes in body composition and nutritional status, which, in turn, facilitate treatment monitoring and contribute to improved patient outcomes.

Do Hypoalbuminaemia Increase the Risk of Surgical Site Infection in Neck of Femur Fracture Patients: A Systematic Review and Meta-Analysis

Serum albumin plays an important role in physiological and inflammatory haemostasis, and low serum levels are linked with an increased incidence of surgical site infections (SSI). Although this has been demonstrated in the spine and elective arthroplasty settings, there is a paucity of evidence with regard to the effect of low serum albumin on rates of SSI following surgery for adult patients suffering from traumatic and acute hip fractures. A systematic review was conducted using the PRISMA guidelines. Four databases were searched for randomised controlled trials (RCTs), cohort studies, and case-controlled studies. The risk of bias was assessed using the Newcastle-Ottawa Score (NOS). Data was collected and pooled using RevMan Web software. Results were reported as odds ratios (OR) with 95% confidence intervals (CI) and statistical significance of p <0.05. An inverse variance model was used in the meta-analysis. Six retrospective studies (five cohorts and one case-control) with a total of 43,059 patients were included. 45.3% (n=19 496) had low serum albumin (<3.5 g/dL). Hypoalbuminemia was associated with a significantly higher risk of any form of SSI (OR 1.25, p=0.008) and deep SSI (OR 1.76, p=0.05). There was no statistical significance between hypoalbuminemia and the incidence of superficial SSI (OR 1.06, p=0.77). Organ-space SSI was associated with hypoalbuminemia, although one study reported this with poor statistical significance (OR 8.74, p<0.054). Hypoalbuminemia increases the risk of most forms of surgical site infections, both superficial and deep. There is a weak conclusion to draw between the incidence of deep-space organ infections and low serum albumin.

Guidance for assessment of the inflammation etiologic criterion for the GLIM diagnosis of malnutrition: A modified Delphi approach

BACKGROUND & AIMS

The Global Leadership Initiative on Malnutrition (GLIM) approach to malnutrition diagnosis is based on assessment of three phenotypic (weight loss, low body mass index, and reduced skeletal muscle mass) and two etiologic (reduced food intake/assimilation and disease burden/inflammation) criteria, with diagnosis confirmed by fulfillment of any combination of at least one phenotypic and at least one etiologic criterion. The original GLIM description provided limited guidance regarding assessment of inflammation and this has been a factor impeding further implementation of the GLIM criteria. We now seek to provide practical guidance for assessment of inflammation in support of the etiologic criterion for inflammation.

METHODS

A GLIM-constituted working group with 36 participants developed consensus-based guidance through a modified-Delphi review. A multi-round review and revision process served to develop seven guidance statements.

RESULTS

The final round of review was highly favorable with 99 % overall "agree" or "strongly agree" responses. The presence of acute or chronic disease, infection or injury that is usually associated with inflammatory activity may be used to fulfill the GLIM disease burden/inflammation criterion, without the need for laboratory confirmation. However, we recommend that recognition of underlying medical conditions commonly associated with inflammation be supported by C-reactive protein (CRP) measurements when the contribution of inflammatory components is uncertain. Interpretation of CRP requires that consideration be given to the method, reference values, and units (mg/dL or mg/L) for the clinical laboratory that is being used.

CONCLUSION

Confirmation of inflammation should be guided by clinical judgement based upon underlying diagnosis or condition, clinical signs, or CRP.

Positive Bacterial Cultures on Spinal Wound Closure Do Not Predict Postoperative Outcomes

BACKGROUND

Complex surgical back wounds represent significant morbidity in patients who have undergone spinal procedures requiring closure or revision by plastic surgeons. This study aimed to assess the utility of bacterial wound culture data for predicting surgical outcomes of wound management.

METHODS

This study is a single-institution retrospective review of consecutive patients who required plastic surgery intervention for wound infection following spinal procedures between the years 2010 and 2021 (n = 70). Statistical analysis was performed for demographics, comorbidities, perioperative laboratory studies, and treatment methods. The primary outcomes of interest were rate of postoperative complications after soft tissue reconstruction and reconstructive failure. The secondary outcome of interest was time to healing in number of days.

RESULTS

The overall complication rate after wound closure was 31.4%, with wound infection in 12.9%, seroma in 10%, dehiscence in 12.9%, and hematoma in 1.4%. Increasing number of debridements before wound closure increased the likelihood of a surgical complication of any kind (odds ratio [OR], 1.772; 95% confidence interval [CI], 1.045-3.002). Positive wound cultures before reconstruction were associated with development of seroma only (OR, 0.265; 95% CI, 0.078-0.893). Use of incisional vacuum-assisted closure devices significantly decreased the odds of postoperative wound dehiscence (OR, 0.179; 95% CI, 0.034-0.904) and increased odds of healing (hazard ratio, 3.638; 95% CI, 1.547-8.613).

CONCLUSIONS

Positive wound cultures were not significantly associated with negative outcomes after complex closure or reconstruction of infected spinal surgical wounds. This finding emphasizes the importance of clinical judgment with a multidisciplinary approach to complex surgical back wounds over culture data for wound closure timing.

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.

Effect of multicomponent intervention on malnutrition in older adults: A multicenter randomized clinical trial

BACKGROUND & AIMS

Malnutrition is a significant geriatric syndrome (GS) prevalent in older adults and seriously affects patient prognosis and quality of life. We assessed the impact of the multicomponent intervention of health education, dietary advice, and exercise with oral nutritional supplementation (ONS) on nutritional status, body composition, physical functions, and quality of life.

METHODS

This multicenter randomized clinical trial (RCT) was performed from April 2021 to April 2022. The intervention lasted for 12 weeks, and 99 older adults with malnutrition or at risk of malnutrition were enrolled in six nursing homes. All participants were randomly assigned to the control (health education plus standard diet plus exercise) or research (health education plus standard diet plus exercise plus ONS) group. The research group consumed ONS (244 kcal, 9.8g protein, and 9.6g fat per time) twice a day between meals. The primary outcomes were changes in the nutritional status and body composition from baseline to 12 weeks. The secondary outcomes were changes in physical function, quality of life and nutritional associated other blood markers.

RESULTS

For primary outcomes, after 12 weeks, body weight increased similarly in both treatment arms (time × treatment effect, P > 0.05). There were no between-group differences in body mass index (BMI) or mini nutritional assessment tool-short form (MNA-SF) scores (time × treatment effects, P > 0.05). The MNA-SF score from 11.0 (10.5, 12.0) to 13.0 (11.0, 13.0) in the research group and from 11.0 (10.0, 12.0) to 12.0 (11.0, 13.0) in the control group (both P < 0.05). There were no between-group differences in the skeletal muscle mass index (SMI), fat-free mass index (FFMI), appendicular skeletal muscle mass (ASMM), fat mass (FAT), or leg muscle mass (LMM) (time × treatment effects, P > 0.05). Both groups showed similar and highly significant increases in SMI, FFMI, and LMM after (P < 0.05). The research group showed an increase in fat-free mass (FFM) and ASMM and a decrease in the percent of body fat (PBF) and waist circumference (WC) (P < 0.05). For secondary outcomes, There were no between-group differences in grip strength, short physical performance battery (SPPB), 6-min walking distance (6MWD), activities of daily living (ADL), instrumental activities of daily living (IADL), frailty status (FRAIL), mini-mental state examination (MMSE), Tinetti, geriatric depression scale-15 (GDS-15), or 12-item short form survey (SF-12) (time × treatment effects, P > 0.05). Although there was no significant difference, the 6MWD changed differentially between the two treatment arms during the study period in favor of the research group. Although not significant, SF-12 scores improved after 12 weeks in both groups. No between-group differences were observed in prealbumin (PRE), c-reactive protein (CRP), vitamin D (VIT-D), insulin-like growth factor 1 (IGF-1), alanine transaminase (ALT), aspartate aminotransferase (AST), serum creatinine (Scr), interleukin-6 (IL-6), interleukin-10 (IL-10), tumor necrosis factor-α (TNF-α), insulin, and adiponectin levels (time × treatment effects, P > 0.05). Insulin and adiponectin levels were significantly higher in the control group (P < 0.05).

CONCLUSION

The twelve-week multicomponent intervention improved the nutritional status of older people in China at risk of malnutrition. ONS may enhance the effects of exercise on muscle mass. This clinical trial was registered (https://www.

CLINICALTRIALS

gov). The trial number is ChiCTR2000040343.

Association between admission albumin levels and 30-day readmission after hip fracture surgery in geriatric patients: a propensity score-matched study

PURPOSE

This study aimed to evaluate the correlation admission albumin levels and 30-day readmission after hip fracture surgery in geriatric patients.

METHODS

In this retrospective cohort study, 1270 geriatric patients admitted for hip fractures to a level I trauma center were included. Patients were stratified by clinical thresholds and albumin level quartiles. The association between admission albumin levels and 30-day readmission risk was assessed using multivariate logistic regression and propensity score-matched analyses. The predictive accuracy of albumin levels for readmission was evaluated by ROC curves. The dose-response relationship between albumin levels and readmission risk was examined.

RESULTS

The incidence of 30-day readmission was significantly higher among hypoalbuminemia patients than those with normal albumin levels (OR = 2.090, 95%CI:1.296-3.370, p = 0.003). Furthermore, propensity score-matched analyses demonstrated that patients in the Q2(35.0-37.9 g/L) (OR 0.621, 95%CI 0.370-1.041, p = 0.070), Q3(38.0-40.9 g/L) (OR 0.378, 95%CI 0.199-0.717, p < 0.001) and Q4 (≥ 41 g/L) (OR 0.465, 95%CI 0.211-0.859, p = 0.047) quartiles had a significantly lower risk of 30-day readmission compared to those in the Q1(< 35 g/L) quartile. These associations remained significant after propensity score matching (PSM) and subgroup analyses. Dose-response relationships between albumin levels and 30-day readmission were observed.

CONCLUSIONS

Lower admission albumin levels were independently associated with higher 30-day readmission rates in elderly hip fracture patients. Our findings indicate that serum albumin may assist perioperative risk assessment, and prompt correction of hypoalbuminemia and malnutrition could reduce short-term readmissions after hip fracture surgery in this high-risk population.

Pediatric perforated appendicitis diagnosis based on the C-reactive protein/prealbumin ratio

Pediatric perforated appendicitis, prone to multiple complications, necessitates identifying potential serum biomarkers for early diagnosis and intervention. A cross-sectional study was conducted on patients under 16 with acute appendicitis, admitted to Hainan Women and Children's Medical Center from January 2019 to July 2023. The patients were categorized into perforated and non-perforated groups. Among the 313 included patients, 106 (33.87%, 95% CI 28.59-39.14%) developed perforation. The C-reactive protein to prealbumin ratio (CPA) showed a significant difference between the perforated and non-perforated groups [6.63 (2.9-13.02) vs. 0.7 (0.11-2.18), p < 0.001]. The AUC of CPA on the ROC curve was 0.691 (95% CI 0.513-0.869, p = 0.084) in patients under 4. In patients aged 4-9, the sensitivity of CPA > 3 predicting perforation was 76.2%, with a specificity of 81.6%, and an AUC of 0.816 (95% CI 0.747-0.886, p < 0.001). For patients aged 9-16, the sensitivity of CPA > 2.2 predicting perforation was 85%, with a specificity of 85.7%, and an AUC of 0.919 (95% CI 0.859-0.979, p < 0.001). CPA > 3 and CPA > 2.2 can predict perforated appendicitis in patients aged 4-9 and 9-16, respectively.

Machine Learning-Based Nomogram for Predicting Overall Survival in Elderly Patients with Cirrhotic Hepatocellular Carcinoma Undergoing Ablation Therapy

Purpose

The aim of the study is to identify and evaluate multifaceted factors impacting the survival of elderly cirrhotic HCC patients following ablation therapy, with the goal of constructing a nomogram to predict their 3-, 5-, and 8-year overall survival (OS).

Patients and Methods

A retrospective analysis was conducted on 736 elderly cirrhotic HCC patients who underwent ablation therapy between 2014 and 2022. LASSO regression, random survival forest (RSF), and multivariate Cox analyses were employed to identify independent prognostic factors for OS, followed by the development and validation of a predictive nomogram. Harrell's concordance index (C-index), calibration plot and decision curve analysis (DCA) were used to assess the performance of the nomogram. The nomogram was finally utilized to stratify patients into low-, intermediate-, and high-risk groups, aiming to assess its efficacy in precisely discerning individuals with diverse overall survival outcomes.

Results

Alcohol drinking, tumor number, globulin (Glob) and prealbumin (Palb) were identified and integrated to establish a novel prognostic nomogram. The nomogram exhibited strong discriminative ability with C-indices of 0.723 (training cohort) and 0.693 (validation cohort), along with significant Area Under the Curve (AUC) values for 3-year, 5-year, and 8-year OS in both cohorts (0.758, 0.770, and 0.811 for training cohort; 0.744, 0.699 and 0.737 for validation cohort). Calibration plots substantiated its consistency, while DCA curves corroborated its clinical utility. The nomogram further demonstrated exceptional effectiveness in discerning distinct risk populations, highlighting its robust applicability for prognostic stratification.

Conclusion

Our study successfully developed and validated a robust nomogram model based on four key clinical parameters for predicting 3-, 5- and 8-year OS among elderly cirrhotic HCC patients following ablation therapy. The nomogram exhibited a remarkable capability in identifying high-risk patients, furnishing clinicians with invaluable insights for postoperative surveillance and tailored therapeutic interventions.

Prognostic significance of preoperative nutritional status for postoperative acute kidney injury in older patients undergoing major abdominal surgery: a retrospective cohort study

BACKGROUND

The association between malnutrition and postoperative acute kidney injury (AKI) has not been well studied. In this study, the authors examined the association between preoperative nutritional status and postoperative AKI in older patients who underwent major abdominal surgery, as well as the predictive value of malnutrition for AKI.

MATERIALS AND METHODS

The authors retrospectively included patients aged 65 or older who underwent major elective abdominal surgery. The nutritional status of the patient was evaluated using three objective nutritional indices, such as the geriatric nutritional risk index (GNRI), the prognostic nutritional index (PNI), and the controlling nutritional status (CONUT). AKI was determined using the KDIGO criteria. The authors performed logistic regression analysis to investigate the association between preoperative nutritional status and postoperative AKI, as well as the predictive value of nutritional scores for postoperative AKI.

RESULTS

A total of 2775 patients were included in the study, of which 707 (25.5%), 291 (10.5%), and 517 (18.6%) had moderate to severe malnutrition according to GNRI, PNI, and CONUT calculations. After surgery, 144 (5.2%) patients developed AKI, 86.1% at stage 1, 11.1% at stage 2, and 2.8% at stage 3 as determined by KDIGO criteria. After adjustment for traditional risk factors, worse nutritional scores were associated with a higher AKI risk. In addition to traditional risk factors, these nutritional indices improved the predictive ability of AKI prediction models, as demonstrated by significant improvements in integrated discrimination and net reclassification.

CONCLUSIONS

Poor preoperative nutritional status, as assessed by GNRI, PNI, and CONUT scores, was associated with an increased risk of postoperative AKI. Incorporating these scores into AKI prediction models improved their performance. These findings emphasize the need for screening surgical patients for malnutrition risk. Further research is needed to determine whether preoperative malnutrition assessment and intervention can reduce postoperative AKI incidence.

Guidance for assessment of the inflammation etiologic criterion for the GLIM diagnosis of malnutrition: A modified Delphi approach

BACKGROUND

The Global Leadership Initiative on Malnutrition (GLIM) approach to malnutrition diagnosis is based on assessment of three phenotypic (weight loss, low body mass index, and reduced skeletal muscle mass) and two etiologic (reduced food intake/assimilation and disease burden/inflammation) criteria, with diagnosis confirmed by fulfillment of any combination of at least one phenotypic and at least one etiologic criterion. The original GLIM description provided limited guidance regarding assessment of inflammation, and this has been a factor impeding further implementation of the GLIM criteria. We now seek to provide practical guidance for assessment of inflammation.

METHODS

A GLIM-constituted working group with 36 participants developed consensus-based guidance through a modified Delphi review. A multiround review and revision process served to develop seven guidance statements.

RESULTS

The final round of review was highly favorable, with 99% overall "agree" or "strongly agree" responses. The presence of acute or chronic disease, infection, or injury that is usually associated with inflammatory activity may be used to fulfill the GLIM disease burden/inflammation criterion, without the need for laboratory confirmation. However, we recommend that recognition of underlying medical conditions commonly associated with inflammation be supported by C-reactive protein (CRP) measurements when the contribution of inflammatory components is uncertain. Interpretation of CRP requires that consideration be given to the method, reference values, and units (milligrams per deciliter or milligram per liter) for the clinical laboratory that is being used.

CONCLUSION

Confirmation of inflammation should be guided by clinical judgment based on underlying diagnosis or condition, clinical signs, or CRP.

Nutrition in Surgery: An Orthopaedic Perspective

➤ Malnutrition is common among subsets of patients undergoing orthopaedic surgery and is associated with an increased risk of postoperative complications.➤ Serum proteins, in particular, albumin, may be used in the evaluation of nutritional status.➤ Anthropometric measurements and surveys also play a role in the evaluation of nutritional status.➤ Increased energy and nutrient requirements due to surgical procedures necessitate increased caloric and protein intake in the perioperative period, which may be achieved through diet or supplementation.➤ Evidence supports the use of protein-calorie, amino acid, and immunonutrition supplements. Vitamin D supplementation is an area of further consideration.➤ Diet restriction, activity alterations, pharmacotherapy, and bariatric surgery are all safe, effective approaches to weight loss, although the optimal timing and magnitude of preoperative weight loss require further investigation.

Iron overload may be critical for liver dysfunction in anorexia nervosa, and the role of haematocrit-adjusted albumin in assessing nutritional status: a case report

BACKGROUND

Anorexia nervosa (AN) is frequently associated with liver dysfunction, but the precise mechanism remains undefined. Since the nutritional marker albumin has a low correlation with changes in body weight in AN, and patients with AN often have dehydration as a complication, we also examined whether haematocrit (HCT)-adjusted serum albumin could be a better nutritional marker in AN.

CASE PRESENTATION

We describe a 15-year-old girl with severe weight loss and liver damage whose liver enzymes normalized after 1.5 months of hospitalization and weight gain. We found a significant correlation between body weight (BW) and HCT-adjusted serum albumin (Spearman's rank correlation coefficient (rs) = 0.66, P = 5.28 × 10-3) and between BW and alanine aminotransferase (ALT) (rs = -0.825, P = 8.45 × 10-5). After division by HCT, correlations between serum albumin and ALT (rs = -0.835, P = 5.24 × 10-5) and between the iron-storage protein ferritin and the liver enzyme gamma-glutamyl transferase (rs = 1.0, P = 0.017) were also statistically significant.

CONCLUSION

These results suggest that improvement of the nutritional status in AN could relieve liver dysfunction and facilitate iron transport. Since a decrease in the iron-transport protein transferrin presumably increases labile non-transferrin-bound iron, resulting in excess reactive oxygen species production, a defect in iron transport due to malnutrition could be one of the causes of liver injury in AN. In addition, HCT-adjusted albumin could be a better marker than its raw data to assess changes in nutritional status in AN.

Factors Associated with Low Albumin in Community-Dwelling Older Adults Aged 75 Years and Above

This study aimed to clarify the factors associated with low albumin in Japanese older adults aged ≥75 years. The data utilized were the health checkup data of older adults aged ≥75 years from 42 municipalities in Gifu Prefecture, which were provided by the National Health Insurance database system. After excluding the data of individuals with incomplete information on serum albumin, BMI, lifestyle habits, or weight at previous year, the data from 18,674 individuals' health checkup were analyzed. A logistic regression showed that low albumin was associated with smoking, not walking at least 1 h/day, slow walking speed, difficulty in chewing, slow eating speed, weight loss in the previous year, and underweight. Furthermore, an analysis conducted for older adults aged ≥85 years showed that low albumin was associated with not walking at least 1 h/day, difficulty in chewing, slow eating speed, weight loss in the previous year, and underweight. In the future, the number of older adults will increase in Japan; therefore, a strategic approach to promote the health of these aged individuals will become even more necessary. An early approach to maintaining an active physical life, an appropriate weight, and good oral function will lead to improved health in older adults.

Nutritional Risk of Candidates for Simultaneous Pancreatic-Kidney Transplantation-A Narrative Review

INTRODUCTION

Not much is known about the significance of nutritional status and support in transplant surgery, least of all in simultaneous pancreatic and kidney transplantation. Malnutrition in the context of simultaneous pancreatic-kidney transplantation seems to be complex and a still poorly investigated problem. Since SPKTX is highly qualified and also has a small volume procedure, it is difficult to obtain data from large cohorts of patients. The aim of this article is to gather existing evidence and information about the subject, as well as to elicit some questions and goals for the future.

METHODS

We searched through the Pub-Med database using the keywords "pancreas and kidney transplantation" combined with "nutritional risk", "nutritional status", "malnutrition", "nutritional intervention", and "frailty", finding a total of 4103 matching results. We then narrowed it down to articles written in English with the full text available. We also researched through the references of articles most accurately matching our researched terms.

RESULTS

There are numerous tools that have been investigated for the screening of malnutrition, such as the NRI index, PNI index, NLR, SGA scale, and NRS-2002 scale, each of which proved to be of some use in predicting patient outcomes in different surgical settings. Since all of them differed in components and assessed parameters and, in the absence of more sensitive or infallible indicators, the most reasonable approach seems to evaluate them jointly.

CONCLUSION

It is important to underline the necessity of nutritional screening and the subsequent introduction of adequate therapy while awaiting transplantation in an attempt to improve results. Considering the complexity of surgical procedures and the severity of underlying diseases with their intense metabolic components, the patient's nutritional status seems to significantly influence results. Consequently, nutritional risk assessments should be a part of the routine care of patients qualified for transplantation.

Interpretations of the Role of Plasma Albumin in Prognostic Indices: A Literature Review

This review assesses how publications interpret factors that influence the serum or plasma albumin (PA) level in prognostic indices, focusing on inflammation and nutrition. On PubMed, a search for "albumin AND prognosis" yielded 23,919 results. From these records, prognostic indices were retrieved, and their names were used as search strings on PubMed. Indices found in 10 or more original research articles were included. The same search strings, restricted to "Review" or "Systematic review", retrieved yielded on the indices. The data comprised the 10 latest original research articles and up to 10 of the latest reviews. Thirty indices had 294 original research articles (6 covering two indices) and 131 reviews, most of which were from recent years. A total of 106 articles related the PA level to inflammation, and 136 related the PA level to nutrition. For the reviews, the equivalent numbers were 54 and 65. In conclusion, more publications mention the PA level as a marker of nutrition rather than inflammation. This is in contrast to several general reviews on albumin and nutritional guidelines, which state that the PA level is a marker of inflammation but not nutrition. Hypoalbuminemia should prompt clinicians to focus on the inflammatory aspects in their patients.

Correlation between Preoperative Platelet Count/(Lymphocyte Count × Prealbumin Count) Ratio and the Prognosis of Patients with Gastric Cancer Undergoing Radical Operation

Objective

To clarify the relationship between preoperative platelet count/(lymphocyte count × prealbumin count) ratio (PLPR) and the prognosis of patients with gastric cancer undergoing a radical operation, combined with Tumor Node Metastasis (TNM) staging, a scoring system was established to guide clinical application.

Methods

The clinical data of 238 patients receiving radical operations for gastric cancer were retrospectively analyzed. According to the area under the Receiver operating characteristic curve, the predictive value of the preoperative PLPR for the 5-year overall survival (OS) of gastric cancer was determined, and the best cut-off value of the ratio was corresponding to the maximum value of Yoden index. Chi-squared test was applied to analyze the correlation between the ratio and clinicopathological features. Kaplan-Meier curve was applied to analyze the influence of this ratio on 5-year OS. The Cox regression model was applied to analyze the hazards affecting the long-term survival of patients. The nomogram model was used to predict the long-term survival rate.

Results

The optimal cut-off point of preoperative PLPR ratio was 7.46, and the patients were segmented into two sets: one set of ratio <7.46 and another set of ratio ≥7.46. The ratio was correlated with the size of the tumor, T stage, N stage, total stage, vascular cancer thrombus, and nerve invasion. In stage I-III patients, the prognosis was better in the low-ratio set than in the high-ratio set (P < 0.001), subgroup analysis indicated the prognosis was obviously better in the low-ratio set than in the high-ratio set in stage II and III patients (P < 0.05 and P < 0.001), but there was no difference in stage I patients (P > 0.05). Age, T stage, N stage, total TNM stage, tumor size, vascular tumor thrombus, nerve invasion, preoperative neutrophil count/lymphocyte count (NLR; reference value 3.68), preoperative PLPR (reference value 7.46), preoperative platelet count/lymphocyte count (PLR; reference value 159.56), and preoperative platelet count × NLR (SII; reference value 915.48) were related to patient prognosis (P < 0.05); meanwhile age, total TNM stage, preoperative PLPR (reference value 7.46), preoperative PLR (reference value 159.56), and preoperative SII (reference value 915.48) were independent hazards for prognosis (P < 0.05). Five independent risk factors were analyzed by nomogram model to predict the 5-year OS of patients who underwent a radical operation for carcinoma of the stomach.

Conclusion

Preoperative PLPR ratio (reference value 7.46) is an independent risk factor for long-term prognosis in patients undergoing a radical operation for gastric cancer. The nomogram scoring system established by postoperative TNM staging combined with this ratio and age, PLR, and SII can better forecast the survival of patients who underwent radical operation for carcinoma of the stomach.

Rapidly progressive interstitial lung disease combined with pneumocystis jiroveci pneumonia in a patient with single anti-TIF-1γ antibody positive dermatomyositis in the context of an underlying tumor

BACKGROUND

Interstitial lung disease (ILD) is a frequently observed comorbidity in autoimmune diseases such as dermatomyositis/polymyositis (DM/PM), and it is significantly associated with specific autoantibody types. One unique antibody type is the anti-transcription intermediate factor-1γ antibody (anti-TIF-1γ Ab), which has a positive rate of only 7%. It is often found in combination with malignancy and rarely with ILD, particularly rapidly progressive ILD (RPILD). In some cases, the presence of ILD in individuals with DM may indicate a paraneoplastic syndrome. Pneumocystis jiroveci pneumonia (PJP) typically occurs due to intensive immunosuppressive therapy, human immunodeficiency virus (HIV) infection, or malignancy, and rarely as an isolated condition.

CASE PRESENTATION

A 52-year-old man with a history of rapid weight loss but non-HIV infected and not immunosuppressed who presented with fever, cough, dyspnea, weakness of the extremities, characteristic rash and mechanic's hand. Pathogenic tests suggested PJP, laboratory tests suggested a single anti-TIF-1γ Ab positive DM, imaging suggested ILD, and pathology revealed no malignancy. RPILD and acute respiratory distress syndrome (ARDS) developed after anti-infection and steroid hormone therapy. After mechanical support therapy such as Extracorporeal Membrane Oxygenation (ECMO), the patient developed late-onset cytomegalovirus pneumonia (CMVP), complicated bacterial infection, and ultimately death. Additionally, we discuss the potential causes of rapid weight loss, the mechanisms by which anti-TIF-1γ Ab may lead to ILD, and the possible connection between anti-TIF-1γ Ab positivity, rapid weight loss, immune abnormalities, and opportunistic infections.

CONCLUSIONS

This case emphasizes the importance of early recognition of malignant tumors and pulmonary lesions, assessment of the body's immune status, prompt initiation of immunosuppressive treatment, and prevention of opportunistic infections in individuals with single anti-TIF-1γ Ab positive DM presenting with rapid weight loss.

Impact of Nutritional Status on Postoperative Outcomes in Cancer Patients following Elective Pancreatic Surgery

BACKGROUND

Pancreatic surgery has been associated with important postoperative morbidity, mortality and prolonged length of hospital stay. In pancreatic surgery, the effect of poor preoperative nutritional status and muscle wasting on postsurgery clinical outcomes still remains unclear and controversial.

MATERIALS AND METHODS

A total of 103 consecutive patients with histologically proven carcinoma undergoing elective pancreatic surgery from June 2015 through to July 2020 were included and retrospectively studied. A multidimensional nutritional assessment was performed before elective surgery as required by the local clinical pathway. Clinical and nutritional data were collected in a medical database at diagnosis and after surgery.

RESULTS

In the multivariable analysis, body mass index (OR 1.25, 95% CI 1.04-1.59, p = 0.039) and weight loss (OR 1.16, 95% CI 1.06-1.29, p = 0.004) were associated with Clavien score I-II; weight loss (OR 1.13, 95% CI 1.02-1.27, p = 0.027) affected postsurgery morbidity/mortality, and reduced muscle mass was identified as an independent, prognostic factor for postsurgery digestive hemorrhages (OR 0.10, 95% CI 0.01 0.72, p = 0.03) and Clavien score I-II (OR 7.43, 95% CI 1.53-44.88, p = 0.018). No association was identified between nutritional status parameters before surgery and length of hospital stay, 30 days reintervention, 30 days readmission, pancreatic fistula, biliary fistula, Clavien score III-IV, Clavien score V and delayed gastric emptying.

CONCLUSIONS

An impaired nutritional status before pancreatic surgery affects many postoperative outcomes. Assessment of nutritional status should be part of routine preoperative procedures in order to achieve early and appropriate nutritional support in pancreatic cancer patients. Further studies are needed to better understand the effect of preoperative nutritional therapy on short-term clinical outcomes in patients undergoing pancreatic elective surgery.

Decreased transthyretin predicts a poor prognosis in primary myelodysplastic syndrome

Background

This study aims to investigate the prognostic significance of transthyretin in newly diagnosed myelodysplastic syndromes (MDS).

Methods

The clinical, laboratory, and follow-up data of 280 newly diagnosed patients with MDS were collected. The relationship between serum transthyretin levels and overall survival (OS) and leukemia-free survival (LFS) were analyzed by Kaplan-Meier analysis and Cox Regression Model.

Result

In the MDS cohort, there were 121 cases in the low transthyretin group and 159 cases in the normal transthyretin group. MDS patients with decreased transthyretin had a higher risk score on the Revised International Prognostic Scoring System (IPSS-R) (p = 0.004) and on the molecular IPSS (IPSS-M) (p = 0.005), a higher frequency of TP53 mutation (p < 0.0001), a shorter OS (p < 0.0001) and LFS (p < 0.0001). Multivariate analyses showed that higher IPSS-R and IPSS-M score were adverse factors for OS (p = 0.008 and p = 0.015, respectively) and LFS (p = 0.024 and p = 0.005, respectively). Mutations of TP53 and NRAS were also poor factors for LFS (p = 0.034 and p = 0.018, respectively). Notably, decreased transthyretin was an independent adverse predictor for OS (p = 0.009, HR = 0.097, 95%CI, 0.017-0.561) but not for LFS (p = 0.167) when IPSS-R was included in the Cox regression model and an independent poor one for OS (p = 0.033, HR = 0.267, 95%CI, 0.080-0.898) and LFS (p = 0.024, HR = 0.290, 95%CI, 0.099-0.848) while IPSS-M involved.

Conclusion

The results indicate that decreased transthyretin could be an independent adverse prognostic factor in patients with MDS and may provide a supplement to IPSS-R and IPSS-M.

Association between neutrophil percentage-to-albumin ratio and pneumonia in patients with traumatic spinal cord injury

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To investigate the association between neutrophil percentage-to-albumin ratio (NPAR) and pneumonia in patients with SCI.

SETTING

Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University.

METHODS

SCI patients admitted to West China Hospital within 24 h of injury were consecutively enrolled. Blood samples were collected on admission. Pneumonia was diagnosed based on chest radiography and clinician records of patient symptoms and laboratory tests. Multivariable logistic regression analysis was performed to determine the relationship between NPAR and pneumonia. Receiver operating characteristic (ROC) curves were generated to assess the predictive value of NPAR.

RESULTS

A total of 264 SCI patients were included, of whom 65 (24.6%) developed pneumonia. NPAR was positively correlated with pneumonia (OR 2.66, 95% CI, 1.06-6.71, p = 0.038). Patients in the upper NPAR tertile (2.35-3.71) had a higher risk of pneumonia than patients in the lower tertile (1.66-2.12) after adjustment for potential confounders (OR 2.55, 95% CI, 1.05-6.19, p = 0.039). The risk of pneumonia increased stepwise across NPAR tertiles (p for trend = 0.031). The optimal cutoff value of NPAR for predicting pneumonia was 2.17 with a sensitivity of 0.82 and a specificity of 0.50. There was a significant interaction between NPAR and neurological level of injury (p for interaction = 0.034), with no significant association between NPAR and pneumonia in patients with cervical SCI.

CONCLUSIONS

A higher NPAR was independently associated with higher risk of pneumonia in a dose-dependent manner in patients with non-cervical SCI.

Hypoalbuminemia and Elevated CRP are Risk Factors for Deep Infections and Urinary Tract Infections After Lumbar Spine Surgery in a Large Retrospective Patient Population

STUDY DESIGN

Retrospective cross-sectional study.

OBJECTIVES

To determine if pre-operative albumin and CRP can predict post-operative infections after lumbar surgery.

METHODS

Patients who underwent an anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), or lumbar discectomy were identified using a patient record database (PearlDiver) and were included in this retrospective study. Patients were stratified by Charlson Comorbidity Index (CCI) scores and pre-operative albumin and CRP status. Post-operative complications included deep infections and urinary tract infections within 3 months of the surgery and revisions within 1 year of the surgery.

RESULTS

74,280 patients were included in this study. 21,903 had pre-operative albumin or CRP lab values. 7,191 (33%), 12,183 (56%), and 2,529 (12%) patients underwent an ALIF, PLIF, and a lumbar discectomy, respectively. 16,191 did not have any complication (74%). The most common complication was UTI (16%). Among all patients, hypoalbuminemia was a significant risk factor for deep infection and UTI after ALIF, deep infection, UTI, and surgical revision after PLIF, and deep infection after lumbar discectomy. Elevated CRP was a significant risk factor for deep infection after ALIF, UTI after PLIF, and deep infection after lumbar discectomy in patients with a CCI ≤ 3.

CONCLUSIONS

Pre-operative hypoalbuminemia and elevated CRP were significant risk factors for deep infection, UTI, and/or revision, after ALIF, PLIT, and/or lumbar discectomy. Future studies with a larger population of patients with low albumin and high CRP values are needed to further elaborate on the current findings.

Role of Branched-Chain Amino Acids and Their Derivative β-Hydroxy-β-Methylbutyrate in Liver Cirrhosis

Branched-chain amino acids (BCAA) supplementation is used to promote protein synthesis in different clinical conditions in which proteolysis is increased. In addition, lower plasma BCAA levels have been related to an increased risk of hepatic encephalopathy in liver cirrhosis. In this article we will review the role of supplementation with BCAAs and BCAA derivative β-hydroxy-β-methylbutyrate (HMB) in liver cirrhosis, focusing on nutritional and clinical effects. Evidence shows that BCAA supplementation slightly increases muscle mass and body mass index, with an upward trend in muscular strength and no change in fat mass. Moreover, BCAA supplementation improves symptoms of hepatic encephalopathy, and is indicated as second-line therapy. The evidence is more limited for BCAA derivatives. HMB supplementation appears to increase muscle mass in chronic diseases associated with cachexia, although this effect has not yet been clearly demonstrated in liver cirrhosis studies. To date, HMB supplementation has no clinical indication in liver cirrhosis.

Impact of C-reactive protein and albumin levels on short, medium, and long term mortality in patients with diffuse large B-cell lymphoma

Objectives and study design: In this population-based study of 602 patients, we amended C-reactive protein (CRP) and plasma albumin (PA) levels around the diagnosis of diffuse large B-cell lymphoma (DLBCL) to the International Prognostic Index (IPI) and assessed 0-90, 91-365, and +365-day survival.Results: The CRP did not contribute to the IPI's prognostic or discriminatory ability, regardless of time period, particularly not in models with PA. In contrast, the PA was an important contributor, especially in the 0-90 day period, but also up to one year after the diagnosis. For day 0-90, the model with the IPI only had an Area Under the Receiver Operating Characteristics (AUROC) of 0.742, whereas the IPI with PA as a continuous variable rendered an AUROC of 0.841. Especially the lower PA quartile (18-32 g/L) contributed to the worse prognosis.Conclusions: The amendment of PA to the IPI may significantly improve the short-term prognostic and discriminative ability.Key messagesThe amendment of the plasma albumin (PA) level to the International Prognostic Index significantly improved the prediction of mortality up to one year after the diagnosis of diffuse large B-cell lymphoma.It was especially the lower quartile of the PA level (18-32 g/L) that contributed to the worse prognosis.

Body impedance analysis to estimate malnutrition in inflammatory bowel disease patients - A cross-sectional study

OBJECTIVE

Malnutrition is a common clinical problem in patients with inflammatory bowel diseases (IBD). However, a gold standard for the detection of malnutrition in IBD patients is lacking.

METHODS

A cross-sectional study to assess malnutrition in patients with IBD and healthy controls (HCs). Clinical characteristics (Montreal classification, disease activity, previous surgery) and mutations in the NOD2 gene in patients with Crohn's disease (CD) were obtained. We performed a nutritional assessment with screening for nutritional risk and diagnosis for malnutrition (Malnutrition Universal Screening Tool [MUST]) score, NRS-2002, European Society for Clinical Nutrition and Metabolism (ESPEN), and Global Leadership Initiative on Malnutrition (GLIM) criteria and performed body impedance analysis (BIA).

RESULTS

101 IBD patients (57 CD and 44 ulcerative colitis (UC) and 50 HC were included in a single northern German tertiary center. GLIM criteria detected malnutrition significantly more often compared to the ESPEN criteria. Active disease, a long-standing disease course, and previous surgery were associated with reduced muscle mass. IBD patients had a higher fat mass index compared to HC. Mutations in the NOD2 gene had no effect on nutritional status.

CONCLUSIONS

The GLIM criteria detect malnutrition at a higher rate compared to ESPEN. Specific disease factors might put IBD patients at a higher risk for the development of malnutrition, so these patients might benefit from a frequently performed screening, which might result in a favorable disease course.

Decrease phase angle one year after Roux-en-Y bypass and sleeve gastrectomy is related to risks to protein nutritional status

BACKGROUND & AIMS

Phase angle (PhA) has been used as an indicator of nutritional status. However, the significance of PhA reduction after bariatric surgery is less known. This study evaluated PhA and its relation with biochemical parameters and prognostic inflammatory and nutritional indices at a one-year follow-up of patients subjected to Roux-en-Y bypass (RYGB) or sleeve gastrectomy (SG).

METHODS

Our final sample consisted of 25 patients subjected to RYGB and 11 to SG. Body mass index, fat-free mass, fat mass, PhA, serum transthyretin (TTR), albumin, C-reactive protein, alpha-1-acid glycoprotein, and prognostic inflammatory and nutritional indices were evaluated at four time points: before and approximately two, six, and 12 months after RYGB or SG. One-way repeated measures ANOVA or the Friedman test with Tukey's post hoc test was used depending on data distribution. The correlation between PhA and biochemical parameters and indices were evaluated using Spearman's or Pearson's correlation coefficients.

RESULTS

Except for serum albumin, all parameters significantly decreased over time (p < 0.001). Only the RYGB group showed transthyretinTR values below reference ones. Prognostic indices significantly decreased in both groups (p < 0.001). We found a significant positive correlation of PhA with TTR in both RYGB (r = 0.475; p < 0.001) and SG (r = 0.457; p < 0.001).

CONCLUSIONS

Data suggest that at a one-year follow-up after bariatric surgery, lower PhA values might indicate a concomitant loss of visceral protein and a worsening of protein nutritional status.

Assessment of Functional and Nutritional Status and Skeletal Muscle Mass for the Prognosis of Critically Ill Solid Cancer Patients

Simple and accessible prognostic factors are paramount for solid cancer patients experiencing life-threatening complications. The aim of this study is to appraise the impact of functional and nutritional status and skeletal muscle mass in this population. We conducted a retrospective (2007−2020) single-center study by enrolling adult patients with solid cancers requiring unplanned ICU admission. Performance status, body weight, and albumin level were collected at ICU admission and over six months. Skeletal muscle mass was assessed at ICU admission by measuring muscle areas normalized by height (SMI). Four-hundred and sixty-two patients were analyzed, mainly with gastro-intestinal (34.8%) and lung (29.9%) neoplasms. Moreover, 92.8% of men and 67.3% of women were deemed cachectic. In the multivariate analysis, performance status at ICU admission (CSH 1.74 [1.27−2.39], p < 0.001) and the six month increase in albumin level (CSH 0.38 [0.16−0.87], p = 0.02) were independent predictors of ICU mortality. In the subgroup of mechanically ventilated patients, the psoas SMI was independently associated with ICU mortality (CSH 0.82 [0.67−0.98], p = 0.04). Among the 368 ICU-survivors, the performance status at ICU admission (CSH 1.34 [1.14−1.59], p < 0.001) and the six-month weight loss (CSH 1.33 [1.17−2.99], p = 0.01) were associated with a one-year mortality rate. Most cancer patients displayed cachexia at ICU admission. Time courses of nutritional parameters may aid the prediction of short- and long-term outcomes.

Monitoring energy balance through clinical and serum biomarkers in patients with hematologic malignancies undergoing chemotherapy

Despite widespread concern about energy imbalance due to tumor and chemotherapy-related side effects, little is known about detailed variations in energy input, metabolic rate, and physical activity. This study explored changes in energy balance components and serum biomarkers of patients with hematologic malignancies undergoing chemotherapy. Our prospective study included 40 patients with hematologic malignancies hospitalized for chemotherapy. We measured energy balance components, physical function, and serum biomarkers at baseline and weekly after chemotherapy for 3 weeks. Significant weight loss, representing negative energy balance, occurred at 2 (p = 0.002) and 3 weeks (p < 0.001) post-chemotherapy. Statistically reduced oral intake was observed at 3 weeks post-chemotherapy (p = 0.040), and resting energy expenditure statistically decreased according to Harris-Benedict equation, but not to Penn State University equation. Physical function according to DEMMI score decreased significantly at 3 weeks post-chemotherapy (p = 0.002). Serum biomarker analysis demonstrated significant changes in albumin, total protein, CXCL13, and GDF15, with exception of leptin. Although conventional serum biomarkers (total protein and albumin) did not reach pathological states despite their statistical differences, subgroup analysis showed CXCL13 in weight loss group and GDF15 in reduced oral intake group were significantly changed. Over half of patients (65.0%, n = 26) suffered from energy imbalance associated with weight loss and reduced oral intake during chemotherapy. Serial laboratory results suggested that novel biomarkers (CXCL13, GDF15) could be correlated with cachexic state and reduced food intake. Monitoring clinical and serum biomarkers associated with energy balance together can help identify needs for nutritional support in patients with hematologic malignancies undergoing chemotherapy.

Prealbumin as a nutrition status indicator may be associated with outcomes of geriatric hip fractures: a propensity score matching and 1-year follow-up study

AIM

Nutrition status may affect bone metabolism and regeneration in the elderly. However, few studies reported a sensitive nutrition indicator or evaluation tool for geriatric hip fractures. This study aimed to explore if prealbumin (PAB), a critical nutrition-related protein, is related to the prognosis of hip fractures.

METHODS

Patients with hip fractures who met the inclusion criteria were included in our study. Geriatric nutritional risk index (GNRI) and prognostic nutritional index (PNI) were calculated. Propensity score matching (PSM) was used to reduce the influence of confounding factors and ROC curves were conducted to explore the optimal cutoff points of PAB and to compare the prognostic value between GNRI, PNI, and PAB. Then Cox and Logistics analyses were performed to identify the relation between PAB and outcomes of hip fractures.

RESULTS

Out of the 546 patients enrolled in this study, 91 patients died within one year. After a 1:1 PSM, the patients with less than 1-year survival had significantly lower PAB (p < 0.001) than those who were still alive at one year. ROC curves showed that the PAB may sensitively predict 6-month survival (AUROC: 0.695), 1-year survival (AUROC: 0.696), and 1-year-free walking ability (AUROC: 0.642). Logistics analysis showed that low PAB may be an independent risk factor for survival and 1-year-free walking ability.

CONCLUSION

Low levels of PAB may be associated with poor survival and walking abilities of older patients after surgery for hip fracture.

Hypoalbuminemia and not undernutrition predicts high-dose methotrexate-induced nephrotoxicity in children with acute lymphoblastic leukemia in resource-constrained centers

BACKGROUND

The standard practice to mitigate high-dose methotrexate (HD-MTX)-induced nephrotoxicity (HMN) in acute lymphoblastic leukemia (ALL) is to monitor levels until serum MTX falls below a predefined threshold. It is not feasible in most resource-constrained centers. Literature on the various factors affecting HMN in these centers is limited, retrospective, and heterogeneous. Though hypoalbuminemia has been postulated as a risk factor for HMN, the relationship of undernutrition with HMN has not been studied.

PROCEDURE

This prospective observational study consecutively enrolled children < 12 years old with ALL receiving HD-MTX. Children with preexisting renal disease and exposed to nephrotoxic drugs two weeks preceding HD-MTX infusion were excluded. HD-MTX was administered over 24 hours (BFM-2009 protocol) with 12 hours of prehydration. Solitary MTX levels at 36 hours (MTX36) were outsourced, and 6-8 doses of leucovorin were given six-hourly. Hydration was continued till last dose of leucovorin. Various factors affecting HMN (rise in creatinine to 1.5 times baseline) were recorded: age, sex, type of ALL, risk group of ALL, first dose of MTX, dose of MTX, undernourishment, serum protein, and albumin along with C-reactive protein and MTX36 levels.

RESULTS

Forty-four children who received 150 HD-MTX cycles were analyzed. HMN was seen in 14% of cycles. On univariate analysis, undernourishment, MTX36 levels, hypoproteinemia, and hypoalbuminemia were significantly associated with HMN. On multivariate analysis, hypoalbuminemia and MTX36 levels significantly predicted the development of HMN with odds ratios of 4.71 and 1.45.

CONCLUSION

Hypoalbuminemia and solitary serum MTX levels predict HMN in centers where serial MTX level monitoring is not feasible.

Demystifying Malnutrition to Improve Nutrition Screening and Assessment in Oncology

OBJECTIVE

Patients with cancer and malnutrition are more likely to experience poor treatment tolerance, prolonged length of hospital stay, and decreased quality of life. Early and sustained nutrition risk screening is the first step to tackling this patient and health care burden. Yet, malnutrition remains largely overlooked and undertreated. Malnutrition mismanagement could be indicative of a systemic misunderstanding. With this narrative review, we aimed to (1) define malnutrition, (2) address common malnutrition misconceptions, and (3) summarize nutrition recommendations for patients with cancer.

DATA SOURCES

PubMed and international clinical practice guidelines were used.

CONCLUSION

Malnutrition represents an unbalanced nutritional state that alters body composition and diminishes function. Malnutrition is not always physically obvious, and albumin is not a reliable marker of nutritional status; therefore, systematically screening all patients with a validated nutrition risk screening tool at time of cancer diagnosis, and periodically throughout treatment, is necessary to provide optimal, equitable care. Nutrition risk screening takes less than 1 minute to complete and can be completed by any health care professional. Patients that screen positive for nutrition risk should be referred to a registered nutritionist or dietitian for comprehensive nutritional assessment, diagnosis, and treatment.

IMPLICATIONS FOR NURSING PRACTICE

All health care professionals can and should be responsible for preventing and treating malnutrition. Registered nurses can actively participate in improving patient outcomes by screening patients for nutrition risk, weighing patients at every visit, referring patients to dietitians for nutrition treatment, and providing supportive medical management of nutrition impact symptoms such as nausea.

The Geriatric Nutritional Risk Index Is an Independent Predictor of Adverse Outcomes for Total Joint Arthroplasty Patients

BACKGROUND

Malnutrition affects patient outcomes after total joint arthroplasty (TJA). Although hypoalbuminemia has been used as a surrogate, there is no unanimous method for screening and assessing malnutrition. This study aimed to determine if malnutrition, as defined by the Geriatric Nutritional Risk Index (GNRI), is independently correlated with short-term (<30 days) postoperative complications and prognosis in patients undergoing TJA.

METHODS

The 2016-2019 American College of Surgeons National Surgical Quality Improvement Program was queried for all patients aged >65 years who underwent TJA. Based on GNRI value, patients were divided into 3 groups: normal nutrition (GNRI >98), moderate malnutrition (GNRI 92-98), and severe malnutrition (GNRI <92). After adjusting for potential confounders, multivariable regression models were used to analyze the association between GNRI and patient outcomes.

RESULTS

A total of 191,087 patients were included in the study. Prevalence of malnutrition based on body mass index (<18.5 kg/m²), albumin (<3.5 mg/dL), and GNRI (≤98) was 0.41% (784), 4.17% (7975), and 15.83% (30,258). Adjusted analysis showed that compared with normal nutrition, moderate and severe malnutrition status were associated with a higher rate of transfusion, readmission, and postoperative length of stay over 8 days (P < .05). Severe malnutrition was also associated with pneumonia, surgical site infection, urinary tract infection, sepsis, and revision surgery (P < .05).

CONCLUSION

Malnutrition, as defined by GNRI, is an independent predictor of adverse outcomes after TJA, including 30-day readmission, revision surgery, and increased length of stay. GNRI can be used to routinely screen and assess patient nutritional status before TJA and counsel patients and families appropriately.

LEVEL OF EVIDENCE

Level 3: Retrospective Cohort Study.

Nutritional and Nutrition-Related Biomarkers as Prognostic Factors of Sarcopenia, and Their Role in Disease Progression

Due to the multifactorial pathogenesis of sarcopenia, it is crucial to identify biomarkers that are risk factors for sarcopenia, and which therefore have a prognostic function. Aim: This narrative review aims to define a set of biomarkers associated with nutrition and sarcopenia. These biomarkers could contribute to individualized monitoring and enable preventive and therapeutic methods. Methods: Two electronic databases, PubMed and Google Scholar, were used. The search strategy was based on a controlled vocabulary (MeSH) and includes studies published up to February 2022. Discussion: Higher levels of serum uric acid are associated with higher handgrip strength and better muscle function in elderly people and, thus, may slow the progression of sarcopenia. Leptin, an adipokine secreted by adipose tissue, promotes the production of pro-inflammatory cytokines, which in turn lead to sarcopenia. This makes leptin a significant indirect biomarker for physical disability and sarcopenic obesity. Additionally, creatinine is a reliable biomarker for muscle mass status because of its easy accessibility and cost-effectiveness. Vitamin D status acts as a useful biomarker for predicting total mortality, hip fractures, early death, and the development of sarcopenia. Therefore, there is an increasing interest in dietary antioxidants and their effects on age-related losses of muscle mass and function. On the other hand, 3-Methylhistidine is a valuable biomarker for detecting increased muscle catabolism, as it is excreted through urine during muscle degradation. In addition, IGF-1, whose concentration in plasma is stimulated by food intake, is associated with the loss of skeletal muscle mass, which probably plays a crucial role in the progression of sarcopenia. Conclusions: Many nutritional biomarkers were found to be associated with sarcopenia, and can therefore be used as prognostic indexes and risk factors. Nutrition plays an important role in the prevention and management of sarcopenia, affecting muscle mass, strength, and function in elderly people.

Serum Albumin: Early Prognostic Marker of Benefit for Immune Checkpoint Inhibitor Monotherapy But Not Chemoimmunotherapy

BACKGROUND

Cancer cachexia exhibits decreased albumin and associates with short overall survival (OS) in patients with non-small cell lung cancer (NSCLC), but whether on-treatment albumin changes associate with OS in NSCLC patients treated with immune checkpoint inhibitors (ICIs) and combination chemoimmunotherapy has not been thoroughly evaluated.

PATIENTS AND METHODS

We conducted a single-center retrospective study of patients with advanced NSCLC who received first-line ICI with or without chemotherapy between 2013 and 2020. The association of pretreatment albumin and early albumin changes with OS was evaluated using Kaplan-Meier method and Cox regression models.

RESULTS

A total of 210 patients were included: 109 in ICI cohort and 101 in ICI + Chemo cohort. Within a median of 21 days from treatment initiation, patients with ≥ 10% of albumin decrease had significantly shorter OS compared to patients without albumin decrease in ICI cohort. Pretreatment albumin and albumin decrease within the first or second cycle of treatment were significantly and independently associated with OS in ICI cohort, but not in ICI + Chemo cohort. The lack of association between albumin and OS with the addition of chemotherapy was more pronounced among patients with ≥ 1% PD-L1 expression in subgroup analysis.

CONCLUSION

Pretreatment serum albumin and early albumin decrease in ICI monotherapy was significantly associated with OS in advanced NSCLC. Early albumin change, as a routine lab value tested in clinic, may be combined with established biomarkers to improve outcome predictions of ICI monotherapy. The underlying mechanism of the observed association between decreased albumin and ICI resistance warrants further investigation.

A Practical Approach to Identifying Pediatric Disease-Associated Undernutrition: A Position Statement from the ESPGHAN Special Interest Group on Clinical Malnutrition

ABSTRACT

Disease-associated undernutrition (DAU) is still common in hospitalized children and is generally accepted to be associated with adverse effects on disease outcomes; hence making proper identification and assessment essential in the management of the sick child. There are however several barriers to routine screening, assessment, and treatment of sick children with poor nutritional status or DAU, including limited resources, lack of nutritional awareness, and lack of agreed nutrition policies. We recommend all pediatric facilities to 1) implement procedures for identification of children with (risk of) DAU, including nutritional screening, criteria for further assessment to establish diagnosis of DAU, and follow-up, 2) assess weight and height in all children asa minimum, and 3) have the opportunity for children at risk to be assessed by a hospital dietitian. An updated descriptive definition of pediatric DAU is proposed as "Undernutrition is a condition resulting from imbalanced nutrition or abnormal utilization of nutrients which causes clinically meaningful adverse effects on tissue function and/or body size/composition with subsequent impact on health outcomes." To facilitate comparison of undernutrition data, it is advised that in addition to commonly used criteria for undernutrition such as z score < -2 for weight-for-age, weight-for-length, or body mass index <-2, an unintentional decline of >1inthese z scores over time should be considered as an indicator requiring further assessment to establish DAU diagnosis. Since the etiology of DAU is multifactorial, clinical evaluation and anthropometry should ideally be complemented by measurements of body composition, assessment of nutritional intake, requirements, and losses, and considering disease specific factors.

Prevalence, diagnosis, and surgical management of complex ileocolic-duodenal fistulas in Crohn's disease

BACKGROUND

The aim of the present study was to review the prevalence and surgical management of patients with Crohn's disease (CD) complicated by ileocolic-duodenal fistulas (ICDF).

METHODS

We performed a retrospective chart review of CD patients who underwent surgical takedown and repair of ICDF during January 2011-December 2021 at two inflammatory bowel disease referral centers.

RESULTS

We identified 17 patients with ICDF (1.3%) out of 1283 CD patients who underwent abdominal surgery. Median age was 42 (20-71) years, 13 patients were male (76%) and median body mass index was 22.7 (18.4-30.3) kg/m². Four patients (24%) were diagnosed preoperatively and only 2 (12%) were operated on for ICDF-related symptoms. The most common procedure was ileocolic resection (13 patients, 76%) including 4 repeat ileocolic resections (24%). The duodenal defect was primarily repaired in all patients with no re-fistulization or duodenal stenosis, regardless of the repair technique. A laparoscopic approach was attempted in the majority of patients (14 patients, 82%); however, only 5 (30%) were laparoscopically completed. The overall postoperative complication rate was 65% including major complications in 3 patients (18%) and 2 patients (12%) who required surgical re-intervention for abdominal wall dehiscence and postoperative bleeding. Preoperative nutritional optimization was performed in 9 patients (53%) due to malnutrition. These patients had significantly less intra-operative blood loss (485 vs 183 ml, p = 0.05), and a significantly reduced length of stay (18 vs 8 days, p = 0.05).

CONCLUSION

ICDF is a rare manifestation of CD which may go unrecognized despite the implementation of a comprehensive preoperative evaluation. Although laparoscopic management of ICDF may be technically feasible, it is associated with a high conversion rate. Preoperative nutritional optimization may be beneficial in improving surgical outcomes in this select group of patients.

Relationship between Undernutrition and Periodontal Diseases among a Sample of Yemeni Population: A Cross-Sectional Study

Undernutrition is an inadequate supply of energy and nutrients. Periodontal diseases (PDs) are defined as a broad form of chronic inflammatory disease of the gingiva, bone, and ligaments supporting the teeth. This study aimed to reveal the relationship between undernutrition, using body mass index (BMI) and serum albumin level (Alb), and PDs in a sample of Yemeni population. A cross-sectional study was conducted at dental teaching clinics at the Faculty of Dentistry, Sana’a University. Of 1920 patients who attended clinics, only 229 matched the study criteria. Oral examination was performed to assess the periodontal clinical parameter measurements. BMI and Alb were measured. Participants of both genders were involved, with a slight increase in males (n = 134, 58.5%), and most of the study sample was in the age group of 18–35 years (n = 209, 91.3%). Regarding habits, only 18.2% (n = 43) of patients were smokers and about half of the participants (n = 136, 59.4%) were khat chewers. Most cases had mild undernutrition according to BMI (n = 139, 60.7%) and normal Alb level (n = 213, 93%). Regarding the periodontal diagnosis, most of the participants were diagnosed with gingivitis (n = 186, 81.2%). BMI and albumin level were nonsignificantly associated with PDs. PDs were statistically significant with the participant’s age, gender, level of education, and smoking ( $P>0.05$ ). However, BMI, khat chewing, and albumin level were nonsignificant factors of periodontal diseases among Yemeni participants ( $P>0.05$ ). In both genders, variables such as age of the patients, smoking, khat chewing, and PDs were nonsignificantly associated with BMI. This study showed that the majority of the participants had been diagnosed with gingivitis, but there was not an association between PDs and undernutrition. This paper is presented on research square URL // https://www.researchsquare.com/article/rs-429796/v1 with DOI 10.21203/rs.3.rs-429796/v1.

Malnutrition in patients admitted to in-hospital cardiac rehabilitation: Clinical correlates and association with mortality

Malnutrition is highly prevalent among hospitalized patients; thus, an accurate identification of malnutrition could improve the outcome of these patients. The aim of the present paper was to apply multiple methods to evaluate the prevalence of malnutrition and clinical correlates in patients admitted to in-hospital cardiac rehabilitation.  We performed a prospective study of 426 patients admitted to in-hospital cardiac rehabilitation: 282 (66.2%) had undergone a major cardiac surgery and 144 (34.8%) had experienced heart failure. The albumin level and Mini Nutritional Assessment (MNA) scores were applied to evaluate the nutritional status of these patients. Serum albumin levels were < 3.5 g/dl in 147 (34.5%) patients, and MNA scores were < 24 in 179 (42.0%) patients. Patients with malnutrition or a risk of malnutrition had lower haemoglobin values, lower EuroQol scores and poorer functional status. Female gender, age, functional status and Cumulative Illness Rating Scale severity were predictors of malnutrition. Over a median follow-up of 47 months, MNA scores <24 were associated with higher mortality, even after correction for confounding variables. In conclusion, in patients admitted to in-hospital cardiac rehabilitation, malnutrition and risk of malnutrition frequently occur and are associated with poor functional status, higher clinical complication rates and long-term mortality.

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.

Association between estimated GFR and incident hypoglycaemia during hospitalization

BACKGROUND

Kidney function is a significant factor associated with increased incidence of hypoglycaemia, especially among patients with diabetes mellitus (DM). We here quantified the association between elevated creatinine and incident hypoglycaemia among patients admitted to internal medicine departments, with and without DM.

METHODS

This is a retrospective cohort analysis study. Included were all patients discharged from internal medicine units between 2010 and 2013. Patients were excluded if creatinine levels rose or dropped more than 0.3 mg/dL during hospitalization. The CKD-EPI equation was used to calculate glomerular filtration rate (eGFR). Logistic regression analysis (backward LR method) was used to study the association between eGFR and hypoglycaemia incidence.

RESULTS

Included were 39 316 patients (mean age 68.0 ± 18.0 years, 49.3% males, 25.9% with DM, eGFR 69.5 ± 24.9 mL/min/1.73 m² ). Among study participants, 6.5% had at least one hypoglycaemic event. Logistic regression modelling showed that eGFR was inversely associated with incident hypoglycaemia (OR 0.988, 95% CI 0.986-0.990, p < .001). Results were similar for patients with and without DM. Estimated GFR was negatively correlated with admission CRP levels for patients with (r = -.143, p < .001) and without DM (r = -.166, p < .001). Estimated GFR was also positively correlated with admission serum albumin levels for both patients with (r = .304, p < .001) and without DM (r = .354, p < .001).

CONCLUSION

Among non-critically-ill patients hospitalized in internal medicine departments, reduced eGFR is associated with increased risk of hypoglycaemia. Glucose monitoring for all inpatients with CKD is suggested, regardless of DM status.

The combination of body composition conditions and systemic inflammatory markers has prognostic value for patients with gastric cancer treated with adjuvant chemoradiotherapy

OBJECTIVE

The aim of this study was to explore the prognostic value of the association between systemic inflammation response markers (red blood cell distribution width, neutrophil platelet score, prognostic nutritional index, neutrophil-to-lymphocyte ratio, neutrophil-to-platelet ratio, lymphocyte-to-monocyte ratio, and systemic immune-inflammation index) and poorer body composition conditions (sarcopenia, myosteatosis, and sarcopenic obesity) among patients with gastric cancer who underwent adjuvant chemoradiotherapy after radical gastrectomy.

METHODS

A computed tomography scan was performed within 2 wk of prechemoradiotherapy to identify sarcopenia, myosteatosis and sarcopenic obesity. Tumor and systemic inflammatory response information was recorded. Logistic analysis was used to explore the potential risk factors associated with body composition. Univariate and multivariate Cox analyses were performed for survival analysis. A nomogram was constructed to serve as a prognostic prediction tool for the 3- and 5-y overall survival rates.

RESULTS

The study included 223 patients (74 women and 149 men) with gastric cancer treated with adjuvant chemoradiotherapy after radical gastrectomy. The incidences of sarcopenia, myosteatosis, and sarcopenic obesity were 30%, 39%, and 16%, respectively. Logistic analysis demonstrated that a low prognostic nutritional index is a risk factor for sarcopenia, myosteatosis, and sarcopenic obesity. Based on survival analysis, stage (hazard ratio [HR], 0.44; 95% confidence interval [CI], 0.23-0.84; P = 0.01), the neutrophil platelet score (HR, 0.50; 95% CI, 0.31-0.82; P = 0.01), the prognostic nutritional index (HR, 0.40; 95% CI, 0.24-0.68; P = 0.00) and sarcopenic obesity (HR, 0.54; 95% CI, 0.31-0.93; P = 0.03) remained independent prognostic factors for overall survival. Accuracy was improved when systemic inflammation markers were incorporated into the nomogram compared with when they were excluded, and the predicted C indexes of the nomogram with and without systemic inflammatory markers were 0.71 (95% CI, 0.67-0.73) and 0.63 (95% CI, 0.57-0.68), respectively.

CONCLUSION

The systemic inflammatory response associated with progressive nutritional conditions and body composition conditions with systemic inflammation markers incorporated presented better prognostic value.

One ring is not enough to rule them all. Albumin-dependent ABCG2-mediated transport of chlorophyll-derived photosensitizers

Breast cancer resistance protein (BCRP, ABCG2) is a member of the ATP-binding-cassette (ABC) superfamily of membrane transporters. It is involved in the efflux of a broad range of xenobiotics of highly diverse structures. BCRP activity greatly influences drug distribution in vivo and is often associated with cancer multidrug resistance, which is observed in the case of both chemotherapy and photodynamic therapy. The set of ABCG2 substrates includes porphyrins and chlorins such as heme, hemin, protoporphyrin IX, chlorin e6, pheophorbide a, and their derivatives. Here we provide an evidence that magnesium- and zinc-substituted derivatives of pheophorbide a, which are very promising photosensitizers for use in photodynamic therapy, are also recognized and transported by ABCG2. Interestingly, despite minor structural differences, they clearly differ in the transport rate, both between each other and compared to pheophorbide a. In addition, their transport rate, like those of other structurally similar compounds, is strictly dependent on the level of serum albumin in the extracellular environment. The results that we present here are crucial for the use of metal-substituted pheophorbides in clinical practice but also provide an important insight into the mechanism of porphyrin transport by ABCG2.

Validity and Reliability of a Nutritional Screening Tool (SCAN) in Children Newly Diagnosed with Cancer

No standardized approach towards nutritional screening and assessment of pediatric oncology patients has been established. The nutrition screening tool for childhood cancer (SCAN) has been previously published as an effective screening method. This is an observational cross-sectional study to assess the validity and reliability of the SCAN tool, compare it to the detection of undernutrition using standard measures of assessment, and determine the overall prevalence of malnutrition and micronutrients alterations in our cohort. We included children newly diagnosed with cancer in a pediatric tertiary hospital in Madrid, Spain from August 2018 to May 2019. The following measurements were performed: SCAN questionnaire, anthropometric measurements, nutritional markers in blood, and micronutrient levels. A total of 49 patients were included. 22 patients (45%) were at risk of malnutrition according to the SCAN questionnaire. Four patients (8%) could be diagnosed with moderate undernutrition. These undernourished patients were distributed homogeneously among at-risk and not at-risk populations identified by the SCAN tool. Several micronutrient deficiencies were identified. We conclude that the SCAN questionnaire is an easy-to-use tool for everyday clinical practice. By not including anthropometric measurements it misses patients considered to be malnourished. Future data might help clarify if it is an effective tool in predicting a higher nutritional risk during the entire treatment course.