Association between Inflammation-Associated Cytokines, Serum Albumins, and Mortality in the Elderly

Neutrophil to albumin ratio: a biomarker in non-alcoholic fatty liver disease and with liver fibrosis

Objective

Given the high prevalence of non-alcoholic fatty liver disease (NAFLD) and its potential to progress to liver fibrosis, it is crucial to identify the presence of NAFLD in patients to guide their subsequent management. However, the current availability of non-invasive biomarkers for NAFLD remains limited. Therefore, further investigation is needed to identify and develop non-invasive biomarkers for NAFLD.

Methods

A retrospective analysis was conducted on 11,883 patients admitted to the Healthcare Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, from January 2016 to December 2019 and divided into NAFLD and non-NAFLD groups. Anthropometric and laboratory examination data were collected. The correlations between variables and NAFLD were evaluated using the student's t-test or Mann-Whitney U test and binary logistic regression analysis. The predictive ability of these variables for NAFLD was assessed using the areas under the curves (AUCs) of receiver operating characteristics.

Results

Among the included patients, 3,872 (32.58%) were diagnosed with NAFLD, with 386 (9.97%) individuals having liver fibrosis. Patients with NAFLD exhibited a higher proportion of males, elevated body mass index (BMI), and increased likelihood of hypertension, diabetes mellitus, and atherosclerosis. Logistic regression analysis identified the neutrophil to albumin ratio (NAR) as the most promising novel inflammation biomarkers, with the highest AUC value of 0.701, a cut-off value of 0.797, sensitivity of 69.40%, and specificity of 66.00% in identifying the risk of NAFLD. Moreover, NAR demonstrated superior predictive value in identifying NAFLD patients at risk of liver fibrosis, with an AUC value of 0.795, sensitivity of 71.30%, and specificity of 73.60% when NAR reached 1.285.

Conclusion

These findings highlight that the novel inflammatory biomarker, NAR, is a convenient and easily accessible non-invasive predictor for NAFLD and NAFLD with liver fibrosis.

Correlation between dysphagia and serum albumin levels and prognosis: a retrospective study

Introduction

Introduction: dysphagia is a common complication of stroke, and serum albumin is widely recognized as a strong prognostic marker of health and/or disease status. However, the correlation between dysphagia and serum albumin levels has not been established. Objectives: to observe the correlation between dysphagia and serum albumin levels and prognosis in patients with stroke. Methods: we performed a retrospective study of patients hospitalized between June 1, 2018, and June 1, 2022. A total of 1,370 patients were enrolled. The patients were divided into two groups: dysphagia and non-dysphagia. Binary logistic regression and multiple linear regression models were used to analyze the correlation between dysphagia, albumin, modified Rankin Scale (mRS), activities of daily living (ADL), and length of hospital stay (LOS). Results: after adjusting for confounding factors, the risk of pneumonia in the dysphagia group was 2.417 times higher than that in the non-dysphagia group (OR = 2.417, 95 % CI: 1.902-3.072, p = 0.000). The risk of mRS ≥ 3 and modified Barthel index (MBI) < 60 in patients with dysphagia was 3.272-fold (OR = 3.272, 95 % CI: 2.508-4.269, p < 0.001) and 1.670-fold (OR = 1.670, 95 % CI: 1.230-2.268, p < 0.001), respectively; and the risk of hypoproteinemia was 2.533 times higher (OR = 2.533, 95 % CI: 1.879-3.414, p = 0.000). Stepwise linear regression showed that dysphagia was significantly correlated with lower albumin levels and higher mRS, lower ADL, and longer LOS in patients with stroke (β = -0.220, β = 0.265, β = -0.210, and β = 0.147, respectively; p < 0.001). Conclusions: dysphagia in patients with stroke is associated with decreased albumin levels and has an impact on its prognosis.

Serum albumin and risk of incident diabetes and diabetic microvascular complications in the UK Biobank cohort

AIM

To examine the associations between serum albumin and the incidences of diabetes and diabetic microvascular complications in participants of the UK Biobank cohort.

METHODS

There were 398,146 participants without diabetes and 30,952 patients with diabetes from the UK Biobank cohort included in this study. Multivariate-adjusted Cox proportional hazard models were used to analyze the association of albumin with the incidences of diabetes and diabetic microvascular complications. Mendelian randomization (MR) analysis was used to determine the genetic relationships between serum albumin and diabetes.

RESULTS

After a median 12.90 years follow-up, 14,710 participants developed incident diabetes (58.83 ± 7.52 years, 56.10% male). After multivariate adjustment, serum albumin was inversely associated with incident diabetes: hazard ratio (HR) [95% confidence interval] per 10 g/l increase 0.88 [0.82;0.94]. MR analyses suggested a potential genetic influence of serum albumin on diabetes in both the UK Biobank and the FinnGen consortium: odds ratios (ORs) [95% confidence interval per 1 g/l increase 0.99 [0.98;1.00] and 0.78 [0.67;0.92], respectively. In patients with diabetes, higher serum albumin levels were significantly associated with lower risk for diabetic microvascular complications. Specifically, per 10 g/l increase in serum albumin, the HRs for diabetic nephropathy, ophthalmopathy, and neuropathy were 0.42 [0.30;0.58], 0.61 [0.52;0.72], and 0.67 [0.51;0.88], respectively.

CONCLUSION

In this large prospective study, serum levels of albumin were inversely associated with the incidences of diabetes and diabetic microvascular complications. These findings underscore the importance of maintaining optimal nutrient status in reducing the risk of diabetes and its complications.

Glucosamine and Chondroitin Use and Mortality Among Adults in the United States from 1999 to 2014

Introduction: Glucosamine and chondroitin are supplements that are often, but not always, used in combination for arthritis and joint pain. Multiple studies have suggested that glucosamine and chondroitin may be associated with reduced risk of several diseases, as well as all-cause, cancer- and respiratory disease-specific mortality. Methods: Nationally representative data from the National Health and Nutrition Examination Survey (NHANES) were used to further evaluate the association between glucosamine and chondroitin with mortality. Participants include 38,021 adults, ages 20+ years and older, who completed the detailed NHANES between 1999 and 2014. Participants were followed for death through linkage with the National Death Index through the end of 2015, over which time 4905 deaths occurred. Adjusted hazard ratios (HRs) for overall and cause-specific mortality were estimated using Cox regression models. Results: Despite glucosamine and chondroitin use appearing to be inversely associated with mortality in the minimally adjusted models, no association was observed in multivariable models (glucosamine: HR = 1.02; 95% confidence interval [CI]: 0.86-1.21, chondroitin: HR = 1.04, 95% CI: 0.87-1.25). No association with cancer mortality or other mortality rate was observed after multivariable adjustment. There was a suggestive, nonsignificant inverse association for cardiovascular-specific mortality (glucosamine HR = 0.72; 95% CI: 0.46-1.15, chondroitin: HR = 0.76; 95% CI: 0.47-1.21). Conclusion: The lack of significant relationship between glucosamine and chondroitin use and all-cause or cause-specific mortality after adjusting extensively for multiple covariates in this nationally representative adult population was in contrast to prior literature. Given the limited power to explore the cause-specific mortality, future well-powered studies will be needed to better understand the potential association with cardiovascular-specific mortality.

Emerging Roles on Immunological Effect of Indoleamine 2,3-Dioxygenase in Liver Injuries

Indoleamine 2,3-dioxygenase (IDO) is one of the initial rate-limiting enzymes of the kynurenine pathway (KP), which causes immune suppression and induction of T cell anergy. It is associated with the imbalance of immune homeostasis in numerous diseases including cancer, chronic viral infection, allergy, and autoimmune diseases. Recently, IDO has extended its role to liver field. In this review, we summarize the dysregulation and potentials of IDO in the emerging field of liver injuries, as well as current challenges for IDO targets. In particular, we discuss unexpected conclusions against previous work published. IDO is induced by pro-inflammatory cytokines in liver dysfunction and exerts an immunosuppressive effect, whereas the improvement of liver injury may require consideration of multiple factors besides IDO.

Low Serum Albumin Predicts Severe Outcomes in COVID-19 Infection: A Single-Center Retrospective Case-Control Study

Background

Coronavirus disease 2019 (COVID-19) can cause serious complications such as multiorgan failure and death which are difficult to predict. We conducted this retrospective case-control observational study with the hypothesis that low serum albumin at presentation can predict serious outcomes in COVID-19 infection.

Methods

We included severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcriptase-polymerase chain reaction (RT-PCR) confirmed, hospitalized patients from March to July 2020 in a tertiary care hospital in the USA. Patients were followed for 21 days for the development of the primary endpoint defined as the composite outcome which included acute encephalopathy, acute kidney injury, the requirement of new renal replacement therapy, acute hypercoagulability, acute circulatory failure, new-onset heart failure, acute cardiac injury, acute arrhythmia, acute respiratory distress syndrome (ARDS), high flow oxygen support, intensive care unit (ICU) stay, mechanical ventilation or death; and the secondary endpoint of death only. Univariate and multivariate logistic regression analyses were performed to study the effect of albumin level and outcomes.

Results

The mean age was 56.76 years vs. 55.67 years (P = 0.68) in the normal albumin vs. the low albumin group. We noticed an inverse relationship between serum albumin at presentation and serious outcomes. The low albumin group had a higher composite outcome (93.88% vs. 6.12%, P < 0.05) and higher mortality (13.87% vs. 2.38%, P < 0.05) in comparison to the normal albumin group. The multivariate logistic regression analysis revealed higher odds of having composite outcomes with lower albumin group (odds ratio (OR) 10.88, 95% confidence interval (CI) 4.74 - 24.97, P < 0.05). In the subgroup analysis, the multivariate logistic regression analysis revealed higher odds of having composite outcomes with the very low albumin group (OR 7.94, 95% CI 1.70 - 37.14, P < 0.05).

Conclusions

Low serum albumin on presentation in COVID-19 infection is associated with serious outcomes not limited to mortality. The therapeutic option of albumin infusion should be investigated.

Signal Detection to Measure Allostatic Load

PURPOSE

To illustrate a means to calculate allostatic load in hospitalized patients using big data from the electronic medical record (EMR).

ORGANIZING CONSTRUCT

To describe the development of the Troubled Outcome Risk (TOR) scale using signal detection in big data.

METHODS

Using both retrospective and prospective observational studies, I describe a mechanism to determine meaning from retrospective data then use the results to improve nursing surveillance to reduce length of stay (LOS) and nursing sensitive indicators on an inpatient medical surgical unit.

FINDINGS

Results from the retrospective study contained over 290,000 individual data points and established an interpretation standard for the TOR score using an algorithm to detect signals. The prospective observational study used the TOR scale and developed an interpretation standard to assist unit charge nurses in assigning staff to patients based on a fully objective measure of patient allostatic load.

CONCLUSIONS

The TOR scale in conjunction with existing nurse staffing methodology reduced inpatient LOS by 0.3 days, reduced allostatic load as measured by the TOR scale, and changed staffing patterns from purely geographic to patient-need based.

CLINICAL RELEVANCE

The TOR scale demonstrates that careful evidence-based criteria can be easily gathered from the EMR and used to positively impact nursing practice and patient outcomes.

Reduced Albumin Concentration Predicts Weight Gain and Higher Ad Libitum Energy Intake in Humans

OBJECTIVE

Circulating albumin is negatively associated with adiposity but whether it is associated with increased energy intake, lower energy expenditure or weight gain has not been examined.

METHODS

In study 1 (n=238; 146 men), we evaluated whether fasting albumin concentration was associated with 24-h energy expenditure and ad libitum energy intake. In study 2 (n=325;167 men), we evaluated the association between plasma albumin and change in weight and body composition.

RESULTS

After adjustment for known determinants of energy intake lower plasma albumin concentration was associated with greater total daily energy intake (β= 89.8 kcal/day per 0.1 g/dl difference in plasma albumin, p=0.0047). No associations were observed between plasma albumin concentrations and 24-h energy expenditure or 24-h respiratory quotient (p>0.2). Over 6 years, volunteers gained on average 7.5 ± 11.7 kg (p<0.0001). Lower albumin concentrations were associated with greater weight [β=3.53 kg, p=0.039 (adjusted for age, sex, follow up time), CI 0.16 to 6.21 per 1 g/dl difference albumin concentration] and fat mass (β=2.3 kg, p=0.022), respectively, but not with changes in fat free mass (p=0.06).

CONCLUSIONS

Lower albumin concentrations were associated with increased ad libitum food intake and weight gain, indicating albumin as a marker of energy intake regulation.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, identifiers NCT00340132, NCT00342732.

Association between neutrophil-to-albumin ratio and mortality in patients with cardiogenic shock: a retrospective cohort study

OBJECTIVES

To investigate the prognostic value of neutrophil-to-albumin ratio (NAR) in critically ill patients with cardiogenic shock (CS).

DESIGN

A retrospective cohort study.

SETTING

A single centre in Boston, USA.

PARTICIPANTS

475 patients with CS were included, among which 272 (57.3%) were men and 328 (69.1%) were white.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was 90-day mortality and the secondary outcomes were 30-day and 365-day mortality.

RESULTS

A significant positive correlation between NAR levels and 90-day, 30-day or 365-day mortality was observed. For 90-day mortality, the adjusted HR (95% CI) values given NAR levels 23.54-27.86 and >27.86 were 1.71 (1.14 to 2.55) and 1.93 (1.27 to 2.93) compared with the reference (NAR<23.47). Receiver operator characteristic curve analysis showed that NAR had a certain prognostic value in predicting 90-day mortality of CS, which was more sensitive than the neutrophil percentage or the serum albumin level alone (0.651 vs 0.509, 0.584). For the secondary outcomes, the upward trend remained statistically significant.

CONCLUSIONS

NAR level was associated with the mortality of CS patients. The prognostic value of NAR was more sensitive than the neutrophil percentage or the serum albumin level alone, but not as good as Sequential Organ Failure Assessment or Simplified Acute Physiology Score.

Baseline serum albumin and its dynamic change is associated with type 2 diabetes risk: A large cohort study in China

BACKGROUND

The study aimed to investigate the associations of baseline serum albumin level and its dynamic change with type 2 diabetes mellitus (T2DM) risk in a large Chinese cohort study.

METHODS

This cohort study included 30 442 adults without T2DM at first entry, who completed at least one follow-up of annual examinations between 2009 and 2016. Serum albumin level was measured at baseline and at every annual check-up. The dynamic change in serum albumin level (∆ALB) was calculated by subtracting serum albumin level at baseline from that at the last follow-up. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated with Cox regression models.

RESULTS

During 7 years of follow-up, we identified 1634 T2DM events. From the lowest to the highest quartile of serum albumin level, adjusted HRs (95% CI) were 1.00 (reference), 0.96 (0.94, 1.01), 0.98 (0.95, 1.02) and 0.88 (0.85, 0.98), respectively. As compared with stable change in serum albumin (-0.2 ≤ ∆ALB <1.0 g/L), the risk of T2DM increased for ∆ALB < -2.0 g/L (HR 1.44, 95% CI 1.24-1.68) and decreased for ∆ALB ≥3.0 g/L (0.81, 0.68-0.97) after adjusting for potential confounding factors. Restricted cubic splines showed a linear dose-response association between baseline serum albumin level and T2DM risk (P_nonlinearity 0.715) and a nonlinear dose-response association between ∆ALB and T2DM risk (P_nonlinearity 0.011).

CONCLUSIONS

Baseline serum albumin level appears to be inversely associated with T2DM risk. Adults with reduced serum albumin level could be early identified for diabetes risk in clinical practice.

Protective Effects of Resveratrol Supplementation on Contusion Induced Muscle Injury

Muscle injuries frequently occur in contact sports events. The current treatment options for soft tissue injuries remain suboptimal and often result in delayed or incomplete recovery of damaged muscles. Resveratrol (RES) is a phenolic phytochemical, well-known for its antioxidant and anti-inflammatory properties. The purpose of this study is to evaluate the potential beneficial effects of RES supplementation on inflammation and regeneration in skeletal muscle after a contusion injury, in comparison to a conventional treatment of nonsteroidal anti-inflammatory drugs (NSAID). After one week of acclimation, forty eight -week-old male ICR mice were randomly divided into the five groups (n=8 per group): 1) normal control (NC), 2) mass-drop injury without any treatment (mass-drop injury, MDI), 3) post-injury NSAID treatment (MDI+ 10mg/kg NSAID), 4) post-injury RES supplementation (MDI+ 25mg/kg/day RES) and 5) post-injury treatment with RES and NSAID (MDI + resveratrol+ NSAID). After muscle contusion injury of the left gastrocnemius muscle, RES or NSAID were orally administered post-injury once a day for 7 days. Results showed that the MDI group had significantly higher serum uric acid (UA), CREA (creatinine), LDH (lactic dehydrogenase) and creatine kinase (CK) than the normal control group. Treatment with resveratrol reduced muscle damage as evidenced by the significantly decreased serum levels of UA, CREA, LDH and CK after contusion-induced muscle injuries in mice. In addition, RES and RES + NSAID groups promoted muscle satellite cell regeneration with increase in desmin protein after injury. Our results suggest that resveratrol combined with NSAID potentially improve muscle recovery and may be a potential candidate for further development as an effective clinical treatment for muscle repair.

Sex Differences in Aging and Associated Biomarkers

Aging is a natural process defined by the gradual, time-dependent decline of biological and behavioural functions, for which individuals of the same chronological age show variability. The capacity of biological systems to continuously adjust for optimal functioning despite ever changing environments is essential for healthy aging, and variability in these adaptive homeostatic mechanisms may reflect such heterogeneity in the aging process. With an ever-increasing aging population, interest in biomarkers of aging is growing. Although no universally accepted definition of biomarkers of healthy aging exists, mediators of homeostasis are consistently used as measures of the aging process. As important sex differences are known to underlie many of these systems, it is imperative to consider that this may reflect, to some extent, the sex differences observed in aging and age-related disease states. This chapter aims to outline sex differences in key homeostatic domains thought to be associated with the pathophysiology of aging, often proposed as biomarkers of aging and age-related disease states. This includes considering sex-based differences and hormonal status with regards to the gonadal and adrenal endocrine systems and immune function.

BUN as an Independent Predictor of Post-Hospital-Discharge Mortality among Older Veterans

BACKGROUND/OBJECTIVES

An elevated blood urea nitrogen (BUN) in known to be an important prognostic indicator in patients with end-stage heart or kidney disease or certain other life-threatening illnesses. However, it is less certain as to whether an elevated BUN is an independent predictor of long-term mortality risk in less seriously ill patients. To address this issue, we examined the relationship between BUN and long-term mortality after adjusting for potential confounders and other indicators of health status/disease severity, in a select population of older medically stable Veterans.

DESIGN

Long-term prospective cohort study.

SETTING

Outpatient follow-up of patients discharged from a recuperative care and rehabilitation unit (RCRU) of a Department of Veterans Affairs Community Living Center.

PARTICIPANTS

383 older Veterans (mean age = 78.6±7.6 years, 98% male, and 87% white) discharged alive and in stable medical condition.

MEASUREMENTS

At discharge, each subject completed a comprehensive assessment and was then monitored as an outpatient for up to 9.3 years. Associations between blood urea nitrogen at RCRU discharge and mortality were identified utilizing Cox proportional hazards (PH) regression analyses adjusting for conditions known to confound this relationship.

RESULTS

Within the follow-up period, 255 subjects (67%) died. In the unadjusted Cox PH model, a BUN ≥ 30 mg/dL was associated with a nearly 2-fold increased risk of mortality (hazard ratio 1.90, 95%CI 1.41 - 2.56). The association between BUN and long-term mortality remained highly significant after adjusting for potential confounders (hazard ratio 1.78, 95%CI 1.29 - 2.44).

CONCLUSION

Our findings support BUN levels as an independent predictor of long-term mortality in older, medically stable Veterans. An elevated BUN may be reflective of global health status rather than solely an indicator of the severity of acute illness or unstable chronic disease.

Disorders of nutritional status in sepsis - facts and myths

The problem of diagnosing nutritional status disorders in septic patients remains unresolved. This is associated with the necessity of the introduction of newer and newer methods of assessing nutritional status, often requiring precise and expensive equipment as well as employment of professionals in this field in hospital wards, primarily including intensive care units (ICU). Methods that have been applied thus far for assessing nutritional status, also used in severely ill septic patients, have little impact on improving treatment results. This is due to the high dynamics of changes in nutritional status in these patients, healing process variability in individual patients, and the “mismatch” of methods for assessing nutritional status in relation to the patient’s clinical status. The diagnostic value of the traditional methods of assessing nutritional status, i.e. anthropometric analysis and selected laboratory tests, as markers of nutritional status disorders in septic patients, is still debatable. There is still no precise method that could become the “gold standard” allowing for early identification of malnutrition in these group of patients. Phase angle, bioelectrical impedance vector analysis (BIVA), and the “illness marker”, obtained directly from the resistance, reactance, and impedance, can be used as prognostic or nutritional indices in severely ill septic patients, but the intensity of research on this subject needs to be increased. Detailed assessment of nutritional status should include tests of selected inflammation markers (including TLC, HMGB1, IL-6, IL-10, IL-1ra, sTNFRI).

Defining malnutrition: A plea to rethink

In a recent consensus report in Clinical Nutrition the undernourished category of malnutrition was proposed to be defined and diagnosed on the basis of a low BMI or unintentional weight loss combined with low BMI or FFMI with certain cut off points. The definition was endorsed by ESPEN despite recent endorsement of a very different definition. The approach aims to assess whether nutritional intake is sufficient but is imprecise because a low BMI does not always indicate malnutrition and individuals with increasing BMI's may have decreasing FFM's. The pathophysiology of individuals, considered to be malnourished in rich countries and in areas with endemic malnutrition, results predominantly from deficient nutrition combined with infection/inflammation. Both elements jointly determine body composition and function and consequently outcome of disease, trauma or treatment. When following the consensus statement only an imprecise estimate is acquired of nutritional intake without knowing the impact of inflammation. Most importantly, functional abilities are not assessed. Consequently it will remain uncertain how well the individual can overcome stressful events, what the causes are of dysfunction, how to set priorities for treatment and how to predict the effect of nutritional support. We therefore advise to consider the pathophysiology of malnourished individuals leading to inclusion of the following elements in the definition of malnutrition: a disordered nutritional state resulting from a combination of inflammation and a negative nutrient balance, leading to changes in body composition, function and outcome. A precise diagnosis of malnutrition should be based on assessment of these elements.

Malnutrition as a Precursor of Pressure Ulcers

Significance: Numerous studies have reported associations between declining nutrition status and risk for pressure ulcers. Oral eating problems, weight loss, low body weight, undernutrition, and malnutrition are associated with an increased risk for pressure ulcers. Moreover, inadequate nutrient intake and low body weight are associated with slow and nonhealing wounds. However, the biologic significance of deterioration in nutrition status and consistent methodologies to quantify malnutrition and diminished micronutrient stores as predictors of skin breakdown remains controversial. Recent Advances: The Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (ASPEN) Consensus Statement: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition provide a standardized and measureable set of criterion for all health professionals to use to identify malnutrition. The Agency for Healthcare Research and Quality identified malnutrition as one of the common geriatric syndromes associated with increased risk for institutionalization and mortality that may be impacted by primary and secondary preventions. Critical Issues: The purpose of this article is to examine the Academy/ASPEN consensus statement on characteristics of adult malnutrition in the context of the National Pressure Ulcer Advisory Panel (NPUAP)/European Pressure Ulcer Advisory Panel (EPUAP) Guidelines on the Prevention and Treatment of Pressure Ulcers. Future Directions: Moreover, clinicians, and in particular, registered dietitians have the opportunity to integrate the Characteristics of Malnutrition with the NPUAP/EPUAP 2009 Prevention and Treatment Clinical Practice Guidelines, into clinical assessment and documentation using the Nutrition Care Process. Consensus guidelines will provide consistent research criteria yielding more useful data than presently available.

Recognizing malnutrition in adults: definitions and characteristics, screening, assessment, and team approach

Appropriate recognition of malnutrition in adults requires knowledge of screening and assessment methodologies. An appreciation for the contributions of inflammation has resulted in a new etiology-based approach to defining malnutrition syndromes. The Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) have published a consensus document that extends this approach to describe characteristics for the identification and documentation of malnutrition in adults. Nutrition screening tools are used to identify patients at nutrition risk and those who are likely to benefit from further assessment and intervention. Nutrition assessment serves to guide appropriate intervention. A systematic approach to nutrition assessment that supports the new diagnostic scheme and criteria from the Academy and A.S.P.E.N. has recently been presented. Since screening delays and failures in the diagnosis and management of malnutrition are all too common, a multidisciplinary team approach is recommended to promote improved communication and quality of care.

Serum albumin levels and 10-year tooth loss in a 70-year-old population

Serum albumin levels are a practical marker of general health status in the elderly and have been used to determine the severity of underlying diseases and the risk for death. This longitudinal study evaluated the relationship between serum albumin concentrations and tooth loss over 10 years in elderly subjects, after controlling for confounding factors. A sample of 554 dentate subjects among enrolled subjects (n = 600) was involved in this planned longitudinal study with follow-up examinations after 5 and 10 years. At the 5-year follow-up, 373 (67·3%), subjects were available for re-examination. In addition, 331 (59·7%) were available at the 10-year follow-up. Multiple Poisson regression analysis was conducted to evaluate the relationship between the number of missing teeth over 5 or 10 years and serum albumin levels at baseline after adjusting for 10 variables: gender, serum markers levels at baseline, dental status, smoking habits and educational years and oral health behaviour. The number of missing teeth over 5 or 10 years was significantly negatively associated with serum albumin levels at baseline [incidence rate ratios (IRR) = 0·373, P < 0·0001 for 5 years; IRR = 0·570, P < 0·0001 for 10 years]. We conclude that elderly subjects with hypoalbuminemia are at high risk for 5- and 10-year tooth loss.

Nonsteroidal anti-inflammatory drug (NSAID) use and sarcopenia in older people: results from the ilSIRENTE study

BACKGROUND

Recently, a great deal of attention has been paid to the role of inflammatory processes in the pathophysiology of sarcopenia. The aim of the present study was to examine the relationship between NSAID use and sarcopenia in a large sample of community-dwelling elderly people aged 80 years or older.

METHODS

Data are from the baseline evaluation of 354 individuals enrolled in the ilSIRENTE Study. Following the recommendations of the European Working Group on Sarcopenia in Older People (EWGSOP), the diagnosis of sarcopenia was established on the basis of low muscle mass plus either low muscle strength or low physical performance. The relationship between NSAID use and sarcopenia was estimated by deriving odds ratios (ORs) from multiple logistic regression models considering sarcopenia as the dependent variable.

RESULTS

Nearly 12% (n = 44) of the study sample used NSAIDs. Using the EWGSOP-suggested algorithm, 103 individuals (29.1%) with sarcopenia were identified. Ninety-nine (31.9%) participants were affected by sarcopenia among non-NSAID users compared with 4 participants (9.1%) among NSAID users (P < .001). Compared with all nonusers, NSAID users had a nearly 80% lower risk of being affected by sarcopenia (OR 0.21, 95% CI 0.07-0.61). After adjusting for potential confounders, NSAID users had a lower risk of sarcopenia compared with nonusers (OR 0.26, 95% CI: 0.08-0.81).

CONCLUSIONS

The results are consistent with the hypothesis that long-term NSAID use might have a protective effect against the loss of muscle mass and function. Interventions able to reduce inflammation-related adverse outcomes at muscle level may be warranted.

Frailty, sarcopenia, and hormones

Frailty is now a definable clinical syndrome with a simple screening test. Age-related changes in hormones play a major role in the development of frailty by reducing muscle mass and strength (sarcopenia). Selective Androgen Receptor Molecules and ghrelin agonists are being developed to treat sarcopenia. The role of Activin Type IIB soluble receptors and Follistatin-like 3 mimetics is less certain because of side effects. Exercise (resistance and aerobic), vitamin D and protein supplementation, and reduction of polypharmacy are keys to the treatment of frailty.

Changes in activities of daily living, nutrient intake, and systemic inflammation in elderly adults receiving recuperative care

OBJECTIVES

To determine the relationships between physical function, systemic inflammation, and nutrient intake in elderly adults who are deconditioned or recovering from medical illness.

DESIGN

Prospective observational study.

SETTING

Recuperative care and rehabilitation setting of a Veterans Affairs hospital.

PARTICIPANTS

Older adults assessed to be in need of and likely to benefit from specialized inpatient care (N = 336, aged 78.9 ± 7.5, median length of stay 24 days).

MEASUREMENTS

Functional assessments and plasma analyses for albumins and inflammatory markers were performed at admission and discharge. Complete nutrient intake assessments were performed daily. Katz (independence in activities of daily living) and walking endurance (distance capability and summation of need for assistive device and human help) scores were based on direct observation and provider query. Data were analyzed using least-squares and logistic regression analyses.

RESULTS

Changes in physical function between admission and discharge were positively correlated with change in nutrient intake and inversely correlated with inflammation at admission and its change. Participants in the upper quartile of change for nutrient intake (particularly improved protein intake) were two to three times as likely to experience a clinically significant change in functional status during the hospitalization. Similarly, the odds of experiencing an improvement in physical function were two to four times as great for participants whose C-reactive protein levels declined as for those whose levels increased. These relationships remained significant after controlling for age, length of stay, and other baseline indicators of health status.

CONCLUSION

Protein intake and inflammation are significantly correlated with functional recovery for aging individuals undergoing recuperative care and rehabilitation. Future studies should investigate whether combined interventions that target these factors improve recovery during hospitalization for this population.

Serum albumin in relation to change in muscle mass, muscle strength, and muscle power in older men

OBJECTIVES

To investigate the relationship between serum albumin and change in muscle mass, grip strength, and leg power.

DESIGN

Prospective cohort.

SETTING

Six U.S. academic medical centers.

PARTICIPANTS

Community-dwelling men aged 65 and older participating in the Osteoporotic Fractures in Men (MrOS) Study.

MEASUREMENTS

Serum albumin was measured at baseline in 5,534 participants. Baseline serum albumin was examined in relation to change in appendicular skeletal muscle (ASM) mass, grip strength, and leg power after 2 and 4.6 years. Two-year change in serum albumin was examined with respect to simultaneous change in these outcomes in 1,267 participants.

RESULTS

Baseline serum albumin <40 g/L was not associated with 2- or 4.6-year change in ASM mass, grip strength, or leg power before or after adjustment for confounders. There was no association between serum albumin change and change in grip strength. A statistically significant trend was observed between serum albumin change and change in ASM mass, but there was substantial overlap across confidence intervals (CIs). Participants with a marked decrease (>3 g/L) and mild decrease (1-2 g/L) in serum albumin over 2 years exhibited a modest change of -8.9 W (95% CI = -25.6 to -7.8 W) and -6.3 W (95% CI = -21.2 to -8.5 W) of leg power, respectively (P for trend = .02), compared with those with no decrease in albumin concentration.

CONCLUSION

Serum albumin demonstrated modest and inconsistent trends with loss of muscle mass and function. Low serum albumin within the normal range is not a risk factor for this process in elderly men.

Evaluation of nutritional status and skin condition among elderly residents in a long-term care hospital

OBJECTIVE

The availability of nutritional screening tools for older adults is limited, depending on their physical characteristics or the setting. We investigated the relationships between various nutritional indicators and skin conditions as possible screening indicators.

DESIGN

Cross-sectional study.

SETTING

A long-term care hospital in Japan.

PARTICIPANTS

90 elderly residents who were aged ≥65 years old.

MEASUREMENTS

The nutritional status of the residents was assessed by body mass index (BMI), involuntary weight loss, arm muscle area, and serum albumin and prealbumin levels. Leg skin condition was evaluated by: 1) functional factors including pH, hydration and transepidermal water loss; 2) skin color including L*, a*, b* and individual typology angle (ITA°) using a tristimulus colorimetric instrument; and 3) skin morphology. Repeated measures analysis of variance was employed, adjusted for demographic characteristics and room temperature, with measurement site as the repeated variable.

RESULTS

Among the skin indicators, b* was significantly correlated with BMI (p=0.018), and weight loss over the previous month (p=0.042) and 6 months (p=0.002). Additionally, ITA° was associated with weight loss over 1 month (p=0.013). Both b* and ITA° showed the area under the receiver operating characteristic curve of 0.64 to 0.80 for weight loss >2% over 1 month.

CONCLUSIONS

Residents with poorer nutritional status had yellower and darker skin color.

Serum albumin level is a limited nutritional marker for predicting wound healing in patients with pressure ulcer: two multicenter prospective cohort studies

BACKGROUND & AIMS

We aimed to investigate the predictive validity of serum albumin for pressure ulcer healing, according to patient condition and wound characteristics.

METHODS

This study was a secondary analysis of pooled data from two multicentre cohort studies undertaken in 2005 and 2007. All adult patients with pressure ulcer were included and were tracked until wound healing or discharge from care. Baseline serum albumin data were obtained from medical charts.

RESULTS

A total of 2530 patients were analyzed. By multivariate Cox proportional hazards analysis, higher serum albumin level was associated with wound healing of only superficial pressure ulcers for patients in acute/postoperative conditions (hazard ratio 1.29, 95% confidence interval 1.13-1.46) and the cutoff point was 24/25 g/L. However, the addition of serum albumin level to other factors resulted in little increase in the ability to predict wound healing as measured by the overall C-statistics. For patients in chronic/palliative conditions, serum albumin level as the continuous variable was not significantly associated with ulcer healing.

CONCLUSIONS

The addition of serum albumin marker may not have much advantage to predict pressure ulcer healing although its level can be associated with ulcer healing, depending on patient condition and wound depth.

The Interrelationships among albumin, nutrient intake, and inflammation in elderly recuperative care patients

OBJECTIVES

To examine the interrelationships among low serum albumin, nutritional depletion, and ongoing inflammation in older patients recovering from illness.

DESIGN

A prospective cohort study.

SETTING

A transitional care unit (TCU) within a Department of Veterans Affairs hospital nursing home care unit.

PARTICIPANTS

275 older veterans (mean age=78.9 ± 7.5y, 99% male) admitted for recuperative care and rehabilitation.

MEASUREMENTS

At admission and discharge (median LOS 24d, IQR 16 to 44d), each subject completed a comprehensive standardized evaluation including a nutritional assessment and measurement of serum albumin, C-reactive protein (CRP), interleukin-6 (IL-6) and its soluble receptor, and tumor necrosis factor-alpha (TNF-α) and its soluble receptors (sTNF-RI and II). Complete nutrient intake assessments (calorie counts) were performed daily.

RESULTS

Both the discharge albumin and the change in albumin (discharge minus admission) were strongly and inversely correlated with various indicators of inflammation, particularly CRP and IL-6. Change in CRP was the strongest correlate of change in albumin (R2 = 0.21, P<.001) and discharge IL-6 the strongest correlate of discharge albumin (R2 = 0.21, P<.001). Nutrient intake also correlated with albumin and its change, but entered the multivariable models after inflammatory indicators and explained a smaller portion of the variance. Although there were significant interactions between time and both nutrient intake and inflammation, the relative importance of inflammation as a potential determinant of the serum albumin concentration appeared to remain unchanged with longer periods of observation.

CONCLUSIONS

Among elderly patients admitted to a TCU, inflammation appears to be a more powerful determinant of albumin and its change during the hospitalization than is nutrient intake. Further study is needed to prove causality and to determine whether the relative importance of inflammation on the albumin concentration diminishes with more prolonged periods of observation.

Comparative analysis of serum proteomes of patients with cardiovascular disease

OBJECTIVES

To monitor increases or decreases in cardiovascular disease (CVD)-related proteins that will be released from the deposits or plaque on the inner wall of blood vessels.

DESIGN AND METHODS

Protein profiles of sera from healthy subjects and CVD patients were determined via 2-DE. Differentially expressed spots in CVD patients were identified by ESI-Q-TOF MS/MS. Retinol binding protein 4 (RBP4), ceruloplasmin, and hemopexin were confirmed by Western blotting and RBP4 was further verified by ELISA.

RESULTS

Approximately, 400 spots were detected in each gel via comparisons of the serum proteome. Among these spots, 19 spots were selected and identified by ESI-Q-TOF MS/MS (P<0.05). The expression levels of RBP4 and ceruloplasmin were higher in CVD patients by Western blotting. The level of immunoreactive RBP4 in CVD patients was higher than that in healthy subjects.

CONCLUSIONS

The three proteins identified in the present study may constitute potential biomarkers for the diagnosis of CVD in patients.

Relationship between admission albumin levels and rehabilitation outcomes in older patients

The relationship between serum albumin level and rehabilitation outcome in older patients has not been fully explored. This study investigated this association in older Chinese patients. We studied 1604 patients in two geriatric convalescence hospitals. Admission albumin levels (g/l) were measured and segregated into three groups: <30 g/l; 30 to <35 g/l; ≥35 g/l. Absolute functional and motor gain were determined by Barthel index (BI) and elderly mobility scale (EMS) and expressed as BI efficacy and EMS efficacy. BI and EMS efficiency were deduced by the efficacy divided by the length of hospital stay (LOS). Satisfactory motor and functional outcomes were defined as discharge EMS≥15 and BI≥75. Significant improvement in EMS and BI scores across all 3 albumin groups on discharge was observed, with lower scores in low albumin groups. The EMS and BI efficacy were the same in 3 albumin groups. However, EMS and BI efficiency were higher in the high albumin groups. Admission albumin was not independent predictors for satisfactory motor and functional outcomes. For satisfactory motor outcome (EMS≥15), female gender (p=0.0004), age (p=0.0009) and urinary incontinence (p=0.0076) were negative predictors while living at home (p=0.0028), admission EMS (p<0.001) and BI score (p=0.0004) were positive predictors. For satisfactory functional outcome (BI≥75), age (p=0.015) and urinary incontinence (p<0.001) were negative predictors while female gender (p=0.0024), LOS (p=0.033), C-MMSE (p<0.001), admission EMS (p=0.003) and BI (p<0.001) were positive predictors. Admission albumin levels were related to functional and motor efficiency, but not with absolute functional and motor gain. Albumin was not an independent predictor for satisfactory motor and functional outcome.

Serum albumin levels as an independent predictor of 4-year mortality in a community-dwelling 80-year-old population

BACKGROUND AND AIMS

Although serum albumin levels are associated with mortality in non-institutionalized elderly people under 80 years old, as well as in the institutionalized very elderly, little is known about the relationship in community-dwelling very elderly people. We, therefore, examined the association in a Japanese population of 80-year-old community residents.

METHODS

Serum albumin levels were measured in 672 (267 men, 405 women) out of 1282 80-year-old individuals. Over the following 4 years, the dates and causes of death were recorded from resident registration cards and official death certificates.

RESULTS

Of the above individuals, 107 subjects died (58 men, 49 women: 27 due to cancer, 27 cardiovascular disease, and 22 pneumonia). Survival rates were compared among 4 groups (highest >or=45 g/L, higher than 43-44 g/L, lower than 41-42 g/L, lowest <or=40 g/L). After adjustment for confounding factors, total death or cardiovascular death in the lowest albumin group was 3.1 times and 10.7 times more incident than in the highest albumin group, but there were no differences among groups as regards deaths due to cancer or pneumonia.

CONCLUSION

Serum albumin levels are an independent predictor of mortality due to all-cause or cardiovascular disease, but not of mortality due to cancer or pneumonia in very elderly Japanese community residents.

Estimation of protein loss from wound fluid in older patients with severe pressure ulcers

OBJECTIVE

Protein loss from wound fluid is usually recognized as one of the factors contributing to the deterioration of the nutritional status in older patients with severe pressure ulcers. We quantified the protein loss owing to pressure ulcers and investigated associations with wound-related factors and nutritional status.

METHODS

This cross-sectional study included 25 patients (>or=60 y) from 10 institutions, with full-thickness pressure ulcers. Wound fluid was collected once after accumulating beneath a film dressing. The amount of protein loss per day was estimated by the volume of wound fluid per hour and the total protein concentration in the wound fluid. Wound evaluations and nutritional assessments were performed. Correlations between variables were obtained using Spearman's rank correlation.

RESULTS

The median age of the patients was 79 y (range 61-100), and median body mass index was 19.6 kg/m(2) (12.2-24.9). The median amount of protein loss was 0.2g/d (0.04-2.1), which corresponded to 0.01 g x kg(-1) x d(-1) (<0.01-0.04) and 0.6% (0.1-13.8) of protein intake. Four wounds characterized as infected or surgically debrided lost 1.5-2.1g of protein per day, which was substantially higher than other wounds lost. Protein loss was correlated with wound severity including area, depth, the wound severity score, and infectious markers (all Ps<0.05), but not with body mass index or arm muscle circumference (P>0.05).

CONCLUSION

The amount of protein loss could be small and thus may not be related directly to nutritional status, although it increased as the wound became more severe.

Sex differences in the association between albumin and all-cause and vascular mortality

BACKGROUND

Low serum albumin levels are associated with cardiovascular disease and mortality risk. This study evaluated the predictive value of low serum albumin for all-cause-mortality in a large Viennese patient cohort and investigated sex differences in the association between serum albumin and mortality.

MATERIALS AND METHODS

Serum albumin concentrations of 285 930 patients, who attended the General Hospital Vienna between 1992 and 2002, were evaluated and linked with the Austrian Death Registry. The median observation period was 7.4 +/- 4.0 years and the death rate was 16.8%. For Cox regression analysis, albumin levels were divided into deciles, the highest category served as reference value. To analyse associations between albumin and mortality independent of liver function, results were adjusted for cholinesterase, which indicates protein synthesis capacity of the liver.

RESULTS

Hazard ratios for all-cause-mortality increased linearly with decreasing albumin levels from 1.05 in the 9th to 2.98 in the 1st decile. Adjusted for cholinesterase, the relative risk for mortality was still 1.91 in the lowest category. Compared with women, men had an average 50% increased risk of death in almost every decile, adjusting for cholinesterase reduced the sex difference to a 10-20% higher mortality risk for men. In critically ill patients, hazard ratios for all-cause-mortality ranged from 4.5 in the 9th decile to 9.5 in the lowest albumin category.

CONCLUSION

This study demonstrates a strong inverse association between serum albumin and mortality in a large patient cohort. The predictive value of low albumin was remarkably higher in men than in women.

The prognostic value of C-reactive protein in long-term care patients requiring prolonged mechanical ventilation

C-reactive protein (CRP), a biomarker of inflammation, has predicted mortality in end-stage respiratory failure and in the critically ill patients. Our aim was to investigate if CRP can predict morbidity and mortality in patients requiring prolonged mechanical ventilation. A prospective study conducted in a ventilator weaning unit of a skilled nursing facility over 13 months included 98 patients older than 18 years of age requiring mechanical ventilation via tracheostomy. Serum CRP and albumin levels were tested on admission. Age, gender, body mass index (BMI), and diagnoses causing respiratory failure were recorded. The outcomes measured were as follows: hospitalization, weaned from mechanical ventilation, and death. Our population had a median age of 77 years and the median BMI, albumin, and mean CRP were 26 kg/m2, 2.25 g/dL, and 5.75 mg/dL, respectively. The most common diseases leading to respiratory failure were pulmonary, neurologic, and cardiac. The patients with the empiric cutoff CRP of <2 mg/dL ( n = 14) had 0% hospitalization rate at 2 weeks and 7% at 30 days, whereas the patients with CRP ≥ 2 mg/dL ( n = 84) had 26% hospitalization rate at 2 weeks and 38% at 30 days. Mortality for the patients with CRP ≥ 2 mg/dL was 26% at 60 days, whereas the CRP < 2 mg/dL patients had no mortality at 60 days ( P = 0.034). The patients who survived 60 days ( n = 70) had significantly lower median CRP levels than the nonsurvivors (4.1 mg/dL vs 8.5 mg/dL, P = 0.009). The area under the receiver operating characteristic (ROC) curve for CRP levels predicting 2-week hospitalization was not large at 0.617 and the optimum CRP cutoff point was >2.7 mg/dL. The sensitivity and negative predictive value of the 2-week hospitalization outcome were equally high at 96%. The area under the ROC curve for 60-day survival was 0.691, and its optimum CRP cutoff point was >3.7 mg/dL with 85% sensitivity and 91% negative predictive value. CRP was not able to predict weaning success in this setting where the 60-day weaning rate was 9%. A CRP level of ≤2.7 mg/dL may be used to screen for patients who are not likely to develop acute illness requiring early 2-week rehospitalization, and a CRP level of ≤3.7 mg/dL may be used to predict 60-day survival in patients with respiratory failure requiring prolonged mechanical ventilation in the long-term care setting.

A rational approach to nutritional assessment

BACKGROUND & AIMS

Consensus regarding definitions of malnutrition and methods to assess nutritional state is lacking. We propose a definition and its operationalization.

METHODS

A definition was formulated on the basis of the pathophysiology of malnutrition, while reviewing the metabolic and physiological characteristics of different populations, considered to be malnourished. The definition was operationalized to yield measures to perform nutritional assessment.

RESULTS

Malnutrition was defined as "a subacute or chronic state of nutrition in which a combination of varying degrees of over- or undernutrition and inflammatory activity has led to a change in body composition and diminished function". Its operationalization led to four elements that may serve as the basis of nutritional assessment: (1) measurement of nutrient balance, (2) measurement of body composition, (3) measurement of inflammatory activity, and (4) measurement of muscle, immune and cognitive function. Most elements measured should be validated with gold standards; normal values should be obtained in different populations. Values obtained in people considered to be at nutritional risk should be related to outcome.

CONCLUSION

A definition is proposed that reflects the pathophysiology of malnutrition and that, when operationalized, will lead to measures reflecting this pathophysiology. Such an approach may yield comparable and reproducible rates and degrees of malnutrition in populations as well as in individuals.