Laboratory tests and nutritional assessment. Protein-energy status

Peri-Operative Fall in Serum Albumin Levels Correlate Well With Outcomes in Children Undergoing Emergency Abdominal Surgery: A Prospective Study From a Resource-Limited Setting

Background

Albumin is a negative acute-phase protein as its levels fall after injury, sepsis, and surgical stress. A review of the literature suggests that serum albumin level drops rapidly after surgery in adults and correlates well with the outcomes. However, there is limited data on the use of peri-operative fall in serum albumin levels as an outcome predictor in children undergoing emergency abdominal surgeries. We aim to investigate the correlation between the degree of peri-operative fall in serum albumin levels and the outcomes in children undergoing emergent abdominal surgeries.

Materials and methods

This prospective study included all children aged 2-15 years undergoing emergent abdominal surgeries between January 2019 to June 2020 at our center. Preoperative serum albumin level (A1) was recorded for all children. Postoperative day 0 serum albumin level (A2) was sent 4-6 hours following the surgery. The degree of peri-operative fall in serum albumin level (∆A) was calculated by subtracting A2 from A1. Patients were then grouped on the basis of ∆ A, i.e. groups 1 and 2 with ∆ A < 0.5 and ≥ 0.5 gm/dl respectively. Additional data like diagnosis, surgical procedure, duration of surgery, complications, and length of hospital stay were also recorded. Recorded parameters in group 1 were then compared to group 2 statistically.

Results

Fifty-six children (male to female ratio {M:F} = 1.5:1), who met the inclusion criteria during the study period, were included in the study. Groups 1 and 2 comprised 38 and 18 children respectively. The postoperative serum albumin levels were significantly lower in group 2 (p = 0.0005). Duration of surgery was significantly higher in group 2 (p = 0.0474). Complications and length of hospital stay were significantly higher in group 2 (p = 0.0107 and p = 0.0375 respectively).

Conclusion

The present study evaluated the fall in peri-operative serum albumin level (∆A) in children undergoing emergent abdominal surgery as a marker of stress. Higher values of ∆A (≥ 0.5 gm/dl) depicted a significant correlation with complications requiring re-laparotomy and a longer length of hospital stay. 

Severe Protein-Calorie Malnutrition-Associated Hepatic Steatosis in a Woman Who Had Roux-en-Y Gastric Bypass for Morbid Obesity Thirteen Years Ago

Hepatic steatosis is common in everyday liver pathology practice. There are many etiologies leading to hepatic steatosis. These etiologies include metabolic syndrome, alcohol, medications, monogenetic disease, infectious diseases, and malnutrition. Correct diagnosis of underlying etiology through clinicopathological correlation is key to adequate treatment and optimal outcome for the patient. In this case report, we describe severe protein-calorie malnutrition as an etiology for hepatic steatosis in a middle-aged woman who presented with lethargy, low body mass index (15.8 kg/m²), abdominal distention and bilateral lower extremity edema, hyperammonemia, and hypoalbuminemia, 13 years after Roux-en-Y gastric bypass for morbid obesity. Laboratory tests revealed hyperammonemia, hypoalbuminemia, and low ceruloplasmin levels. Hemodynamic measurement demonstrated high hepatic venous pressure gradient of 12 mm Hg. Transjugular liver biopsy showed moderate macrovesicular steatosis, mild siderosis, and abundant lipofuscin but no evidence of fibrosis, cirrhosis, or steatohepatitis. This patient was treated with lactulose and enteral feeding, however, the patient died of progressive liver failure 3 weeks after admission. We also review relevant literature to help diagnose protein-calorie malnutrition (kwashiorkor) and hepatic steatosis as a possible late complication of Roux-en-Y gastric bypass. In patients with hepatic steatosis, encephalopathy, hyperammonemia and portal hypertension, malnutrition should be considered as an etiology and diagnosed with a synthesis of clinical, pathological, and laboratory information. Kwashiorkor is a severe disease and should be treated promptly as it may be fatal as in our case.

Molecular Mechanisms and Treatment of Sarcopenia in Liver Disease: A Review of Current Knowledge

Sarcopenia is characterized by progressive and generalized loss of skeletal muscle mass and strength that occurs with aging or in association with various diseases. The condition is prevalent worldwide and occurs more frequently in patients with chronic diseases owing to the intrinsic relationship of muscles with glucose, lipid, and protein metabolism. Liver cirrhosis is characterized by the progression of necro-inflammatory liver diseases, which leads to fibrosis, portal hypertension, and a catabolic state, which causes loss of muscle tissue. Sarcopenia is of significant concern in the state of liver cirrhosis because sarcopenia has been associated with higher mortality, increased hospital admissions, worse post-liver transplant outcomes, decreased quality of life, and increased risk for other complications associated with cirrhosis. Therefore, sarcopenia is also an important feature of liver cirrhosis, representing a negative prognostic factor and influencing mortality. An increased understanding of sarcopenia could lead to the development of novel therapeutic approaches that could help improve the cognitive impairment of cirrhotic patients; therefore, we present a review of the mechanisms and diagnosis of sarcopenia in liver disease and existing therapeutic approaches.

Serum albumin perturbations in cyanotics after cardiac surgery: Patterns and predictions

INTRODUCTION

Hypoalbuminemia is a well-recognized predictor of general surgical risk and frequently occurs in patients with cyanotic congenital heart disease (CCHD). Moreover, cardiopulmonary bypass (CPB)-induced an inflammatory response, and the overall surgical stress can effect albumin concentration greatly. The objective of his study was to track CPB-induced changes in albumin concentration in patients with CCHD and to determine the effect of hypoalbuminemia on postoperative outcomes.

MATERIALS AND METHODS

Prospective observational study conducted in 150 patients, Group 1 ≤18 years (n = 75) and Group 2 >18 years (n = 75) of age. Albumin levels were measured preoperatively (T1), after termination of CPB (T2) and 48 h post-CPB (T3). Primary parameters (mortality, duration of postoperative ventilation, duration of inotropes and duration of Intensive Care Unit [ICU] stay) and secondary parameters (urine output, oliguria, arrhythmias, and hemodynamic parameters) were recorded.

RESULTS

The albumin levels in Group 1 at T1, T2, and T3 were 3.8 ± 0.48, 3.2 ± 0.45 and 2.6 ± 0.71 mg/dL; and in Group 2 were 3.7 ± 0.50, 3.2 ± 0.49 and 2.7 ± 0.62 mg/dL respectively. All patients showed a significant decrease in albumin concentration 48 h after surgery (P < 0.01). Analysis between the groups, however, showed no statistical difference. Eleven patients expired during the study period, and nonsurvivors showed significantly lower serum albumin concentration 48 h after surgery 2.3 ± 0.62 mg/dL versus 3.7 ± 0.56 mg/dL in the survivors (P < 0.05). Receiver operating characteristic curve showed that a baseline albumin cut-off value of 3.3 g/dL predicts mortality with a positive predictive value 47.6% and a negative predictive value of 99.2% (P < 0.05). A strong correlation was seen between albumin levels at 48 h with duration of CPB (r2 = 0.6321), ICU stay (r2 = 0.7447) and incidence of oliguria (r2 = 0.8803).

CONCLUSIONS

The study demonstrated similar fall in albumin concentration in cyanotic patients (both adult and pediatric) in response to CPB. Low preoperative serum albumin concentrations (<3.3 g/dL) can be used to identify and prognosticate subset of cyanotics predisposed to additional surgical risk.

Construction of a synthetic phage-displayed Nanobody library with CDR3 regions randomized by trinucleotide cassettes for diagnostic applications

Background

Nanobodies (Nbs) have proved their great value as therapeutic molecules and clinical diagnostic tools. Although the routine procedure to obtain Nbs is to immunize camels with antigens, it is unavailable to immunize a camel when the antigens are highly toxic, pathogenic or nonimmunogenic. A synthetic phage display library is an alternative to generate Nbs against such targets, besides all the other ones.

Methods

We constructed a large and diverse synthetic phage display Nanobody (Nb) library based on the conserved camel single-domain antibody fragment (VHH) framework of cAbBCII10. Diversity was introduced in the complementarity-determining region 3 (CDR3) by means of randomization of synthetic oligonucleotides. Then human prealbumin (PA) and neutrophil gelatinase-associated lipocalin (NGAL) were used to select specific Nbs from this library. Furthermore, a sandwich enzyme-linked immunosorbent assay (ELISA) was developed to detect PA based on horseradish peroxidase (HRP)-conjugated anti-PA Nb isolated from this study and another biotinylated anti-PA Nb obtained from an immune library, in our previous study.

Results

A large and diverse synthetic phage display Nb library with CDR3 regions randomized by trinucleotide cassettes was constructed. The library size was 1.65 × 10⁹ CFU/mL and the correct insertion ratio was nearly 100%. A Nb against human PA and against NGAL was successfully isolated from the synthetic library. The obtained anti-PA Nb was effectively used to develop a sandwich ELISA for PA detection and it demonstrated a working range from 50 to 1000 ng/mL, with a limit of detection (LOD) of 27.1 ng/mL.

Conclusion

This proposed novel synthetic library was a good source for obtaining some antigen-specific Nbs. This approach could provide crucial support to an immune library and a naïve library in the acquisition of specific Nbs, potentially functioning as a great resource for medical diagnostic applications. In addition, we have successfully developed a novel sandwich ELISA to detect PA, which could provide great assistance for clinical PA detection.

Post-operative endothelial dysfunction assessment using laser Doppler perfusion measurement in cardiac surgery patients

BACKGROUND

Coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB) is associated with systemic inflammatory response and endothelial dysfunction. Our hypothesis is that CPB-induced post-operative endothelial dysfunction may be detected using laser Doppler perfusion monitoring (LDPM) in the skin microcirculation.

METHODS

We used LDPM to investigate the subacute effects of the CPB on systemic microvascular reactivity among patients undergoing CABG surgery with CPB. Thirty patients were submitted to the study of skin microcirculation and blood sample collection at baseline (pre-surgery) and at 7 days post-surgical procedure. The skin microcirculation was evaluated by acetylcholine (ACh) and sodium nitroprusside (SNP) iontophoresis, and thermal hyperemia (TH). Plasma levels of nitrite/nitrate were also analyzed, and cytokine profiles were determined using a multiplex system.

RESULTS

On-pump CABG surgery induced a significant reduction of the increased microvascular dermal flux observed after cumulative doses of ACh iontophoresis and after TH. On-pump CABG surgery did not induce any significant changes in the microvascular flux after cumulative doses of SNP. Patients still presented high levels of interleukin (IL)-6, IL-8, and C-reactive protein, and low bioavailability of nitric oxide 7 days after the CABG surgery with CPB.

CONCLUSION

We observed a significant impairment of systemic microvascular endothelial function and well-preserved endothelium-independent vasodilatation in the skin microcirculation of patients 1 week after CABG surgery with CPB. Our results suggest that LDPM is a useful tool for the assessment of on-pump CABG-induced subacute post-operative endothelial dysfunctions.

Undernutrition in Santal children: a biochemical and hematological study

The nutritional status of the children can be measured by biochemical and hematological parameters and dietary assessment. The objectives of the present study were to evaluate the causes of the undernutrition in the surveyed Santal children, where high degree of undernutrition exists, by measuring selected hematological and biochemical parameters and dietary intake. Nutritional status was assessed by height-for-age Z-score. Total count of red blood cells (RBC count), packed cell volume (PCV), hemoglobin concentration (Hb%), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH) and mean corpuscular hemoglobin concentration (MCHC) were measured. Biochemical parameters such as serum iron, total iron binding capacity (TIBC), serum ferritin, serum transferrin, transferrin saturation (TS) and serum albumin were also measured. Serum iron, serum ferritin, transferrin saturation, hemoglobin level and serum albumin of stunted children were significantly lower (p<0.05) than those in children of normal stature. Total iron binding capacity and serum transferrin of stunted children were significantly higher (p<0.05) than the values in children of normal stature. More than 29% of surveyed children were suffering from iron deficiency. Hemoglobin concentration was found to be strongly associated (p<0.001) with the nutritional status. Dietary intake of almost all nutrients in all age groups was found to be lower than the recommended dietary allowances (RDA) in both sexes. A mild iron deficiency was found in stunted Santal children. The stunting may be associated with the deficiency of specific nutrients such as iron and protein in surveyed Santal children.

Nutritional therapy improves growth and protein status of children with a urea cycle enzyme defect

BACKGROUND

Poor growth has been described in patients with urea cycle enzyme defects treated with protein-restricted diets, while protein status is seldom reported.

OBJECTIVE

To assess the effects of nutritional therapy with a medical food on growth and protein status of patients with a urea cycle enzyme defect.

METHODS

A 6-mo multicenter outpatient study was conducted with infants and toddlers managed by nutrition therapy with Cyclinex-1 Amino Acid-Modified Medical Food with Iron (Ross Products Division, Abbott Laboratories, Columbus, OH). Main outcome variables were anthropometrics and plasma amino acids (selected), albumin, and transthyretin concentrations.

RESULTS

Seventeen patients completed the study. Mean (+/-SE) baseline age was 11.30+/-3.20 months (median 4.40 months; range 0.22-38.84 months). Length and weight z-scores increased significantly during the 6-month study. Head circumference increased, but not significantly. Three patients were stunted and two were wasted (-2.0 z-score) at baseline while at study end, only one patient was both stunted and wasted. The majority of patients increased in length, head circumference, and weight z-scores during study. Mean (+/-SE) plasma albumin concentration increased from 34+/-2g/L at baseline to 38+/-1g/L at study end. Plasma transthyretin increased from a mean (+/-SE) of 177+/-13 mg/L at baseline to 231+/-15 mg/L at study end. No correlation was found between plasma NH(3) concentrations and medical food intake. Plasma NH(3) concentration was positively correlated with the percentage of Food and Agriculture Organization/World Health Organization/United Nations recommended protein ingested.

CONCLUSIONS

Intakes of adequate protein and energy for age result in anabolism and linear growth without increasing plasma NH(3) concentrations. Medical food intakes did not correlate with plasma NH(3) concentrations.

Serum albumin and clinical outcome in pediatric cardiac surgery

OBJECTIVE

We evaluated the behavior of serum albumin concentrations in response to metabolic stress that is associated with cardiac surgery and the role of this protein as a predictor of clinical outcome in children at high surgical risk who undergo operative correction of congenital heart defects.

METHODS

Serum albumin concentrations were measured in 30 children who had heart disease and were at high surgical risk. Analyses were performed before surgery, on the second postoperative day, and on discharge from the intensive care unit. Preoperative serum concentrations of albumin were compared with those of a control group that consisted of 20 healthy and well-nourished children.

RESULTS

Preoperative albumin concentrations of patients were lower than those of the control group (3.4+/-0.25 g/dL versus 4.0+/-0.18 g/dL, P<0.05). Serum levels decreased on the second postoperative day and at discharge from the intensive care unit (3.1+/-0.65 g/dL and 3.2+/-0.44 g/dL, P<0.05) compared with preoperative concentrations. Preoperative concentrations lower than 3.0 g/dL were associated with increased postsurgical infection (P=0.0026) and with increased mortality (P=0.0138). Patients whose postoperative levels were lower than 3.0 g/dL had longer hospital stays compared with those whose concentrations were higher than 3.0 g/dL (14.5+/-1.3 d versus 10+/-2.2 d, P<0.05).

CONCLUSION

The results suggest that hypoalbuminemia is common among children who have heart disease and are at high surgical risk, and serum albumin concentrations lower than 3 g/dL may be related to outcome in the period after cardiac surgery.

Outcomes of a nutrition audit in a tertiary paediatric hospital: implications for service improvement

OBJECTIVE

To examine the process of anthropometric assessment of nutritional status in a tertiary paediatric hospital, to identify the barriers and to make recommendations for service improvement.

METHODS

The accuracy of height and weight scales in wards was checked. Dietitians measured height and weight of a representative sample of 245 inpatients and checked whether these measurements had been recorded on bed charts. Patients were classified as overweight, obese or under-nourished. Diagnoses and procedures were obtained for each patient. Funding implications were modelled for inappropriate coding of nutritional status.

RESULTS

The barriers to nutritional assessment and management of nutritional comorbidities were: (i) inaccurate height scales in seven out of 12 wards; (ii) under-recording of height and weight on patient bed charts (73% height missing, 12% both height and weight missing); (iii) under-reporting of obesity and under-nutrition in medical notes (one of eight obese patients, and none of 28 undernourished patients, reported); and (iv) low referral rate of obese or under-nourished children to dietetic services (two of 42 overweight/obese patients referred, five of 28 undernourished patients referred). Funding simulation showed that if under-nourished patients were correctly diagnosed then the potential facility reimbursement would have increased by $A52 326.

CONCLUSIONS

Barriers to nutritional assessment can lead to failure to diagnose and treat both over- and under-nutrition, thereby affecting quality of patient care, and may have financial implications for hospitals. Suggestions for service improvement include provision of accurate equipment, adequate training of staff undertaking nutritional assessments and clear definitions of staff responsibilities in all aspects of the process.

Nutritional risk factors for postoperative complications in Brazilian elderly patients undergoing major elective surgery

OBJECTIVE

In this prospective study, we assessed nutritional and immunologic risk factors for infectious complications and deaths related to infection in elderly patients undergoing major elective surgery.

METHODS

Seventy patients 60 y or older were enrolled in this study. The preoperative variables analyzed were body mass index, body mass index knee height, triceps skinfold, subscapular skinfold, mid-arm muscle circumference, mid-arm muscle area, albumin, transferrin, prealbumin, and retinol-binding protein levels, immunoglobulins G, A, and M, C3, and C4 levels, total lymphocyte counts, and the occurrence of delayed hypersensitivity reactions (multitest).

RESULTS

Abnormally low levels of prealbumin (P = 0.004), retinol-binding protein (P = 0.05), and transferrin (P = 0.04) were related to infectious complications. Prealbumin levels (P = 0.02) and lymphocyte counts below 1500 cells/mm(3) (P = 0.04) were associated with mortality secondary to infection. Univariate regression analysis showed that levels of prealbumin (P = 0.02, odds ratio = 13.3, 95% confidence limits = 1.6, 110.9), retinol-binding protein (P = 0.03, odds ratio = 4.8, 95% confidence limits = 1.2, 19.3), and transferrin (P = 0.03; odds ratio = 4.2, 95% confidence limit = 1.2, 15.6) were associated with infectious complications. Multivariate analysis associated only prealbumin levels with infectious complications (P = 0.02, odds ratio = 13.3, 95% confidence limit = 1.6, 110.9). Regression analysis provided no conclusion regarding mortality because of the small number of deaths recorded.

CONCLUSIONS

In patients with a good cardiac index (Goldman I and II) who underwent major elective surgery, prealbumin protein, retinol-binding protein, and transferrin levels below normal values represented a significant risk for postoperative infectious complications. Lymphocyte counts lower than 1500/m(3) and abnormal prealbumin values were associated with postoperative mortality secondary to infection. The anthropometric variables evaluated did not predict postoperative infectious complications and mortality.

Nutritional follow-up of critically ill infants receiving short term parenteral nutrition

Few studies have tried to characterize the efficacy of parenteral support of critically ill infants during short period of intensive care. We studied seventeen infants during five days of total parenteral hyperalimentation. Subsequently, according to the clinical conditions, the patients received nutritional support by parenteral, enteral route or both up to the 10th day. Evaluations were performed on the 1st, 5th, and 10th days. These included: clinical data (food intake and anthropometric measurements), haematological data (lymphocyte count), biochemical tests (albumin, transferrin, fibronectin, prealbumin, retinol-binding protein) and hormone assays (cortisol, insulin, glucagon). Anthropometric measurements revealed no significant difference between the first and second evaluations. Serum albumin and transferrin did not change significantly, but mean values of fibronectin (8.9 to 16 mg/dL), prealbumin (7.7 to 18 mg/dL), and retinol-binding protein (2.4 to 3. 7 mg/dL) increased significantly (p < 0.05) from the 1st to the 10th day. The hormonal study showed no difference for insulin, glucagon, and cortisol when the three evaluations were compared. The mean value of the glucose/insulin ratio was of 25.7 in the 1st day and 15. 5 in the 5th day, revealing a transitory supression of this hormone. Cortisol showed values above normal in the beginning of the study. We conclude that the anthropometric parameters were not useful due to the short time of the study; serum proteins, fibronectin, prealbumin, and retinol-binding protein were very sensitive indicators of nutritional status, and an elevated glucose/insulin ratio, associated with a slight tendency for increased cortisol levels suggest hypercatabolic state. The critically ill patient can benefit from an early metabolic support.

Pre-operative nutritional assessment

Protein-energy undernutrition, or the possibility of its development, has been documented to occur frequently in surgical patients admitted to hospital. Nutritional status is known to deteriorate over the course of the hospital stay, with poor awareness by medical and nursing staff as to the deleterious effects of impaired nutritional status on clinical outcome and hospital costs. While there is no consensus on the best method for assessment of the nutritional status of surgical patients pre-operatively, there are a number of techniques available. These techniques can be divided into two types, those suitable for screening for nutrition risk on admission to hospital and those used to fully assess nutritional status. Both techniques have their limitations, but if used correctly, and their limitations recognized, should identify the appropriate degree of nutritional intervention for an individual patient in a timely and cost-effective manner. The techniques currently available for nutritional screening and nutritional assessment are reviewed, and their applicability to the Irish setting are discussed in the present paper.

Problems of nutritional assessment in the acute setting

Surveys have shown that 20-50% of hospital admissions suffer from nutritional depletion and that there is failure to recognize its existence and significance. More emphasis must be placed in clinical medicine on identifying subjects who are at high risk of developing disease-related malnutrition. There is a need to screen patients on admission to hospital to identify those at risk of nutrition-related complications. More formal determination of nutritional status should be carried out to define the nutritional status of the patient and to monitor changes in nutritional status during nutritional support. The most frequently used tests of nutritional status include dietary, anthropometric, biochemical and functional indices of nutritional status. It is important, and indeed is the skill of the nutritional care team (particularly the dietitian) to be able to evaluate these measurements, as many of them are affected by non-nutritional factors. There is no consensus on the best method for the accurate assessment of nutritional status. Practical difficulties arise with individual measurements and in their interpretation in the acute setting. The aim of the present paper is to identify the most relevant variables to measure in clinical medicine, and to discuss the limitations of their use in the acute setting.

Development and validation of an automated latex-enhanced immunoassay for prealbumin

The measurement of circulating prealbumin has been shown to be clinically useful in the assessment of nutritional status, both as an initial screen and in the monitoring of nutritional recovery. We describe a fully automated, noncompetitive, homogenous, light-scattering immunoassay that has been developed for this analyte on a Dimension® (Dade) analyzer. A sheep anti-prealbumin IgG fraction was covalently coupled to 40-nm chloromethyl styrene particles and, after the addition of sample, polyethylene glycol-assisted immunoagglutination was monitored by turbidimetry. The prealbumin working assay range was 8–550 mg/L at a sample volume of 2 μL and a reaction time of 6.5 min. When data were analyzed using ANOVA, total and within-run assay imprecision values (CVs) were 1–5%, and calibration and reagent stabilities were in excess of 40 days. Mean analytical recoveries were 102% ± 4% (SD), and there was no lack of parallelism. Hemolysis, lipemia, and bilirubin did not interfere. Both plasma anticoagulated with heparin or EDTA and serum from plain or serum-separation tubes were acceptable as sample matrices. Comparison with the Beckman Array® method gave a Passing and Bablok regression of: Dimension analyzer = 1.01Beckman + 7.1 (n = 103), using a common calibrator. We conclude that the prealbumin method is appropriate for clinical use according to the analytical criteria used in this study.

Cardiorespiratory status after treatment for acute lymphoblastic leukemia

The use of certain chemotherapeutic agents is associated with dose-related cardiotoxicity and, potentially, with restrictive lung disease. Therefore, we assessed the cardiopulmonary status and exercise capacity of 19 patients (pts; 9M:10F) 1.1 to 7.1 years (mean 4.6 +/- 1.5 years) after successful treatment of acute lymphoblastic leukemia (ALL) with Dana Farber Cancer Institute protocols. As body mass and nutritional status may influence exercise capacity, we also evaluated their anthropometric status and the plasma levels of rapid turnover proteins. Seven pts designated as "standard risk for relapse" (SR) had received low cumulative doses of doxorubicin (50 +/- 21 mg/m2), while twelve pts at "high or very high risk for relapse" (HR/VHR) had received higher doses (349 +/- 16 mg/m2). The evaluations included a questionnaire, anthropometric assessments, echocardiography, pulmonary function studies, exercise testing, and nutritional assays. Patients' data were compared with published normative data or with control values from our laboratories. In addition, we compared SR pt data with HR/VHR pt data. No pt had overt symptoms or signs of cardiorespiratory compromise. The pts had a higher percent of body fat than age-matched healthy controls (29.7 +/- 7.9% vs. 20 +/- 6%; P < 0.001). On echocardiography, cardiac systolic function was within normal limits in all. However, HR/VHR pts had lower left ventricular (LV) shortening fractions than SR pts (P < 0.05). LV filling velocity, indicative of diastolic function (the E/A ratio), was normal in most pts. Pulmonary function studies were normal. Exercise capacity was below predicted in most cases but heart rates at peak exercise and leg muscle function were within normal limits, suggesting a deconditioned state. Plasma levels of rapid turnover proteins were also normal. Despite lack of overt morbidity in our pt population, subtle abnormalities persist in cardiac function while pulmonary function is normal. Longitudinal studies will identify if further abnormalities or overt morbidity develop. In later years, continuing obesity and a sedentary state may contribute to clinically relevant heart disease.

Nutritional management of failure to thrive

Failure to thrive, or failure to grow or gain weight, could have several causes that are reviewed in this article. Infant behaviors are discussed, together with nutritional management, catch-up growth, effects of nutritional rehabilitation on body composition, follow-up, and long-term prognosis.

Evaluation of early enteral feeding in children less than 3 years old with smaller burns (8-25 per cent TBSA)

Early enteral feeding and high protein nutrition have been advocated for burned patients. The safety and efficacy of early high protein nasogastric feeding (NG) have not been evaluated in very young children. The present study evaluated such feeding in children less than 3 years old with smaller burns (8-25 per cent of total body surface area). Children (n = 10) were able to tolerate high protein intake without detrimental effects. The incidences of gastrointestinal complications related to NG feeding were low. The children needed approximately 2 weeks of supplemental NG feeding which provided two-thirds of total energy intake and three-fourths of protein intake. In spite of smaller burns, the mean measured resting metabolic expenditure (REE) was 1.3 x predicted REE. The mean energy intake of 92 per cent of recommended daily allowances (RDA) for energy or 1.7 x predicted REE was able to maintain body weight. The mean protein intake was 4.3 g/kg/day with a non-protein calorie ratio of 114:1. During the first week postburn, plasma concentrations of prealbumin, albumin and transferrin were low. The high protein intake was able to raise these visceral proteins to normal ranges. These results indicate that early NG feeding is safe and efficacious for achieving increased energy intake and improved protein status in very young children.

Biochemical markers of nutrition in osteoporosis

Thirty-six women with vertebral osteoporosis showed significantly decreased levels of biochemical markers of nutrition, transferrin (P < 0.001), prealbumin (P < 0.001), retinol binding-protein (P < 0.001), and fibronectin (P < 0.001), compared with 40 healthy women of similar age. Multiple regression analysis showed a significant (R2 = 0.509; P = 0.0068) correlation between bone mineral content and biochemical markers of nutrition in the osteoporotic patients but not in the control group. These data suggest that postmenopausal osteoporosis may be associated with a nutritional deficiency.

Protein energy malnutrition and the nervous system

Protein-energy malnutrition (PEM), a natural ramification of poverty, continues to be a perennial source of concern to a large segment of the world population. The developing nervous system of a child is specially vulnerable to deprivations in nurture. Peripheral nerve and muscle derangements are clinically evident by weakness, hypotonia and hyporeflexia in accordance with severity and duration of PEM. Motor and sensory nerve conduction studies exhibit significant abnormalities and often furnish useful and ominous correlation with grades of PEM. The human sural nerve histology in cases of severe PEM is characterized by persistence of small myelinated fibres, striking failure of internodal elongation and significant segmental demyelination. Young rhesus monkeys are ideal experimental PEM models and they show myopathic EMG changes amenable to rehabilitation. Muscle pathology comprises obliteration of cross-striations, streaming of Z bands, increased interfibrillary spaces, mitochondriomegaly and small-for-age fibres. Radioisotope assays reveal anomalous incorporation into various nerve and muscle constituents. Central nervous system, specially the neuropsychological functions are affected in a lasting manner. Learning deficits, behavioural problems and manual indexterity are most obtrusive features.

Follow-up of nutritional status and dietary survey in children with cow's milk allergy

The nutritional status of children with cow's milk allergy was followed during an elimination diet in 19 children (9 boys and 10 girls) beginning at the mean age of two years (range 0.6-4.1 years). The cow's milk allergy had been verified in hospital by a challenge test at a mean age of 0.9 years (range 0.2-1.9 years). Weight, height and laboratory indices to test protein, mineral and vitamin status were measured at three follow-up visits at three-month intervals. In addition to cow's milk allergy all these children had some other food allergies, and six of the 19 children were allergic to soy protein. Only two of the 19 children were given a soy-based formula. In the diets of the other children, cow's milk was replaced by increasing amounts of other foodstuffs and supplementary calcium. At the beginning of the study the relative heights of the children were slightly retarded (-0.6 SD) and remained unchanged during follow-up (-0.8 SD at the end of the study). The relative weights were found to be decreased during follow-up (p less than 0.05). There was a significant reduction in serum prealbumin values; eight of the 19 children showed abnormally low values. Low serum zinc values were seen in 12 children. Serum iron concentration was low in two children and two had high serum alkaline phosphatase values. Seven-day food recording indicated that dietary intake of energy was below the recommendation in some children, but protein intake was high. Some children had low intakes of riboflavin.(ABSTRACT TRUNCATED AT 250 WORDS)

Parenteral nutrition, and fluid and electrolyte therapy

The provision of fluid and electrolytes during parenteral nutrition can be a challenge in the malnourished child or the child with complicating illnesses. The practitioner using the basic concepts of maintenance and deficit therapy--in this case for calories--must adapt his or her therapy to the expansion of the intracellular as well as the extracellular fluid compartment. Impairment of other organ systems further complicates the ability to deliver therapy. Careful monitoring and individually tailored solution will provide adequate caloric fluid and electrolyte therapy during parenteral nutrition in children.