Serum albumin as indicator of clinical evolution in patients on parenteral nutrition. Multivariate study

Risk factors associated with wheezing in severe pediatric community-acquired pneumonia: a retrospective study

BACKGROUND

Wheezing is a common clinical manifestation in children with pneumonia. However, the risk factors associated with the development of wheezing pneumonia and its clinical features are not fully characterized, especially in children with severe pneumonia.

METHODS

We retrospectively recruited 1434 pediatric patients diagnosed with severe pneumonia between April 2012 and September 2019 in Fujian Maternity and Child Health Hospital. The medical records regarding demographic information, clinical manifestations, radiographic/laboratory findings, and complications were collected. Based on the presence or absence of wheezing symptoms and signs, subjects were divided into wheezing cohort (N.=684) and non-wheezing cohort (N.=750), and their clinical data were compared. Multivariate cox regression analysis was performed to identify independent risk factors of wheezing.

RESULTS

Demographic features including gender, weigh, onset season, birth weight, full-term birth or not, history of pneumonia were significantly associated with the occurrence of wheezing in severe CAP (P<0.05). Specifically, male gender, onset seasons in autumn/winter, and absence of a history of pneumonia were identified as independent risk factors of wheezing in multivariate analysis (P<0.05). As for clinical features, wheezing cohort differed from the non-wheezing one in terms of clinical manifestation (higher incidence of cough and breathless, but lower incidence of fever), laboratory finding (higher levels of red blood cells, hemoglobin, and albumin and lower levels of total or indirect bilirubin and creatine), pathogen detection (higher incidence of respiratory syncytial viral infection), and clinical complications (lesser risk of sepsis and hydrothorax) (P<0.05).

CONCLUSIONS

Severe CAP with wheezing is a special clinical entity of severe pneumonia in children, which has specific risk factors and differ from non-wheezing pneumonia in terms of clinical features and etiologic pathogens.

Compromised Nutritional Status as a Risk Factor for the Incidence of Nosocomial Infections

Background Poor nutritional status may lead to longer hospital stays, increased mortality and morbidity, increased cost, and higher suffering. Nosocomial infections (NI) are a global health concern, and several risk factors are associated with their higher incidence. This study aimed to reveal that compromised nutritional status is one of the risk factors for developing NIs. Methodology The study was conducted in a tertiary care hospital in Pune, India. This was a prospective cohort study with a sample size of 200 hospitalized participants. Data collection was based on standard tools and structured forms which had two parts. In the first part, the assessment of nutritional status was done for which patients were categorized into two groups, namely, well-nourished and undernourished. Additionally, biochemical parameters (serum albumin) were also assessed. The second part included a follow-up of participants to evaluate the development of NIs including their laboratory investigation. Results were analyzed statistically using R software. Results Among 200 participants, 60 were female, of whom 15% developed NIs. Of the 140 males, 8% had NIs. Among 200 participants, 101 (51%) were well-nourished, of whom two (2%) developed NIs. Of the 99 (49%) undernourished participants, 18 (18%) had NIs. Those who were undernourished (univariate relative risk = 6.10, 95% confidence interval) were more prone to developing NIs compared to the well-nourished group. Conclusions NIs are widespread globally but are less studied and given less emphasis in developing countries. This study reports various types of NIs along with their incidence in well-nourished and undernourished groups. The incidence of NI observed in this study may reflect the higher severity of illness, age, poor nutritional status, and longer hospital stays. Identifying risk factors that can contribute to developing NI may help in their prevention by maximizing patient safety.

Early predicting indicators of conversion from mild to moderate in overseas-imported COVID-19 cases

Background

Due to the ongoing pandemic of coronavirus disease 2019 (COVID-19) in foreign countries and regions, many overseas people arrive in China by air. Currently, most of the new cases of COVID-19 were imported from overseas. Here, we evaluated the predictive effect of the level of blood albumin (ALB) and serum prealbumin (PA) level in overseas-imported cases on the conversion of mild COVID-19 to moderate and its value in guiding nutritional support for these travelers.

Methods

We retrospectively analyzed serum levels of ALB and PA of 193 patients with imported COVID-19 admitted to the Shanghai Public Health Clinical Center at the time of admission on April 8, 2020.

Results

Since the first overseas-imported case was admitted to Shanghai on March 5, 2020, 195 overseas-imported cases have been treated in the Shanghai Public Health Clinical Center. The disease was mild or moderate. A total of 193 patients (111 males and 82 females) entered our analysis and the disease was moderate in 108 patients and mild in 85 patients. Patients were aged 6 to 66 years (mean: 28 years). There was a strong negative correlation between the proportion of moderate type and ALB (P=0.0073); thus, patients with a lower level of ALB were more likely to be diagnosed with moderate type. The correlation coefficient was close to 0 in the scatter plot, indicating that there was no linear correlation between PA and the diagnosis of moderate type (P>0.05). There was a strong negative correlation between age and ALB level (P<0.001), while length of hospital stay did not show a linear correlation with ALB or PB levels (both P>0.05). Therefore, older patients had lower levels of ALB and were more likely to develop moderate COVID-19.

Conclusions

The serum ALB level can be an early predictive indicator for the conversion of mild COVID-19 to moderate in cases imported overseas and may guide nutritional support.

Feasibility and efficacy of home rectal irrigation in neonates and early infancy with Hirschsprung disease

PURPOSE

A single-stage pull-through (SSPT) is the most commonly performed procedure for Hirschsprung disease (HSCR) and has been shown to be better than multi-stage procedures. However, performing a SSPT in the neonatal period or early in infancy is a risk factor for an inaccurate diagnosis, post-operative enterocolitis, and a protracted post-operative recovery. The present study was primarily designed to evaluate the feasibility and efficacy of home rectal irrigation in the neonatal period and early in infancy, followed by a delayed and planned SSPT in a prospective cohort with HSCR.

METHODS

Between January 2014 and December 2016, a total of 147 neonates diagnosed with HSCR were enrolled in the study. Six patients were excluded as a result of ganglion cells found in second rectal biopsies after the neonatal period. One hundred twenty-two patients successfully underwent 2-4 months of home rectal irrigation during the neonatal period, followed by a SSPT procedure after the neonatal period (group A, n = 122). Nineteen patients were not candidates for home rectal irrigation, and thus, colostomies were performed during the neonatal period followed by multi-stage procedures after the neonatal period (group B, n = 19). One hundred twenty-two healthy children, age- and gender-matched to group A were enrolled as the healthy control group for assessment of nutrition status (group C, n = 122). The birth weight, gender ratio, aganglionic segment, age, and Hirschsprung-associated enterocolitis (HAEC) score at the time of HSCR diagnosis were measured to evaluate the feasibility of home rectal irrigation in neonates and early in infancy. The nutritional indices, including weight, body length, serum albumin, serum prealbumin, serum retinol-binding protein, and incidence of HAEC after 2-4 successful home rectal irrigation, were used to assess the efficacy of home rectal irrigation. Anastomotic strictures or leakage, perianal excoriation, frequency of defecation, and morbidity of post-operative HAEC were recorded to evaluate the beneficial effects to pull through (PT), which were facilitated by home rectal irrigation.

RESULTS

Higher HAEC scores and older age at the time of diagnosis of HSCR were associated with group B, compared to group A (4.34 ± 1.25 vs. 11.0 ± 2.56 [t = 18.20, p < 0.05] and 2.8 ± 1.46 days vs. 12.1 ± 5.3 days [t = 16.10, p < 0.05], respectively). The ratio of rectosigmoid HSCR to non-rectosigmoid HSCR was higher in group A than group B (104/18 vs. 4/15 [χ² = 34.29, p < 0.05]). There were no differences in birth weight, weight at the time of diagnosis of HSCR, and gender ratio between groups A and B. There were no differences in birth weight, birth length, post-home rectal irrigation age, post-home rectal irrigation weight, post-home rectal irrigation length, and post-home rectal irrigation serum albumin between groups A and C (3.47 ± 0.42 kg vs. 3.48 ± 0.40 kg [t = 0.10, p > 0.05], 50.02 ± 0.49 cm vs. 50.05 ± 0.46 cm [t = 0.61, p > 0.05], 98.59 ± 13.34 days vs. 97.83 ± 13.58 days [t = 0.44, p > 0.05], 6.77 ± 0.66 kg vs. 6.97 ± 0.87 kg [t = 1.95, p > 0.05], 61.55 ± 2.14 cm vs. 61.70 ± 2.07 cm [t = 0.59, p > 0.05], and 41.78 ± 2.42 g/L vs. 41.85 ± 2.37 g/L [t = 0.22, p > 0.05], respectively). The rate of HAEC in the period of home rectal irrigation in group A was low; however, the post-home rectal irrigation serum prealbumin level and retinol-binding protein were significantly lower in group A than group C (0.15 ± 0.04 g/L vs. 0.17 ± 0.05 g/L [t = 3.50, p < 0.05] and 22.51 ± 7.53 g/L vs. 30.57 ± 9.26 g/L [t = 7.46, p < 0.05], respectively). There were no anastomotic strictures or leakage after definitive PT performed in group A. The frequency of defecation ranged from 2-6 times per day, 10 patients had perianal excoriation 3 months after PT, and 11 patients had post-operative HAEC during 6 months of follow-up after PT.

CONCLUSION

Home rectal irrigation in neonates and early in infancy, followed by a delayed and planned SSPT is feasible and effective in patients with HSCR, and could be beneficial to definitive PT. However, for patients with an extended aganglionic segment, older age, or high HAEC score at the time of diagnosis of HSCR, rectal irrigation maybe not suitable.

TRIAL REGISTRATION

This was a prospective comparative study designed to evaluate the effects of home rectal irrigation for facilitating and enhancing recovery after PT, and was registered at Clinical Trials.gov as NCT02776176.

Preoperative controlling nutritional status (CONUT) score as a novel immune-nutritional predictor of survival in non-metastatic clear cell renal cell carcinoma of ≤ 7 cm on preoperative imaging

PURPOSE

This study aimed at investigating the prognostic value of Preoperative controlling nutritional status (CONUT) score in non-metastatic clear-cell renal cell carcinoma of ≤ 7 cm on preoperative imaging.

METHODS

We retrospectively included 1046 among 1637 patients who underwent radical or partial nephrectomy for solid renal masses ≤ 7 cm (2005-2014) after excluding other pathology, conditions affecting CONUT score components, metastasis, regional lymphadenopathy, positive margin, and follow-up < 12 months. We defined high and low CONUT according to cut-off of (2). Multivariate Cox-regression analysis was used to predict factors affecting recurrence and survival. Kaplan-Meier curve was used for survival analysis.

RESULTS

The median age and follow-up were 56 years and 63 months, respectively. 41 patients had recurrence (3.9%). CONUT was a predictor for recurrence-free, cancer-specific, and overall survival (HR 3.09, P = 0.003 and HR 4.66, P = 0.004 and HR 2.81, P = 0.003, respectively). A higher CONUT was significantly associated with worse 5 years recurrence-free (88.2% vs. 97.1%), cancer-specific (96.2% vs. 98.8%) and overall (90.9% vs. 96.5%) survival (log-rank, P = < 0.001, P = 0.006 and P = < 0.001, respectively).

CONCLUSIONS

The preoperative CONUT is an independent prognostic marker for survival after curative surgery for non-metastatic clear-cell renal cell carcinoma of ≤ 7 cm on preoperative imaging.

Comparison of accuracy between pre-hemodialysis and post-hemodialysis levels of nutritional factors for prediction of mortality in hemodialysis patients

BACKGROUND

The nutritional status of hemodialysis (HD) patients is usually assessed using pre-HD laboratory data. However, it remains unclear whether the most diluted laboratory value is appropriate for assessment. We compared the pre-HD and post-HD laboratory data for their accuracy in predicting mortality.

METHODS

Maintenance HD patients (n = 96 700; men, 61.5%) were enrolled. The outcome events were one-year and five-year mortalities. Their laboratory data included body mass index (BMI), and serum albumin, creatinine, and blood urea nitrogen (BUN) levels. Bootstrap resampling was used to compare the accuracy in predicting the mortalities between pre-HD and post-HD levels using area under receiver operating characteristic curves (AUCs) adjusted for baseline characteristics.

RESULTS

The mean age ± standard deviation was 65.7 ± 12.2 years, and the vintage was 8.3 ± 6.7 years. The numbers of patients who died were 6442 (6.7%) in one year and 30 965 (32.0%) in five years. The adjusted AUCs for predicting the one-year and five-year mortalities showed that the pre-HD albumin and creatinine levels and the pre-HD BMI and BUN levels were more accurate than the post-HD levels (each p < 0.0001). The pre-HD albumin and creatinine levels showed the highest adjusted AUC for predicting one-year mortality [0.613 (95% CI 0.598, 0.629)] and five-year mortality [0.591 (95% CI 0.586, 0.595)], respectively.

CONCLUSIONS

Pre-HD albumin and creatinine levels are more accurate than post-HD levels and other nutritional indices in predicting one-year and five-year mortalities in HD patients.

Clinical relevance of trace element measurement in patients on initiation of parenteral nutrition

Background and Aims Serum zinc, copper and selenium are measured in patients prior to commencing on parenteral nutrition; however, their interpretation can be difficult due to acute phase reactions. We assessed (i) the relationship of raised C-reactive protein with trace elements and albumin (ii) benefits of measuring trace elements when C-reactive protein is raised in patients requiring short-term parenteral nutrition. Methods Samples were collected for zinc, copper, selenium and albumin at baseline and then every two weeks and correlated with C-reactive protein results in patients on parenteral nutrition. Results were categorized into four groups based on the C-reactive protein concentrations: (i) <20 mg/L, (ii) 20-39 mg/L, (iii) 40-79 mg/L and (iv) ≥80 mg/L. Results In 166 patients, zinc, selenium and albumin correlated (Spearman's) negatively with C-reactive protein; r = -0.26, P < 0.001 (95% CI -0.40 to -0.11), r = -0.44, P < 0.001 (-0.56 to -0.29) and r = -0.22 P = 0.005 (-0.36 to -0.07), respectively. Copper did not correlate with C-reactive protein (r = 0.09, P = 0.25 [-0.07 to 0.25]). Comparison of trace elements between the four groups showed no difference in zinc and copper (both P > 0.05), whereas selenium and albumin were lower in the group with C-reactive protein > 40 mg/L ( P < 0.05). Conclusion In patients on short-term parenteral nutrition, measurement of C-reactive protein is essential when interpreting zinc and selenium but not copper results. Routine measurement of trace elements prior to commencing parenteral nutrition has to be considered on an individual basis in patients with inflammation.

Influence of supplemental parenteral nutrition approach on nosocomial infection in pediatric intensive care unit of Emergency Department: a retrospective study

BACKGROUND & AIMS

Nutritional support for patients in the intensive-care unit (ICU) is a part of standard care which promotes medical quality and decreases nosocomial infection. Supplemental parenteral nutrition (SPN) approach (enteral nutrition (EN) combined with parenteral nutrition (PN) when EN alone is insufficient) has become one major concern in nutrition research field. This research aims to explore the following relationships: (i) the relationship between SPN and nosocomial infection, (ii) the relationship between early and late SPN initiation and the development of nosocomial infection.

METHODS

A retrospective study was conducted in patients who met the inclusion criteria from February 2012 to February 2015 in Pediatric ICU (PICU). Patients were classified into two groups according to nutrition delivery approach-SPN group and EN alone group. Then SPN group were further divided into two subgroups by initiation timing, which were defined as early-initiation SPN and late-initiation SPN group respectively. Age, gender, serum albumin at admission, severity of disease, length of stay in PICU, nutrition delivery approach, amounts of delivered caloric intake and occurence of nosocomial infection were recorded. Univariate analysis and binary logistic regression analysis were performed to identify the risk factors and assess the independent effect of SPN approach on nosocomial infection in PICU of Emergency Department.

RESULTS

204 patients were included in our study. Compared with EN alone group, patients delivered by SPN approach had a higher nosocomial infection rate (34.0 vs.10.9%, p < 0.001). The late-initiation subgroup of SPN approach was found to be an independent predictor of nosocomial infection in the logistic regression analysis model (OR = 3.40; 95% CI, 1.13 ~ 10.19; p = 0.029). Serum albumin at admission (OR = 0.91; 95% CI, 0.84 ~ 0.97; p = 0.008), mechanical ventilation (OR = 3.85; 95% CI, 1.43 ~ 10.39; p = 0.008), severity of disease (OR = 3.79; 95% CI, 1.03 ~ 13.99; p = 0.045) and PICU length of stay (OR = 1.23; 95% CI, 1.11 ~ 1.35; p < 0.001) were also identified as significant risk factors for nosocomial infection.

CONCLUSIONS

Our study shows late-initiation SPN approach increases the incidence of nosocomial infection compared with early-initiation approach in critically ill children in PICU of Emergency Department. Compared with EN alone group, patients delivered by SPN approach had a higher nosocomial infection rate.

Preoperative nutritional status is an important predictor of survival in patients undergoing surgery for renal cell carcinoma

BACKGROUND

The role of malnutrition has not been well studied in patients undergoing surgery for renal cell carcinoma (RCC).

OBJECTIVE

Our aim was to evaluate whether nutritional deficiency (ND) is an important determinant of survival following surgery for RCC.

DESIGN, SETTING, AND PARTICIPANTS

A total of 369 consecutive patients underwent surgery for locoregional RCC from 2003 to 2008. ND was defined as meeting one of the following criteria: body mass index <18.5 kg/m(2), albumin <3.5 g/dl, or preoperative weight loss ≥ 5% of body weight.

INTERVENTION

All patients underwent radical or partial nephrectomy.

MEASUREMENTS

Primary outcomes were overall and disease-specific mortality. Covariates included age, Charlson comorbidity index (CCI), preoperative anemia, tumor stage, Fuhrman grade, and lymph node status. Multivariate analysis was performed using a Cox proportional hazards model. Mortality rates were estimated using the Kaplan-Meier product-limit method.

RESULTS AND LIMITATIONS

Eighty-five patients (23%) were categorized as ND. Three-year overall and disease-specific survival were 58.5% and 80.4% in the ND cohort compared with 85.4% and 94.7% in controls, respectively (p<0.001). ND remained a significant predictor of overall mortality (hazard ratio [HR]: 2.41, 95% confidence interval [CI], 1.40-4.18) and disease-specific mortality (HR: 2.76; 95% CI, 1.17-6.50) after correcting for age, CCI, preoperative anemia, stage, grade, and nodal status. This study is limited by its retrospective nature.

CONCLUSIONS

ND is associated with higher mortality in patients undergoing surgery for locoregional RCC, independent of key clinical and pathologic factors. Given this mortality risk, it may be important to address nutritional status preoperatively and counsel patients appropriately.

The effect of preoperative weight loss and body mass index on postoperative outcome in patients with esophagogastric carcinoma

Studies have shown that weight loss is associated with adverse outcomes in all treatment modalities for esophagogastric carcinoma. Because of the increased prevalence of obesity and the effectiveness of perioperative nutrition, a number of patients are now obese or have normal body mass index (BMI) at the time of treatment. We investigated the relationship between weight loss, BMI, and outcome of surgery for patients with esophagogastric carcinoma. Data were collected over a 38-month period for all patients diagnosed with operable esophagogastric cancer at two UK centers. All patients underwent resection by a single Consultant Upper Gastrointestinal Surgeon and the use of perioperative jejunal feeding was universal. Ninety-three patients (57 male) underwent esophagogastric resection; 48 had no preoperative weight loss (34 with a BMI > 25 and 14 with a BMI < 25). Forty-five patients had preoperative weight loss (20 with BMI > 25 and 25 with BMI < 25). There was no significant difference in complication rates, median hospital stay, or mortality between the four groups. A significantly higher number of patients displaying preoperative weight loss were found to have stage III disease, but difference in survival of up to 3 years did not reach statistical significance on multivariate analysis. Preoperative weight loss and low BMI did not significantly influence the complication rate, perioperative mortality rate, length of hospital stay, or short-term prognosis. We conclude that preoperative weight loss can not be reliably used as an independent predictor of poor outcome in patients undergoing surgery for esophagogastric carcinoma. However, patients with preoperative weight loss and low BMI are more likely to have advanced disease.

Predicting the outcome of artificial nutrition by clinical and functional indices

OBJECTIVE

Artificial nutrition (AN) is now considered medical therapy and has progressively become one of the mainstays of the different therapeutic options available for home or hospitalized patients, including surgical, medical, and critically ill patients. The clinical relevance of any therapy is based on its efficacy and effectiveness and thus on the improvement of its cost efficiency, i.e., the ability to provide benefits to the patients with minimal wasting of human and financial resources. The aim of the present study was to identify those indices, clinical, functional, or nutritional, that may reliably predict, before the start of AN, those patients who are likely not to benefit from nutritional support.

METHODS

Three hundred twelve clinical charts of patients receiving AN between January 1999 and September 2006 were retrospectively examined. Data registered before starting AN were collected and analyzed: general data (age, sex), clinical conditions (comorbidity, quality of life, frailty), anthropometric and biochemical indices, type of AN treatment (total enteral nutrition, total parenteral nutrition, mixed AN), and outcome of treatment.

RESULTS

The percentage of negative outcomes (death or interruption of AN due to worsening clinical conditions within 10 d after starting AN) was meaningfully higher in subjects >80 y of age and with reduced social functions, higher comorbidity and/or frailty, reduced level of albumin, prealbumin, lymphocyte count, and cholinesterase and a higher level of C-reactive protein. The multivariate analysis showed that prealbumin and comorbidity were the best predictors of AN outcome. The logistic regression model with these variables showed a predictive value equal to 84.2%.

CONCLUSION

Proper prognostic instruments are necessary to perform optimal evaluations. The present study showed that a patient's general status (i.e., comorbidity, social quality of life, frailty) and nutritional and inflammatory statuses (i.e., lymphocyte count, albumin, prealbumin, C-reactive protein) have good predictive value on the effectiveness of AN.

Renal function impacts outcomes after intestinal transplantation

BACKGROUND

Although renal dysfunction (RD) has been commonly associated with poor outcome after other solid organ transplants, it has not been studied in detail after intestinal transplantation (ITx). Here we provide a detailed analysis of renal function after ITx, and identify predictors of post-ITx RD.

METHODS

A retrospective analysis of patients undergoing ITx from 1991 to 2006 was performed. For each patient, the estimated glomerular filtration rate (eGFR) was compared with the normal GFR for age and gender to obtain the percent of normal eGFR. Chi-square analysis and log-rank tests were used to identify categorical variables associated with RD (eGFR <75% of normal) and to determine if RD was predictive of post-ITx survival.

RESULTS

Sixty-eight transplantations were performed in 62 patients. Overall patient survival at 1 and 5 years was 78% and 56%, respectively. Renal dysfunction was observed in 16% of patients post-ITx. The most frequent predictors of post-ITx RD were preoperative eGFR less than 75% of normal, pre-ITx location in the intensive care unit, and high-dose tacrolimus immunotherapy. An eGFR less than 75% of normal at days 7, 28, and 365 was predictive of poor patient survival (P<0.05).

CONCLUSIONS

This study provides the first detailed analysis of renal function after ITx. We identified specific risk factors for the development of RD in the first year post-ITx and found a significant association of RD with decreased long-term survival. Given the strong correlation of RD with poor outcome, preserving renal function may be key to improving long-term outcomes in ITx recipients.

Serum albumin level in the management of postoperative enteric fistula for gastrointestinal cancer patients

Postoperative enteric fistula is a serious complication and cause of death following gastrointestinal (GI)-tract surgery. Many reports have demonstrated the effectiveness of parenteral nutrition in the spontaneous closure of enteric fistula. Our study was aimed at analyzing the prognostic factors of parenteral nutritional support in the treatment of enteric fistula for patients with GI-tract cancer following surgery. GI-tract cancer patients receiving surgical interventions, which then unfortunately developed enteric fistula, were included in our study. All of them had to have received parenteral nutrition soon after leakages were recognized, and they were subsequently divided into successful and unsuccessful (classified as "failure") groups according to spontaneous closure of fistula or not, respectively. The studied patients' laboratory data were collected to identify the clinically relevant prognostic factors. Fifty-three primary GI-tract cancer patients with postoperative enteric fistulas were enrolled into our study. Of these, 33 patients were considered as successful parenteral nutritional therapy (successful group) and the other 20 patients (failure group) were not. After a period of parenteral nutritional therapy, serum total bilirubin, creatinine, C-reactive protein (CRP), hemoglobin, and albumin were significantly different between these two groups (all p < .05). Using a multivariate logistic regression analysis, it was determined that increased serum albumin level was an independent predictive factor of successful management for enteric fistula (p = .029), in addition to the well-known lower drainage amount (< 500 mL/day) from the enteric fistula (p = .013). Our observations show that both serum albumin levels and drainage amounts from the enteric fistula can be potentially used as important prognostic predictors of healing enteric fistula under total parenteral nutrition in patients following surgery for GI-tract malignancies.

Malnutrition is an independent factor associated with nosocomial infections

The aim of the present prospective study was to determine if malnutrition, measured using a simple validated score, is an independent risk factor for nosocomial infections (NI) in non-selected hospital in-patients. Between 29 and 31 May 2001, a survey on the prevalence of NI was conducted on all 1637 in-patients (61 (sd 25) years old) in a French university hospital as part of a national survey. Actual and usual body weights were recorded in all in-patients, and serum albumin levels were measured on all blood samples taken during the week before the study. Nutritional status was evaluated by using the nutritional risk index (NRI). Albumin values were obtained in 1084 patients, and complete weight information was obtained in 911. Therefore, NRI was calculated in 630 patients (61 (sd 20) years old): 427 (67·8%) were malnourished. NI prevalence was 8·7%: 4·4% in non-malnourished patients, 7·6% in moderately malnourished patients and 14·6% in severely malnourished patients. In univariate analysis, the odds ratios for NI were 1·46 (95% CI 1·2, 2·1) in moderately malnourished patients and 4·8 (95% CI 4·6, 6·4) in severely malnourished patients. In multivariate analysis, age, immunodeficiency and NRI class influenced NI risk. Vascular and urinary catheters, and surgical intervention, were the extrinsic factors associated with NI, with odds ratios ranging from 2·0 (95% CI 1·8, 2·6) for vascular catheters to 10·8 (95% CI 8·8, 12·6) for association of the three factors. In conclusion, in non-selected hospitalized patients, malnutrition assessed with a simple and objective marker is an independent risk factor for NI. An early screening for malnutrition may therefore be helpful to reduce the high prevalence of NI.

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.

Nutrition support of the chronically critically ill patient

Providing nutrition and metabolic support to the CCI patient is based on the rational application of scientifically derived data and clinical experience with this unique population. Much of the data presented has been extrapolated from the critically ill ICU patients and the chronically ill hospitalized or nursing home patient, as there are limited data solely based on an experience with the CCI [table: see text] patient population. The key principles are: (1) primacy of protein provision and avoidance of overfeeding energy, (2) use of combined modality (enteral, parenteral, and oral) nutrition to meet needs as required, (3) use of adjunctive agents to promote nitrogen retention when needed, and (4) recognition of and adjustment for altered nutrient requirements (Table 3).