The use of prealbumin and C-reactive protein for monitoring nutrition support in adult patients receiving enteral nutrition in an urban medical center

Predictive significance of systemic immune-inflammation index combined with prealbumin for postoperative pneumonia following lung resection surgery

BACKGROUND

We aimed to determine whether systemic immune-inflammation index (SII) combined with prealbumin can provide better predictive power for postoperative pneumonia in patients undergoing lung resection surgery.

METHODS

We identified eligible patients undergoing lung resection surgery at the Affiliated Hospital of Nantong University from March 2021 to March 2022. Demographic characteristics, clinical data, and laboratory information were collected and reviewed from the electronic medical records of the patients. To test the effect of the combined detection of SII and prealbumin, we made an equation using logistic regression analysis. The receiver operating characteristic curve (ROC) was plotted to evaluate the predictive powers, sensitivity, and specificity of prealbumin, SII, and SII combined with prealbumin. Decision curve analysis (DCA) was used to determine the clinical validity and net benefit of different methods of detection.

RESULTS

Totally 386 eligible patients were included with a median age of 62.0 years (IQR: 55.0, 68.0), and 57 (14.8%) patients presented with postoperative pneumonia within 7 days after surgery. The multivariate regression analysis showed that preoperative SII as continuous variable was associated with an increased risk of postoperative pneumonia (OR: 1.38, 95% CI: 1.19-2.83, P = 0.011), whereas the prealbumin as continuous variable remained as an independent protective predictor of postoperative pneumonia in the adjusted analysis (OR: 0.80, 95% CI: 0.37-0.89, P = 0.023). Compared to SII or prealbumin, the combined detection of preoperative SII and prealbumin showed a higher predictive power with area under curve of 0.79 (95% CI: 0.71-0.86, P < 0.05 for all). Additionally, DCA indicated that the combined detection was superior over preoperative SII or prealbumin alone in clinical validity and net benefit.

CONCLUSION

Both preoperative SII and prealbumin are independent influencing factors for postoperative pneumonia after lung resection surgery. The combined detection of preoperative SII and prealbumin can significantly improve prediction capability to identify potential postoperative pneumonia-susceptible patients, facilitating early interventions to improve postoperative quality of life for surgical lung resection patients.

Dynamic assessment of prealbumin for nutrition support effectiveness in critically ill patients

BACKGROUND & AIMS

Serum prealbumin is considered to be a sensitive predictor of clinical outcomes and a quality marker for nutrition support. However, its susceptibility to inflammation restricts its usage in critically ill patients according to current guidelines. We assessed the performance of the initial value of prealbumin and dynamic changes for predicting the ICU mortality and the effectiveness of nutrition support in critically ill patients.

METHODS

This monocentric study included patients admitted to the ICU between 2009 and 2016, having at least one initial prealbumin value available. Prospectively recorded data were extracted from the electronic ICU charts. We used both univariable and multivariable logistic regressions to estimate the performance of prealbumin for the prediction of ICU mortality. Additionally, the association between prealbumin dynamic changes and nutrition support was assessed via a multivariable linear mixed-effects model and multivariable linear regression. Performing subgroup analysis assisted in identifying patients for whom prealbumin dynamic assessment holds specific relevance.

RESULTS

We included 3136 patients with a total of 4942 prealbumin levels available. Both prealbumin measured at ICU admission (adjusted odds-ratio (aOR) 0.04, confidence interval (CI) 95% 0.01-0.23) and its change over the first week (aOR 0.02, CI 95 0.00-0.19) were negatively associated with ICU mortality. Throughout the entire ICU stay, prealbumin dynamic changes were associated with both cumulative energy (estimate: 33.2, standard error (SE) 0.001, p < 0.01) and protein intakes (1.39, SE 0.001, p < 0.01). During the first week of stay, prealbumin change was independently associated with mean energy (6.03e-04, SE 2.32e-04, p < 0.01) and protein intakes (1.97e-02, SE 5.91e-03, p < 0.01). Notably, the association between prealbumin and energy intake was strongest among older or malnourished patients, those suffering from increased inflammation and those with high disease severity. Finally, prealbumin changes were associated with a positive mean nitrogen balance at day 7 only in patients with SOFA <4 (p = 0.047).

CONCLUSION

Prealbumin measured at ICU admission and its change during the first-week serve as an accurate predictor of ICU mortality. Prealbumin dynamic assessment may be a reliable tool to estimate the effectiveness of nutrition support in the ICU, especially among high-risk patients.

Clinical practice guidelines for nutritional assessment and monitoring of adult ICU patients in China

The Chinese Society of Critical Care Medicine (CSCCM) has developed clinical practice guidelines for nutrition assessment and monitoring for patients in adult intensive care units (ICUs) in China. This guideline focuses on nutrition evaluation and metabolic monitoring to achieve optimal and personalized nutrition therapy for critically ill patients. This guideline was developed by experts in critical care medicine and evidence-based medicine methodology and was developed after a thorough review of the system and a summary of relevant trials or studies published from 2000 to July 2023. A total of 18 recommendations were formed and consensus was reached through discussions and reviews by expert groups in critical care medicine, parenteral and enteral nutrition, and surgery. The recommendations are based on currently available evidence and cover several key fields, including screening and assessment, evaluation and assessment of enteral feeding intolerance, metabolic and nutritional measurement and monitoring during nutrition therapy, and organ function evaluation related to nutrition supply. Each question was analyzed according to the Population, Intervention, Comparison, and Outcome (PICO) principle. In addition, interpretations were provided for four questions that did not reach a consensus but may have potential clinical and research value. The plan is to update this nutrition assessment and monitoring guideline using the international guideline update method within 3-5 years.

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

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

Changes in serum albumin concentrations over 7 days in medical inpatients with and without nutritional support. A secondary post-hoc analysis of a randomized clinical trial

BACKGROUND

Serum albumin concentrations are frequently used to monitor nutritional therapy in the hospital setting but supporting studies are largely lacking. Within this secondary analysis of a randomized nutritional trial (EFFORT), we assessed whether nutritional support affects short-term changes in serum albumin concentrations and whether an increase in albumin concentration has prognostic implications regarding clinical outcome and response to treatment.

METHODS

We analyzed patients with available serum albumin concentrations at baseline and day 7 included in EFFORT, a Swiss-wide multicenter randomized clinical trial that compared individualized nutritional therapy with usual hospital food (control group).

RESULTS

Albumin concentrations increased in 320 of 763 (41.9%) included patients (mean age 73.3 years (SD ± 12.9), 53.6% males) with no difference between patients receiving nutritional support and controls. Compared with patients that showed a decrease in albumin concentrations over 7 days, those with an increase had a lower 180-day mortality [74/320 (23.1%) vs. 158/443 (35.7%); adjusted odds ratio 0.63, 95% CI 0.44 to 0.90; p = 0.012] and a shorter length of hospital stay [11.2 ± 7.3 vs. 8.8 ± 5.6 days, adjusted difference -2.2 days (95%CI -3.1 to -1.2)]. Patients with and without a decrease over 7 days had a similar response to nutritional support.

CONCLUSION

Results from this secondary analysis indicate that nutritional support did not increase short-term concentrations of albumin over 7 days, and changes in albumin did not correlate with response to nutritional interventions. However, an increase in albumin concentrations possibly mirroring resolution of inflammation was associated with better clinical outcomes. Repeated in-hospital albumin measurements in the short-term is, thus, not indicated for monitoring of patients receiving nutritional support but provides prognostic information.

TRAIL REGISTRATION

ClinicalTrials.gov Identifier: NCT02517476.

Comparison of predictive equations and indirect calorimetry in critical care: Does the accuracy differ by body mass index classification?

BACKGROUND

Nutrition support professionals are tasked with estimating energy requirements for critically ill patients. Estimating energy leads to suboptimal feeding practices and adverse outcomes. Indirect calorimetry (IC) is the gold standard for determining energy expenditure. However, access is limited, so clinicians must rely on predictive equations.

METHODS

A retrospective chart review of critically ill patients who underwent IC in 2019 was conducted. The Mifflin-St Jeor equation (MSJ), Penn State University equation (PSU), and weight-based nomograms were calculated using admission weights. Demographic, anthropometric, and IC data were extracted from the medical record. Data were stratified by body mass index (BMI) classifications, and relationships between estimated energy requirements and IC were compared.

RESULTS

Participants (N = 326) were included. Median age was 59.2 years, and BMI was 30.1. The MSJ and PSU were positively correlated with IC in all BMI classes (all P < 0.001). Median measured energy expenditure was 2004 kcal/day, which was 1.1-fold greater than PSU, 1.2-fold greater than MSJ, and 1.3-fold greater than weight-based nomograms (all P < 0.001).

CONCLUSION

Despite the significant relationships between measured and estimated energy requirements, the significant fold-differences suggest that using predictive equations leads to significant underfeeding, which may result in poor clinical outcomes. Clinicians should rely on IC when available, and increased training in the interpretation of IC is warranted. In the absence of IC, the use of admission weight in weight-based nomograms could serve as a surrogate, as these calculations provided the closest estimate to IC in participants with normal weight and overweight, but not obesity.

Prognostic analysis of the plasma fibrinogen combined with neutrophil-to-lymphocyte ratio in patients with non-small cell lung cancer after radical resection

BACKGROUND

To investigate the correlation between the fibrinogen combined with neutrophil-to-lymphocyte ratio (F-NLR) and the clinicopathologic features of non-small cell lung cancer (NSCLC) patients who underwent radical resection.

METHODS

This study reviewed the medical records of 289 patients with NSCLC who underwent radical resection. The patients were stratified into three groups based on F-NLR as follows: patients with low NLR and fibrinogen were group A, patients with high NLR or fibrinogen were group B, and patients with high NLR and fibrinogen were group C. Receiver operating characteristic curve and Youden index were used to determine the cutoff value of the NLR and fibrinogen. Survival curves were described by Kaplan-Meier method and compared by log-rank test. The univariate and multivariate analyses were performed with the Cox proportional hazard model to identify the prognostic factors.

RESULTS

A value of 3.19 was taken as the optimal cutoff value of NLR in this study. A value of 309 was used as the optimal cutoff value of fibrinogen. Cox multivariate analysis showed that tumor, nodes, metastasis (TNM) stage and F-NLR were independent prognostic factors affecting the survival rate of patients. The first-, third-, and fifth-year survival rates in group A were 99.2%, 96.6%, and 95.0%, respectively. The first-, third-, and fifth-year survival rates in group B were 98.4%, 76.6%, and 63.2%, respectively. The first-, third-, and fifth-year survival rates in group C were 91.3%, 41.1%, and 22.8%, respectively. F-NLR was significantly correlated with overall survival in patients with NSCLC (p < 0.001).

CONCLUSIONS

The F-NLR level is markedly related to the prognosis of patients with NSCLC undergoing radical surgery. Therefore, closer attention should be given to patients with NSCLC with a high F-NLR before surgery to provide postoperative adjuvant therapy.

Nutritional indices may have prognostic value in elderly critically ill patients with sepsis

Aim: Nutritional indicators are associated with adverse outcomes in critically ill elderly patients. In this study, we aimed to evaluate the prognostic potential of prealbumin and albumin in the prediction of mortality in elderly patients with sepsis. Material and Method: A total of 108 patients who developed intensive care unit-acquired sepsis were divided into two groups: Survivors (n=72) and Non-survivors (n=36). Results: Patients in the Non-survivors group were often older (68 vs 74) and presented lower prealbumin (15.1 vs 11), and higher Charlson index (4 vs 6), Sequential Organ Failure Assessment (SOFA) score (8.5 vs 10), C-reactive protein (CRP) (68.8 vs 91) and procalcitonin (PCT) (6 vs 8.4) (p< 0.05). The area under the curve of PCT was the highest at 0.74. Prealbumin presented the best sensitivity (75%) and 12 mg/dL cut-off value, while PCT had the best specificity (75%) and a cut-off value of 7 ng/mL. Although prealbumin was negatively correlated to SOFA score in a significant way (r=-0.226, p=0.019), White blood cells, CRP, and PCT were positively correlated to SOFA score (r=0.198, p=0.040; r=0.233, p=0.015; r=0.286, p=0.003, respectively). In addition, a weak negative correlation was observed between prealbumin and CRP and PCT (r=-0.203, p=0.037; r=-0.215, p=0.026, respectively). Multivariate analysis showed that a reduction in serum prealbumin levels compared to steady prealbumin greater than 4 mg/dL increased the risk of death by 85% (aHR: 1.85, 95% CI: 1.05-2.56, p=0.029). Conclusion: Changes in serum prealbumin in the acute phase of sepsis may assist in determining the risk of mortality and in the administration of specific treatment in critically ill elderly patients.

Albumin to prealbumin ratio in peritoneal dialysis patients: Clinical implication and outcome prediction

Background

Serum prealbumin level is slightly higher, whereas albumin is lower in peritoneal dialysis (PD) than hemodialysis (HD) patients. It is unknown whether albumin to prealbumin ratio (APR) is associated with mortality risk among PD patients. This study aimed to evaluate the clinical implications of APR and its prediction value on long-term outcomes of PD patients.

Methods

The study population were prevalent PD patients at a tertiary hospital. Based on APR, a total of 220 PD patients were divided into 3 groups: group 1: top tertile, median APR: 121.1; IQR:109.5–131.9 (n = 73, male: 37%; age: 59±13); group 2: middle tertile, median APR: 97.1; IQR 93.5–100.0 (n = 73, male:37%; age: 54±14), and group3: bottom tertile, median APR: 81.3; IQR:76.8–85.0 (n = 74, male:38%; 54±11). Patients were followed up for a maximum of 5 years. Outcome of interest was all-cause mortality.

Results

Group 1 was characterized by older age, higher prevalence of diabetes, lower nPCR, higher Davies score and hs-CRP level. APR positively correlated to hs-CRP (β = 0.149, p = 0.045), but negatively correlated to nPCR (β = -0.161, p = 0.034). Hyperprealbuminemia, accounting for 0%, 23.3%, and 82.4% in groups 1,2, and 3, was associated with a lower risk for mortality (HR:0.41, 95%CI = 0.23–0.73). The cumulative survival is significantly lower in group 1 than the other two groups. By multivariable Cox regression, APR (HR:1.02; 95%CI:1.01–1.03) was found to be an independent predictor of long-term mortality.

Conclusion

PD patients with high APR are characterized by having more comorbidities and marked malnutrition-inflammation status, and are associated with long-term mortality, whereas hyperprealbuminemia and lower APR are favorable prognostic factors.

Umbilical Cord and Neonatal Transthyretin and Their Relationship to Growth and Nutrition in Preterm Infants

BACKGROUND

Transthyretin (TTR), also known as prealbumin, has been suggested as an indicator of protein and nutritional status.

OBJECTIVE

The aim of this study was to examine the maternal and umbilical cord (UC) TTR in relation to intrauterine growth, and the serum TTR of preterm infants in relation to nutritional status and growth.

METHODS

After application of exclusion criteria, 49 preterm infants (mean gestational age and birth-weight 32.9±2.9 weeks and 1822±556 g) were included in the study. Transthyretin was sampled at birth and on days 14, 28, and at discharge with growth parameters and nutritional laboratory test results.

RESULTS

Mean UC and maternal TTR were positively correlated (8.5±2.4 mg/dL and 20.4±7.0 mg/dL, r=0.31, P=0.07). Umbilical cord TTR was neither an index of maturity nor of intrauterine growth. Umbilical cord TTR was higher in females (9.4±2.6 versus 7.6±1.8 mg/dL, P=0.015). Maternal TTR was lower in twin pregnancies (16.8±4.9 versus 22.5±7.3 mg/dL, P=0.007). Although TTR levels gradually increased over time in correlation with post-menstrual and chronological ages (r=0.24, P=0.011 and r=0.40, P<0.001, respectively), there was no correlation to weight gain (r=0.10, P=0.41), nutritional status, protein intake, or nutritional laboratory test results. The only significant correlations were between TTR and glucose and triglycerides levels (r=0.51, P<0.001 for both).

CONCLUSIONS

Although TTR levels increased over time, we could not demonstrate significant correlations between TTR and indices of the nutritional status in preterm infants at birth or during the neonatal course.

C-reactive protein to prealbumin ratio: a useful inflammatory and nutritional index for predicting prognosis after curative resection in esophageal squamous cell carcinoma patients

PURPOSE

Although C-reactive protein to prealbumin ratio (CPR) can predict the outcomes of several types of cancer surgeries, little is known about the implication of CPR in patients undergoing esophagectomy for esophageal squamous cell carcinoma (ESCC).

METHODS

Between 2009 and 2018, 682 consecutive ESCC patients who underwent curative esophagectomy were enrolled. The clinicopathological factors and prognoses were compared between the groups stratified by preoperative CPR levels. A logistic regression model was used to determine the risk factors of postoperative pneumonia. Survival curves were constructed using the Kaplan-Meier method and compared using the log-rank test. The Cox proportional hazards model was used to elucidate prognostic factors.

RESULTS

There were more elderly patients, more males, and more advanced clinical T and N categories in the high CPR group than in the low CPR group. Also, the incidence of postoperative pneumonia was significantly higher in the high CPR group than in the low CPR group (32.4% vs. 20.3%, p < 0.01). In multivariate analyses, high CPR was one of the independent predictive factors for postoperative pneumonia (OR, 1.71; 95% CI, 1.15-2.54; p < 0.03). Moreover, high CPR was an independent prognostic factor for overall, cancer-specific, and recurrence-free survivals (HR 1.62; 95% CI 1.18-2.23; p < 0.01, HR 1.57; 95% CI 1.08-2.32; p = 0.02, HR 1.42; 95% CI 1.06-1.90; p = 0.02).

CONCLUSION

Preoperative CPR was found to be a useful inflammatory and nutritional indicator for predicting the occurrence of pneumonia and prognosis in patients with ESCC undergoing esophagectomy.

Correlation between intestinal flora disruption and protein–energy wasting in patients with end-stage renal disease

Background

Different dialysis treatments may affect the composition and structure of the intestinal flora of dialysis-treated chronic kidney disease (CKD) patients. This study aimed to analyze the correlations between the different flora and the nutritional indexes and further explore the potential metabolic pathways in patients with CKD in end-stage renal disease (ESRD).

Methods

Altogether, 102 patients with ESRD were recruited and categorized into the hemodialysis (HD) group (N = 49) and the peritoneal dialysis (PD) group (N = 53). Their biochemical indexes, anthropometric indicators, and inflammatory markers were determined. The total genomic DNA was extracted for 16S ribosomal DNA sequencing. Furthermore, bioinformatics analysis was employed for functional analysis.

Results

Anthropometric indicators, including handgrip strength, mid-upper arm circumference, mid-upper arm muscle circumference, and body mass index, in the HD and PD groups showed a positive correlation with butyric acid-producing bacteria (Rosella and Phascolarctobacterium) and a negative correlation with conditional pathogens (Escherichia spp.). Meanwhile, the inflammatory markers, including high-sensitivity C-reactive protein and interleukin-6, were significantly higher in the PD-protein–energy wasting (PEW) group than in the PD-non-protein–energy wasting (NPEW) group; although they showed an increasing trend in the HD-PEW group, no significant difference was noted. Rosella was considerably scarce in the HD-PEW group than in the HD-NPEW group, whereas Escherichia was substantially more abundant in the PD-PEW group than in the PD-NPEW group. Compared with the HD group, the essential amino acid synthesis pathway, amino acid metabolism-related enzyme pathways, and aminoacyl-transfer RNA biosynthesis pathways were weakened in the PD group. Most carbohydrate metabolic pathways were weakened, although the tricarboxylic acid cycle was slightly enhanced. Concurrently, the fatty acid metabolism was enhanced, whereas fatty acid synthesis was weakened; the metabolic pathways of B vitamins were also weakened. These potential metabolic pathways of the various compounds released by intestinal flora showed a significant correlation with blood biochemical indexes, anthropometric indicators, and inflammatory markers.

Conclusion

In patients with ESRD, different dialysis treatments affected the abundance of butyric acid-producing bacteria (Rosella and Phascolarctobacterium) and conditional pathogens (Escherichia spp.). Butyric acid-producing bacteria showed a positive correlation with PEW and showed a negative correlation with Escherichia. Improving the intestinal diversity and increasing the amount of butyric acid-producing bacteria, such as Blautella, Faecococcus, and Phascolarctobacterium, are potential therapeutic approaches to enhance protein–energy consumption in patients with ESRD.

Predictive Value of Globulin to Prealbumin Ratio for 3-Month Functional Outcomes in Acute Ischemic Stroke Patients

Objective

We aimed to evaluate and compare the association between globulin to albumin ratio (GAR) and globulin to prealbumin ratio (GPR) and 3-month functional prognosis of acute ischemic stroke (AIS) patients receiving intravenous thrombolysis therapy.

Methods

234 AIS patients undergoing intravenous thrombolysis were retrospectively enrolled with acute ischemic stroke from February 2016 to October 2019. Blood sample was collected within 24 h after admission. Poor outcome was defined as the modified Rankin Scale (mRS) ≥ 3 and a favorable outcome as mRS < 3. Severe stroke was defined as the National Institutes of Health Stroke Scale (NIHSS) score > 10 on admission. Student's t-test, Mann–Whitney U test, Chi-square test, logistics' regression analysis, and receiver operating characteristic (ROC) analysis were performed.

Results

Patients with poor functional outcome had higher GAR and GPR levels compared with favorable functional group (p = 0.001, p < 0.001, respectively). Severe stroke was also associated with these two increasing variables. After adjustment for confounding factors, multivariate logistic regression analysis indicated that GPR was an independent indicator predictor of AIS.

Conclusions

The 24 h GPR level can predict the 3-month functional outcome in AIS patients accepting recombinant tissue plasminogen activator (r-tPA) intravenous thrombosis.

GLIM-Defined Malnutrition in Patients with Head and Neck Cancer during the Qualification Visit for Home Enteral Nutrition

Patients with head and neck cancer (HNC) present multiple symptoms that increase the risk of malnutrition. Nutritional care, including enteral nutrition (EN), plays a crucial role in the management of this group of patients. The aim of the study was to determine the Global Leadership Initiative on Malnutrition (GLIM)-based stages of malnutrition and the relationship with selected biochemical parameters during the home enteral nutrition (HEN) qualification visit of patients with HNC. The retrospective analysis involved 224 patients with HNC referred for HEN. The following parameters were evaluated: body mass index (BMI), percent weight loss, and laboratory tests (serum albumin, total serum protein, C-reactive protein (CRP), and total lymphocyte count (TLC)). Malnutrition was defined using GLIM-based criteria. The prevalence of malnutrition based on GLIM criteria was 93.75% (15.18% moderately malnourished, 78.57% severely malnourished). There was a positive correlation between malnutrition based on GLIM criteria, serum albumin, and CRP. In the model assessing the odds of severe malnutrition according to the criteria of GLIM, TLC and CRP had a statistically significant effect on the chance in the probability of qualifying a patient to the severe malnutrition group, but the strength of the results was weak. The prevalence of malnutrition in HNC patients enrolled to HEN is high and most of them are severely malnourished. This suggests that it is important to identify more efficiently patients with risk of malnutrition at an earlier stage. GLIM criteria for malnutrition can be easily applied in this group of patients, but the definition of inflammation criteria should be clarified.

Effect of Whey Proteins on Malnutrition and Extubating Time of Critically Ill COVID-19 Patients

The novel SARS-CoV-2 virus has led to a severe pandemic, starting from early 2020. Intensive care (ICU) management of the COVID-19 disease is difficult with high morbidity and mortality. Early nutritional support, especially with whey protein, seems to be crucial in this medical case. Thus, we aimed to assess the effects of an adequate nutritional protocol rich in whey protein on nutritional and inflammatory status, extubating time, and mortality of critically ill COVID-19 patients (CICP). Methods: A prospective single-center exploratory observational study was undertaken on 32 consecutive CICP admitted to the ICU of Santa Maria Hospital, Terni, Italy, and treated with whey protein-enriched formula. Patients’ demographics, nutritional status, indexes of inflammation, daily pre-albumin serum levels, duration of mechanical ventilation, and mortality were recorded. Results: Thirty-two patients were enrolled. Ninety-five percent of them showed a gradual reduction in C-reactive protein (CRP) values and increase in pre-albumin levels after the whey protein-enriched formula. Prealbumin levels were not correlated with a better nutritional status but with a shorter extubating time and better survival. Conclusions: An adequate administration of whey protein during COVID-19 patients’ ICU stays can provide fast achievement of protein targets, reducing the duration of mechanical ventilation, and improving inflammatory status and ICU survival. Further prospective and large-scale, controlled studies are needed to confirm these results.

Acute Gastrointestinal Injury and Feeding Intolerance as Prognostic Factors in Critically Ill COVID-19 Patients

BACKGROUND

Although acute gastrointestinal injury (AGI) and feeding intolerance (FI) are known independent determinants of worse outcomes and high mortality in intensive care unit (ICU) patients, the incidence of AGI and FI in critically ill COVID-19 patients and their prognostic importance have not been thoroughly studied.

METHODS

We reviewed 218 intubated patients at Stony Brook University Hospital and stratified them into three groups based on AGI severity, according to data collected in the first 10 days of ICU course. We used chi-square test to compare categorical variables such as age and sex and two-sample t-test or Mann-Whitney U-tests for continuous variables, including important laboratory values. Cox proportional hazards regression models were utilized to determine whether AGI score was an independent predictor of survival, and multivariable analysis was performed to compare risk factors that were deemed significant in the univariable analysis. We performed Kaplan-Meier survival analysis based on the AGI score and the presence of FI.

RESULTS

The overall incidence of AGI was 95% (45% AGI I/II, 50% AGI III/IV), and FI incidence was 63%. Patients with AGI III/IV were more likely to have prolonged mechanical ventilation (22 days vs 16 days, P-value <0.002) and higher mortality rate (58% vs 28%, P-value <0.001) compared to patients with AGI 0/I/II. This was confirmed with multivariable analysis which showed that AGI score III/IV was an independent predictor of higher mortality (AGI III/IV vs AGI 0/I/II hazard ratio (HR), 2.68; 95% confidence interval (CI), 1.69-4.25; P-value <0.0001). Kaplan-Meier survival analysis showed that both AGI III/IV and FI (P-value <0.001) were associated with worse outcomes. Patients with AGI III/IV had higher daily and mean D-dimer and CRP levels compared to AGI 0/I/II (P-value <0.0001).

CONCLUSIONS

The prevalence of AGI and FI among critically ill COVID-19 patients was high. AGI grades III/IV were associated with higher risk for prolonged mechanical ventilation and mortality compared to AGI 0/I/II, while it also correlated with higher D-dimer and C-reactive protein (CRP) levels. FI was independently associated with higher mortality. The development of high-grade AGI and FI during the first days of ICU stay can serve as prognostic tools to predict outcomes in critically ill COVID-19 patients.

Is Preoperative Serum Albumin Predictive of Adverse Surgical Outcomes in Maxillofacial Fracture Repair?

PURPOSE

Malnutrition has been recognized as a predictor of postoperative adverse outcomes across many surgical subspecialties. The purpose of this study was to evaluate the relationship between serum albumin and adverse outcomes in patients undergoing operative repair of maxillofacial fractures.

METHODS

The authors utilized the 2011 to 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases to identify patients with facial fractures undergoing operative repair. The primary predictor variable was preoperative serum albumin level. Outcome variables included complications and other adverse outcomes occurring within 30 days of the index operation. Descriptive, bivariate, and multiple logistic regression statistics were utilized to evaluate the relationship between serum albumin and adverse outcomes.

RESULTS

During the study period 1211 subjects underwent operative repair of a facial fracture and had a documented serum albumin level. Of these subjects, 1037 (85.6%) had normal albumin levels and 174 (14.4%) had hypoalbuminemia. A total of 90 subjects experienced a complication (7.43%), although albumin level was not associated with surgical complications or any complication. In bivariate analysis, subjects with hypoalbuminemia were significantly more likely to have an extended length of stay (P ≤ .001), adverse discharge disposition (P ≤ .001), and be readmitted (P = .002). In multivariate analysis, hypoalbuminemia was an independent predictor of an extended length of stay (P ≤ .001, 95% CI 2.50 to 7.62), adverse discharge disposition (P = .048, 95% CI 1.01 to 3.75), and readmission (P = .041, 95% CI 1.03 to 3.47).

CONCLUSIONS

Serum albumin was not an independent predictor of complications after maxillofacial trauma repair. However, it was an independent predictor of other adverse outcomes including extended length of stay, adverse discharge disposition, and readmission. Targeted nutritional optimization may represent an opportunity to improve outcomes in this demographic.

Nutritional Assessment in Older Adults : MNA® 25 years of a Screening Tool and a Reference Standard for Care and Research; What Next?

A tool to assess nutritional status in older persons was really needed. It took 5 years to design the MNA® (Mini Nutrition Assessment) tool, complete the first validations studies both in Europe and in the U.S. and to publish it. After the full MNA®, the MNA® short form and the self-MNA® have been validated. As well as Chinese and other national MNA® forms. Now more than 2000 clinical research have used the MNA® all over the world from community care to hospital. At least 22 Expert groups included the MNA® in new clinical practice guidelines, national or international registries. The MNA® is presently included in almost all geriatric and nutrition textbook and part of the teaching program for medicine and other health care professional worldwide. The urgent need is to target the frail older adults more likely to have weight loss and poor appetite and to prevent frailty and weight loss in the robust. We present in this paper the review of 25 years of clinical research and practice using the MNA® worldwide.

Review of evolution and current status of protein requirements and provision in acute illness and critical care

Nutrition therapy, by enteral, parenteral, or both routes combined, is a key component of the management of critically ill, surgical, burns, and oncology patients. Established evidence indicates overfeeding (provision of excessive calories) results in increased risk of infection, morbidity, and mortality. This has led to the practice of "permissive underfeeding" of calories; however, this can often lead to inadequate provision of guideline-recommended protein intakes. Acutely ill patients requiring nutritional therapy have high protein requirements, and studies demonstrate that provision of adequate protein can result in reduced mortality and improvement in quality of life. However, a significant challenge to adequate protein delivery is the current lack of concentrated protein solutions. Patients often have fluid administration restrictions and existing protein solutions are frequently not sufficiently concentrated to deliver a patient's protein requirements. This has led to the development of new enteral and parenteral nutrition solutions incorporating higher levels of protein in smaller volumes. This review article summarizes current evidence supporting the role of higher protein intakes, especially during the early phases of nutrition therapy in acute illness, methods for assessing protein requirements, as well as, the currently available high-protein enteral and parenteral nutrition solutions. There is sufficient evidence (albeit limited from true randomized, controlled studies) to indicate that earlier provision of guideline-recommended protein intakes may be key to improving patient outcomes and that nutritional therapy that tailors caloric and protein intake to the patients' needs should be considered a desired standard of care.

Transthyretin at Admission and Over Time as a Marker for Clinical Outcomes in Critically Ill Trauma Patients: A Prospective Single-Center Study

Background

Transthyretin (TTR) has been described as a predictor for outcomes in medical and surgical patients. However, the association of TTR on admission and over time on outcomes has not yet been prospectively assessed in trauma patients.

Methods

This is a prospective observational study including trauma patients admitted to the intensive care unit (ICU) of a large Level I trauma center 05/2014–05/2015. TTR levels at ICU admission and all subsequent values over time were recorded. Patients were observed for 28 days or until hospital discharge. The association of outcomes and TTR levels at admission and over time was assessed using multivariable regression and generalized estimating equation (GEE) analysis, respectively.

Results

A total of 237 patients with TTR obtained at admission were included, 69 of whom had repeated TTR measurements. Median age was 40.0 years and median ISS 16.0; 83.1% were male. Below-normal TTR levels at admission (41.8%) were independently associated with higher in-hospital mortality (p = 0.042), more infectious complications (p = 0.032), longer total hospital length of stay (LOS) (p = 0.013), and ICU LOS (p = 0.041). Higher TTR levels over time were independently associated with lower in-hospital mortality (p = 0.015), fewer infections complications (p = 0.028), shorter total hospital and ICU LOS (both p < 0.001), and fewer ventilator days (0.004).

Conclusions

In critically ill trauma patients, below-normal TTR levels at admission were independently associated with worse outcomes and higher TTR levels over time with better outcomes, including lower in-hospital mortality, less infectious complications, shorter total hospital and ICU LOS, and fewer ventilator days. Based on these results, TTR may be considered as a prognostic marker in this patient population.

The Use of Visceral Proteins as Nutrition Markers: An ASPEN Position Paper

Serum albumin and prealbumin, well-known visceral proteins, have traditionally been considered useful biochemical laboratory values in a nutrition assessment. However, recent literature disputes this contention. The aim of this document is to clarify that these proteins characterize inflammation rather than describe nutrition status or protein-energy malnutrition. Both critical illness and chronic illness are characterized by inflammation and, as such, hepatic reprioritization of protein synthesis occurs, resulting in lower serum concentrations of albumin and prealbumin. In addition, the redistribution of serum proteins occurs because of an increase in capillary permeability. There is an association between inflammation and malnutrition, however, not between malnutrition and visceral-protein levels. These proteins correlate well with patients' risk for adverse outcomes rather than with protein-energy malnutrition. Therefore, serum albumin and prealbumin should not serve as proxy measures of total body protein or total muscle mass and should not be used as nutrition markers. This paper has been approved by the American Society for Parenteral and Enteral Nutrition Board of Directors.

Indirect Calorimetry Measurements Compared With Guideline Weight-Based Energy Calculations in Critically Ill Stroke Patients

BACKGROUND

Perturbations in resting energy expenditure (REE) among critically ill stroke patients are ill defined, and guidelines recommend weight-based dosing when indirect calorimetry (IC) is not feasible to estimate daily energy requirements. We aimed to determine whether guideline-recommended weight-based dosing provides adequate energy requirements compared with guidelines recommended IC target.

METHODS

IC data was collected on stroke patients admitted to a neurocritical care unit. We compared low-weight-based dosing (25 kcal/kg) and high (30 kcal/kg) with the IC REE target. Subsequently, we analyzed the effect of stroke subtype on the differences among these measurements.

RESULTS

Seventy-two metabolic studies were performed (45.1% intracerebral hemorrhage [ICH], 18.3% aneurysmal subarachnoid hemorrhage [aSAH], and 36.6% acute ischemic stroke [AIS]). Energy needs, estimated using low-weight-based group, were significantly lower than IC REE target (1496 kcal/day [IQR, 1224-1850] vs 1770 kcal/day [IQR, 1400-2150]; P = .003). High weight-based group energy measurements were similar to IC REE target (1806 kcal/day [IQR, 1530-2236] vs 1770 kcal/day; P = .343). Subgroup analysis showed that low-weight-based calculations were significantly lower than those of IC in ICH and aSAH, but they were similar in AIS (P ≤ .001, .016, and .078, respectively). Linear regression analysis showed that weight, height, and hemorrhagic stroke subtype were associated with IC (P ≤ .001, .024, and .051, respectively).

CONCLUSION

Important differences between weight-based estimation of energy needs and guideline-recommended IC estimation exist for critically ill stroke patients. Low-weight-based calculations of REE underestimate energy needs in ICH and aSAH patients.

Failure of Healing in Chronic Diabetic Wounds: A Case Report

Stalled healing in chronic wounds is a challenging problem for providers and remains multifactorial in etiology. Older adults with insulin-dependent diabetes are at very high risk. In this case report, two patients with large nonhealing wounds were considered for treatment with daily jet lavage irrigation in an attempt to remove the inflammatory products of their respective chronic wounds and eliminate the persisting biofilm bacteria. Several attempts were made to reduce treatments to two to three times per week, and negative-pressure wound therapy was initiated in both cases only to see the return of inflammation and necrosis of the wound bed. In both cases, the daily jet lavage irrigation was successful in creating a granulating wound bed that slowly healed over many months. One patient died with an open sacral pressure injury, and the other patient died 4 months after complete healing of a large heel pressure injury. The interesting observation is the necessity of daily high-intensity wound irrigation to correct the chronic infectious process. Diabetic chronic wounds in high-risk older adults are recalcitrant to standard wound treatments, and providers should consider daily jet lavage wound irrigation to deal with this problem.

The Predictive and Prognostic Factors in Patients with Gastric Cancer Accompanied by Gastric Outlet Obstruction

Purpose

This study is aimed at evaluating the clinicopathological features and prognostic significance of gastric outlet obstruction (GOO) in patients with distal gastric cancer.

Methods

A retrospective review of 1564 individuals with distal gastric cancer from 2002 to 2010 was performed. In total, 157 patients had GOO. The clinicopathological features of the patients with GOO were compared with those of the patients without GOO. A Kaplan-Meier survival analysis and Cox proportional hazard model were used to assess the overall survival.

Results

The patients with distal gastric cancer with GOO generally presented more aggressive pathologic features, a poorer nutritional status, more duodenal infiltration, and peritoneal dissemination than those with cancer without GOO. In the univariate analysis, curability, GOO, age, prealbumin, albumin, hemoglobin (Hb), the tumor size, the macroscopic type, lymph node metastasis, and the depth of invasion had a statistically significant influence on prognosis. The multivariate analysis showed that curability, GOO, the tumor size, lymph node metastasis, and the depth of invasion were independent prognostic factors.

Conclusions

Gastric cancer with GOO exhibits aggressive biological features and has poor outcomes. The multivariate analysis showed that curability, GOO, the tumor size, lymph node metastasis, and the depth of invasion were independent prognostic factors. The gastric outlet status should be considered in the selection of surgical treatment methods for patients with gastric cancer.

Malnutrition and its effects in severely injured trauma patients

Purpose

In hospitalized patients, malnutrition is associated with adverse outcomes. However, the consequences of malnutrition in trauma patients are still poorly understood. This study aims to review the current knowledge about the pathophysiology, prevalence, and effects of malnutrition in severely injured patients.

Methods

A systematic literature review in PubMed and Embase was conducted according to PRISMA-guidelines.

Results

Nine review articles discussed the hypermetabolic state in severely injured patients in relation to malnutrition. In these patients, malnutrition negatively influenced the metabolic response, and vice versa, thereby rendering them susceptible to adverse outcomes and further deterioration of nutritional status. Thirteen cohort studies reported on prevalences of malnutrition in severely injured patients; ten reported clinical outcomes. In severely injured patients, the prevalence of malnutrition ranged from 7 to 76%, depending upon setting, population, and nutritional assessment tool used. In the geriatric trauma population, 7–62.5% were malnourished at admission and 35.6–60% were at risk for malnutrition. Malnutrition was an independent risk factor for complications, mortality, prolonged hospital length of stay, and declined quality of life.

Conclusions

Despite widespread belief about the importance of nutrition in severely injured patients, the quantity and quality of available evidence is surprisingly sparse, frequently of low-quality, and outdated. Based on the malnutrition-associated adverse outcomes, the nutritional status of trauma patients should be routinely and carefully monitored. Trials are required to better define the optimal nutritional treatment of trauma patients, but a standardized data dictionary and reasonable outcome measures are required for meaningful interpretation and application of results.

Electronic supplementary material

The online version of this article (10.1007/s00068-020-01304-5) contains supplementary material, which is available to authorized users.

Hypoglycemia, Malnutrition and Body Composition

Hypoglycemia is one of the most significant factors to affect prognosis, and is detrimental to patients regardless of diabetes mellitus (DM) status. The classical paradigms dictate that hypoglycemia is a result of overtreatment with glucose lowering agents (iatrogenic hypoglycemia), or, as among patients without DM, this condition is attributed to disease severity. New information shows that hypoglycemia occurs among patients that have a tendency for it. Incident hypoglycemia is very prevalent in the hospital setting, occurring in 1:6 patients with DM and in 1:17 patients without DM (Leibovitz E, Khanimov I, Wainstein J, Boaz M; Diabetes Metab Syndr Clin Res Rev. 13:222-226, 2019).One of the major factors associated with incidence of hypoglycemia is the nutritional status on hospital admission and during the hospitalization. Assessment of nutritional status using questionnaires and biomarkers might be helpful in determining risk of hypoglycemia. Moreover, administration of oral nutritional supplements was shown to decrease this risk.It is also well known that a high burden of comorbidities is associated with an increased risk of hypoglycemia. For example, kidney disease, whether acute or chronic, was shown to increase the risk for hypoglycemia, as well as some endocrine disorders.In this review we elaborate on specific findings that are characteristic of patients at risk for developing hypoglycemia, as well as treatment aimed at preventing its occurrence.

Acute Phase Proteins as Predictors of Survival in Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease Requiring Mechanical Ventilation

Few studies have tried to assess prognostic variables in chronic obstructive pulmonary disease (COPD) patients requiring mechanical ventilation (MV). We evaluated serum C reactive protein, (CRP) pre-albumin (PA) and transferrin (TR) levels in AE-COPD patients requiring MV as prognostic markers of in hospital mortality. 93 AE-COPD patients on MV were evaluated. Detailed clinical evaluation was done daily. Serum CRP & PA were measured on admission, 3rd, 8th and 16th day; TR was measured on admission, 8th and 16th day. Demographics, baseline parameters, CRP, PA and TR were correlated with mortality. Of 93 patients, 49 (52.69%) survived whereas 44 patients (47.31%) died. APACHE II, serum urea & albumin were similar in survivors & non-survivors. Baseline CRP (≥10.5 mg/dl) had sensitivity of 60.5%, specificity of 60.2%, with area under curve (AUC) of 0.62 as predictor of mortality. CRP (≥7 mg/dl) on day 3 had sensitivity (65.5%) and specificity (63.3%) with AUC 0.70 as predictor of mortality. Baseline serum prealbumin was 11.00 (0.09-29.26) mg/dl, and similar in survivors & non-survivors (p = 0.7). Prealbumin at day 8 (n = 50) < 13.5 mg/dl had sensitivity 54.6%, and specificity 51.4% with AUC 0.54 (95% CI 0.34-0.75) as predictor of mortality. Transferrin at day 8 (n = 50) of <148.9 had sensitivity 63.4% and specificity 61.4% with AUC 0.61 with respect to mortality. High CRP levels at baseline, persistently elevated CRP (on day 3) may predict mortality in AE-COPD patients requiring MV. Further studies are required to establish prognostic variables in this patient population.

Prealbumin Is Associated With In-Hospital Mortality in Critically Ill Patients

BACKGROUND

Prealbumin (PAB) has been shown to be a useful index of nutrition status in clinically stable patients. In the setting of critical illness, however, PAB is a negative acute phase reactant and may also reflect severity of illness. The purpose of this study was to evaluate the relationship between PAB and clinical outcomes in critically ill patients.

METHODS

This was a single-center, retrospective, nonrandomized cohort study of adult intensive care unit (ICU) patients. Baseline PAB and change in PAB were analyzed. The primary outcome was in-hospital mortality, and the secondary outcome was hospital length of stay (LOS). Data collected included PAB levels, Charlson Comorbidity Index, LOS, in-hospital mortality, and nutrition intake. Linear and logistic regressions were used to characterize the association between PAB levels and clinical outcomes.

RESULTS

Our study included 926 patients. Patients expiring in hospital experienced a greater decrease in PAB over time, -1.3 vs -0.7 mg/dL (odds ratio 0.94 [0.9-0.98] in multivariable regression, P = .002). Baseline PAB was not associated with in-hospital mortality or LOS. Exploratory analyses demonstrated a weak correlation between nutrition and change in PAB.

CONCLUSION

Our data demonstrate that change in PAB is associated with hospital mortality. Nutrition intake weakly correlated with change in PAB. PAB does not appear to be a robust marker of nutrition therapy but may have value as a prognostic indicator in the ICU setting.

Feeding During Resuscitation After Burn Injury

Burn injury results in a sustained hypermetabolic state with resulting increased caloric and protein requirements to support the stress and immune responses; augmented protein, fat, and carbohydrate catabolism; oxidative stress; and exudative losses. Along with surgical debridement, nutrition and resuscitation are the foundations of patient management after severe burn injury. Recent literature has demonstrated a clear benefit to early enteral nutrition initiation during the resuscitation period. This review aims to examine recent literature discussing both physiologic impact of burn injury and approaches to feeding during resuscitation after burn injury; including methods of determining nutrition requirements, routes, timing, and monitoring response and the associated benefits and consequences thereof.

Effect of Enhanced Recovery After Surgery program on pancreaticoduodenectomy: a randomized controlled trial

BACKGROUND

This study aims to investigate the noninferiority of Enhanced Recovery After Surgery (ERAS) for pancreaticoduodenectomy (PD).

METHODS

In this single-center trial, we randomly assigned 276 adult patients who underwent open PD into ERAS and conventional groups with 138 patients in each, from 2015 through 2017. The primary endpoint was the incidence of overall morbidity until postoperative 3 months. The secondary endpoints were in-hospital or 30-day mortality, postoperative length of stay (LOS), nutritional status and overall hospital costs.

RESULTS

Overall morbidity was reported in 64 patients (52.0%, ERAS group) and in 68 patients (54.8%, conventional group) (risk difference [RD] -2.81 percentage points (pp); 90% two-sided confidence interval -13.24 to 7.63). Mortality did not occur in any patients. The two groups did not differ significantly in median postoperative LOS (both 11 days; RD -8.46 pp), body mass index (22.4 ± 2.75 vs. 22.4 ± 2.65 kg/m² ; RD -3.48 pp), Patient-Generated Subjective Global Assessment score over 4 (45 [40.5%] vs. 50 [43.1%] patients; RD -2.56 pp), and median overall hospital cost (15.61 vs. 16.04, ×10⁶ KRW; RD -6.08 pp).

CONCLUSIONS

Even in PD, modified ERAS protocol was not inferior to conventional protocol, while reducing treatment burden.

Inflammation-nutrition score predicts prognosis of patients with resectable hepatocellular carcinoma

BACKGROUND

Various inflammation-based prognostic scores have been associated with poor survival in patients with hepatocellular carcinoma (HCC).

METHODS

Data were collected retrospectively from 674 HCC patients who underwent curative resection. The correlation between INS (inflammation-nutrition score), BCLC (Barcelona Clinic Liver Cancer) stage and inflammatory indices and overall survival (OS) and disease free survival (DFS) was examined.

RESULTS

An elevated INS was associated with both tumor and host clinical characteristics. The combination of INS and BCLC stage stratifies OS and DFS from 80% and 65% (INS = 0, stage A) to 0% (INS = 2, stage C). Univariate and multivariate analyses revealed that the INS was an independent predictor for OS and DFS, and was superior to inflammation-based scores. In addition, INS was demonstrated to be a prognostic factor for patients with early stage and had a higher AUC value in comparison with inflammation scores.

CONCLUSION

This study demonstrates that the INS is an independent marker of poor prognosis in patients with resectable HCC, especially for those with early stage, and it provides complimentary prognostic information to BCLC stage, and may aid in treatment strategy.

Effect of prealbumin level on mortality in heatstroke patients

This study investigated whether serum prealbumin level is associated with mortality in heatstroke patients. A retrospective study of 102 heatstroke patients admitted to the ICU in the Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University from June 2010 to November 2017 was performed they were divided into normal serum prealbumin group (n=79) and low prealbumin group (n=23) according to the difference in PA expression. The clinical data, laboratory inspection data, invasive positive pressure ventilation (IPPV), co-infection, shock and length of ICU stay during the ICU were compared between the two groups of patients. The study endpoints, deaths at admission, were recorded, and the survival curve plotted. Cox regression analysis was performed based on the clinical data of patients, and ROC curve plotted based on Cox multivariate independent prognostic indicators. There were significant differences in clinical variables PLT, ALT, AST, TBIL, ALB, TCH, LDH, TNI, BNP, creatinine, PT, APTT, FBG and D-dimer (P<0.05). The incidence of infection, shock and IPPV was significantly lower in normal serum prealbumin group of patients than those in low prealbumin group (P<0.05). There was a statistically significant difference in short-term survival rate between the groups of patients (χ²=29.101, P<0.001). Prognostic factors for heatstroke patients were IPPV, heart rate, WBC count, PLT count, ALB, PA, TBIL, LDH, CPK, Cr, PCT, PT, APTT, D-dimer, co-infection and shock at admission. Independent prognostic-related factors for heatstroke patients were IPPV, PA level, PLT level, ALB level, CPK level and PT level. When prealbumin <17.95 mg/dl was used as the death threshold for predicting at 28 days, the sensitivity was 77.8%, and the specificity was 85.7%. Significantly associated with the prognosis of heatstroke patients, prealbumin level can be used as an important predictive indicator of the disease progression and worse clinical outcomes.

Sarcopenia Index Is a Simple Objective Screening Tool for Malnutrition in the Critically Ill

BACKGROUND

Reliable and valid tools to screen for malnutrition in the intensive care unit (ICU) remain elusive. The sarcopenia index (SI) [(serum creatinine/serum cystatin C) × 100], could be an inexpensive, objective tool to predict malnutrition. We evaluated the SI as a screening tool for malnutrition in the ICU and compared it with the modified-NUTRIC score.

MATERIALS AND METHODS

This was a historical cohort study of ICU patients with stable kidney function admitted to Mayo Clinic ICUs between 2008 and 2015. Malnutrition was defined by the Subjective Global Assessment. Diagnostic performance was evaluated with the area under the receiver operating characteristic curve (AUC) and multivariable logistic regression.

RESULTS

Of the 398 included patients, 181 (45%) had malnutrition, with 34 (9%) scored as severely malnourished. The SI was significantly lower in malnourished patients than in well-nourished patients (64 ± 27 vs 72 ± 25; P = 0.002), and reductions in SI corresponded to increased malnutrition severity (P = 0.001). As a screening tool, the SI was an indicator of malnutrition risk (AUC 0.61) and performed slightly better than the more complex modified-NUTRIC score (AUC = 0.57). SI cutoffs of 101 and 43 had >90% sensitivity and >90% specificity, respectively, for the prediction of malnutrition. Patients with a low SI (≤43) had a significantly higher risk of mortality (HR = 2.61, 95% CI 1.06-6.48, P = 0.038).

CONCLUSION

The frequency of malnutrition was high in this critically ill population, and it was associated with a poor prognosis. The SI could be used to assess nutrition risk in ICU patients.

A Pilot Study of Amino Acids in Unresectable Non-Small-Cell Lung Cancer Patients During Chemotherapy: A Randomized Serial N-of-1 Trials Design

The aim of this study was to evaluate the effect of amino acids (AAs) on immune function and inflammation level in patients with NSCLC receiving chemotherapy. We conducted a series of randomized, multiple-crossover, double-blind, placebo-controlled N-of-1 trials comparing AAs with isocaloric glucose in unresectable NSCLC patients and combined the individual results using Bayesian statistical modeling. 25 patients completed two cycles of chemotherapy. The baseline total blood albumin (ALB) level in all patients was 28 ± 3.3 g/l, and the mean total ALB level in patients receiving AAs supplementation and isocaloric glucose was 29.2 ± 2.2 and 28.1 ± 3.7 g/l, respectively (P = 0.028). Patients' baseline C-reactive protein (CRP) level was 4 ± 1.2 mg/l, the mean total CRP level in patients receiving AAs supplementation and isocaloric glucose was 11 ± 2.8 and 13 ± 3.2 mg/l, respectively (P = 0.028). The baseline total blood CD4⁺ T cells level was 36 ± 7.8%. The percentage of CD4⁺ T cells in patients receiving AAs supplementation and isocaloric glucose was 42 ± 6.4 and 33.7 ± 17.3, respectively (P = 0.034). Our preliminary results indicated that AAs improve immune status and suppress inflammation in unresectable NSCLC patients receiving chemotherapy.

Clinical diagnostic significance of prealbumin, cholinesterase and retinol binding protein in liver cirrhosis combined with encephalopathy

OBJECTIVE

Hepatic encephalopathy is a common consequence of liver cirrhosis, but diagnosis can be difficult as it is based on clinical criteria alone. We hypothesised that serum prealbumin, cholinesterase and retinol binding protein (RBP) can help support the diagnosis of hepatic encephalopathy.

METHODS

We enrolled 306 cirrhotic patients (110 with encephalopathy), 100 chronic hepatitis B patients and 50 healthy controls, measuring routine liver function tests (ALT, AST, GGT, ALP, and bilirubin), albumin, prothrombin time, prealbumin, cholinesterase and RBP by routine methods. Logistic regression analysis and areas under the receiver operating characteristic curves (AUCs) were used to find predictive factors for hepatic encephalopathy.

RESULTS

There were differences in all laboratory indices between the three groups (all p < 0.001). In univariate analysis, albumin, prothrombin time, prealbumin, cholinesterase and RBP were significantly altered in those with encephalopathy (p < 0.01), but only prealbumin, cholinesterase and RBP levels were significant predictors in multivariate analysis, and each was linked to the severity of liver fibrosis defined by the Child-Pugh score (all p < 0.001). The AUCs (95% CI) of prealbumin, cholinesterase and RBP for diagnosing liver cirrhosis with hepatic encephalopathy were comparable at 0.85 (81-90), 0.81 (0.76-0.85) and 0.81 (0.76-0.86), respectively (all p < 0.01).

CONCLUSIONS

Serum prealbumin, cholinesterase and RBP levels are of potential clinical value in diagnosis of liver cirrhosis complicated by encephalopathy.

Prealbumin and lymphocyte-based prognostic score, a new tool for predicting long-term survival after curative resection of stage II/III gastric cancer

The aim of this retrospective study was to investigate the prognostic significance of pre-treatment immunological and nutritional statuses in patients with locally advanced gastric cancer (GC), and to use the risk factors to develop a predictive score. A total of 731 patients who underwent gastrectomy for stage II/III GC from November 2010 to December 2015 were recruited into this retrospective study. On the basis of univariate and further multivariate Cox regression analyses, decreased pretreatment lymphocyte count (<1·5×109/litre) and prealbumin concentrations (<180 mg/l) were identified to be independently associated with poorer overall survival (OS) and disease-free survival (DFS). Low albumin concentrations (<33 g/l) were identified as an independent risk factor only for OS, but not for DFS. Thereafter, patients who had a decreased prealbumin concentration and lymphocyte count were given a combination of serum prealbumin concentration and lymphocyte count (Co-PaL) score of 2. Patients with only one or neither of these concentrations were given a Co-PaL score of 1 or 0, respectively. Both the OS and the DFS time were inversely related to the Co-PaL scores, and the differences among the three groups were all significant. In contrast, the prognosis did not differ significantly between patients with good nutrition and those with mild to moderate malnutrition according to the prognostic nutritional index. This study indicated that the simple scoring system could accurately predict the prognosis of patients who underwent gastrectomy for stage II/III GC. The score might be helpful in terms of clinical preoperative decision-making.

Lipid paradox in patients with acute myocardial infarction: Potential impact of malnutrition

BACKGROUND & AIMS

Aggressive lipid reduction is recommended for patients with AMI, but reverse epidemiology, the lipid paradox, has been reported in several clinical studies. The cause of lipid paradox remains uncertain, and nutrition is one possible explanation. In this single-center retrospective study, we investigated the relationships between baseline LDL concentrations and clinical outcomes in patients with AMI, stratified by different nutritional status.

METHODS

Totally 409 patients were enrolled for analysis. The Nutritional Risk Index (NRI) was used to estimate the risk of malnutrition. Subjects were grouped into tertiles according to their NRIs. Clinical outcomes were compared among patients with varying NRIs and LDL levels.

RESULTS

Patients in the lowest NRI tertile had increased incidences of in-hospital mortality, cardiogenic shock, decompensated heart failure, renal failure, and sepsis. This tertile was also associated with increased long-term mortality during the follow-up period of 832 ± 744 days. Mortality was increased among patients with baseline LDL concentrations ≤70 mg/dL in the lowest NRI tertile (log rank test, p = 0.0257), but not in the high or median tertiles. Moreover, baseline LDL level ≤70 mg/dL was an independent risk factor of all-cause mortality (adjusted hazard ratio = 1.73; 95% confidence interval, 1.01-2.94; p = 0.045) in the lowest NRI tertile.

CONCLUSIONS

Lipid paradox was observed in the high-risk of malnutrition population among patients with AMI. Aggressive lipid-lowering therapy is still recommended for patients with AMI and fair nutritional status. However, when treating patients at high risk of malnutrition, the improvement of nutritional status may be more beneficial than strict LDL control.

Prealbumin and Retinol Binding Proteins Are Not Usable for Nutrition Follow-Up in Pediatric Intensive Care Units

PURPOSE

Feeding children is a problem in pediatric intensive care units (PICU) and it is difficult to know the correct amount. The purpose of this study is to evaluate if prealbumin or retinol binding proteins (RBP) are effective relative to daily enteral nutrition, without being affected by severity of diseases or infections and can be used to follow up nutritional amount.

METHODS

This is a prospective observational study that includes 81 patients admitted to PICU in Akdeniz University with estimated duration >72 hours, age between 1 month and 8 years. Daily calorie and protein intake were calculated and prealbumin, RBP and C-reactive protein (CRP) levels were measured on the first, third, fifth and seventh mornings.

RESULTS

We find moderate correlation between daily calorie intake and prealbumin levels (r=0.432, p<0.001), RBP levels and daily protein intake (r=0.330, p<0.001). When we investigated the relationship between changes of prealbumin, RBP, CRP, calorie and protein intake during intensive care stay, we found that increase of Prealbumin and RBP levels are explained by decrease of CRP levels (r=-0.546 and -0.645, p<0.001) and not with increase of nourishment.

CONCLUSION

Even adjusted for PRISM3, age and CRP, prealbumin and RBP are correlated with last 24 hours' diet. However, it is not convenient to use as a follow up biomarker because increase of their levels is related with decrease of CRP levels.

Transthyretin for the routine assessment of malnutrition: A clinical dilemma highlighted by an international survey of experts in the field

The value of transthyretin (TTR) measurement for assessing malnutrition is under debate due to its sensitivity to inflammation and frequent confusion over its meaning (i.e. as a marker of diagnosis, prognosis, or efficacy of refeeding). Moreover, there is still no ESPEN/ASPEN guideline on its use and cut-off values. Here the aim was to evaluate the overall perception of the value of this parameter and its utilization worldwide. A panel of international experts in the field were surveyed on the use of TTR in clinical practice in their country, on the guidelines issued by their national health authorities, and on the cut-off values used to diagnose malnutrition. A total of 31 experts (nutrition [n = 9], surgery [n = 8], critical care [n = 4], geriatrics [n = 4], biology [n = 3], pediatrics [n = 1], internal medicine [n = 1] and gastroenterology [n = 1]) from 16 countries participated. TTR only appears in Italian, Polish, British and French national guidelines giving cut-off values for mild/moderate/severe malnutrition. TTR is frequently used in research yet rarely if ever in clinical practice in most countries, the reasons cited being lack of evidence for its usefulness, lack of specificity, or its high cost/effectiveness ratio. Given the difficulty of finding a consensus tool for the diagnosis of malnutrition, there is every reason to consider such a simple and inexpensive marker as TTR. However, further studies are needed to define and unify international guidelines on the use of TTR in terms of inflammation level and the associated cut-off values.

Nutritional and Bioenergetic Considerations in Critically Ill Patients with Acute Neurological Injury

The brain, due to intensive cellular processes and maintenance of electrochemical gradients, is heavily dependent on a constant supply of energy. Brain injury, and critical illness in general, induces a state of increased metabolism and catabolism, which has been proven to lead to poor outcomes. Of all the biochemical interventions undertaken in the ICU, providing nutritional support is perhaps one of the most undervalued, but potentially among the safest, and most effective interventions. Adequate provisions of calories and protein have been shown to improve patient outcomes, and guidelines for the nutritional support of the critically ill patient are reviewed. However, there are no such specific guidelines for the critically ill patient with neurological injury. Patients with primary or secondary neurological disorders are frequently undernourished, while data suggest this population would benefit from early and adequate nutritional support, although comprehensive clinical evidence is lacking. We review the joint recommendations from the Society for Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition, as they pertain to neurocritical care, and assess the recommendations for addressing nutrition in this patient population.

Application of an early oral feeding protocol after pylorus-preserving pancreaticoduodenectomy

PURPOSE

This study evaluates the effect of an enhanced recovery after surgery (ERAS)-based nutrition support protocol on oral intake and weight change in patients who underwent pylorus-preserving pancreaticoduodenectomy (PPPD).

METHODS

A 14-day postoperative nutrition support protocol was developed to initiate oral intake after 1 week of enteral tube feeding and parenteral nutrition (early oral feeding, EOF). Forty-eight patients who underwent PPPD participated in the study (non-EOF, n = 23; EOF, n = 25). General information, nutrition supply route and amount, blood chemistry, and weight changes were tracked.

RESULTS

The enteral tube feeding duration was 2.7 days shorter in the EOF group than in the non-EOF group. Furthermore, the EOF group started oral liquid and soft diets 1.1 and 2.5 days earlier than the non-EOF group, respectively. Compared with the non-EOF group, the EOF group reported a higher energy intake (22.1%; p = 0.001) and protein intake (17.4%; p = 0.000) via oral route. Although cumulative energy and protein intakes were similar in both groups, weight reduction in the EOF group (3.6 ± 0.1%, 2.2 ± 0.7 kg) was significantly less than the non-EOF group (8.2 ± 0.9%, 5.2 ± 0.5 kg). The blood levels of total protein and transferrin increased and prealbumin decreased, regardless of the EOF application. Serum albumin increased significantly only in the EOF group.

CONCLUSION

The EOF protocol developed for post-PPPD patients enables the early initiation and increase in the amount of oral intake while significantly alleviating weight loss.