Malnutrition in Healthy Individuals Results in Increased Mixed Cytokine Profiles, Altered Neutrophil Subsets and Function

Malnutrition disrupts adaptive immunity during visceral leishmaniasis by enhancing IL-10 production

Protein-energy malnutrition (PEM) is a risk factor for developing visceral leishmaniasis (VL). However, the impact on adaptive immunity during infection is unknown. To study the effect of malnutrition on chronic VL, we used a polynutrient-deficient diet (deficient protein, energy, zinc, and iron), which mimics moderate human malnutrition, followed by Leishmania infantum infection. The polynutrient-deficient diet leads to growth stunting and reduced mass of visceral organs. Malnourished-infected mice harbored more parasites in the spleen and liver, had a reduced number of T lymphocytes, reduced production of IFN-γ by T cells, and exhibited enhanced IL-10 production. To test whether IL-10 blockade would lessen disease in the malnourished mice, we treated infected mice with monoclonal antibody α-IL-10R. α-IL-10R treatment reduced the parasite number of malnourished mice, restored the number of T cells producing IFN-γ, and enhanced hepatic granuloma formation. Our results indicate that malnutrition increases VL susceptibility due to a defective IFN-γ-mediated immunity attributable to increased IL-10 production.

Author Summary

Malnutrition contributes to the development of VL. Despite the advances regarding this association, how malnutrition affects the adaptive immune mechanisms in VL is still unclear. We found that malnutrition disrupts the ability to control parasite replication in the spleen and liver in VL due to defective IFN-γ-mediated immunity, reduced hepatic granuloma formation, and enhanced IL-10 production. Blocking IL-10R signaling restored the protective mechanisms to control parasite replication in the malnourished mice without interfering with the undernutrition state. Thus, we demonstrate that malnutrition disrupts the adaptive immunity against VL due to an aberrant IL-10 production. Understanding the association between malnutrition and VL will provide insights into therapeutic approaches.

A metabolic perspective of the neutrophil life cycle: new avenues in immunometabolism

Neutrophils are the most abundant innate immune cells. Multiple mechanisms allow them to engage a wide range of metabolic pathways for biosynthesis and bioenergetics for mediating biological processes such as development in the bone marrow and antimicrobial activity such as ROS production and NET formation, inflammation and tissue repair. We first discuss recent work on neutrophil development and functions and the metabolic processes to regulate granulopoiesis, neutrophil migration and trafficking as well as effector functions. We then discuss metabolic syndromes with impaired neutrophil functions that are influenced by genetic and environmental factors of nutrient availability and usage. Here, we particularly focus on the role of specific macronutrients, such as glucose, fatty acids, and protein, as well as micronutrients such as vitamin B3, in regulating neutrophil biology and how this regulation impacts host health. A special section of this review primarily discusses that the ways nutrient deficiencies could impact neutrophil biology and increase infection susceptibility. We emphasize biochemical approaches to explore neutrophil metabolism in relation to development and functions. Lastly, we discuss opportunities and challenges to neutrophil-centered therapeutic approaches in immune-driven diseases and highlight unanswered questions to guide future discoveries.

Direct therapeutic effect of sulfadoxine-pyrimethamine on nutritional deficiency-induced enteric dysfunction in a human Intestine Chip

BACKGROUND

Sulfadoxine-pyrimethamine (SP) antimalarial therapy has been suggested to potentially increase the birth weight of infants in pregnant women in sub-Saharan Africa, independently of malarial infection. Here, we utilized female intestinal organoid-derived cells cultured within microfluidic Organ Chips to investigate whether SP could directly impact intestinal function and thereby improve the absorption of essential fats and nutrients crucial for fetal growth.

METHODS

Using a human organ-on-a-chip model, we replicated the adult female intestine with patient organoid-derived duodenal epithelial cells interfaced with human intestinal endothelial cells. Nutrient-deficient (ND) medium was perfused to simulate malnutrition, resulting in the appearance of enteric dysfunction indicators such as villus blunting, reduced mucus production, impaired nutrient absorption, and increased inflammatory cytokine secretion. SP was administered to these chips in the presence or absence of human peripheral blood mononuclear cells (PBMCs).

FINDINGS

Our findings revealed that SP treatment effectively reversed multiple intestinal absorptive abnormalities observed in malnourished female Intestine Chips, as validated by transcriptomic and proteomic analyses. SP also reduced the production of inflammatory cytokines and suppressed the recruitment of PBMCs in ND chips.

INTERPRETATION

Our results indicate that SP could potentially increase birth weights by preventing enteric dysfunction and suppressing intestinal inflammation. This underscores the potential of SP as a targeted intervention to improve maternal absorption, subsequently contributing to healthier fetal growth. While SP treatment shows promise in addressing malabsorption issues that can influence infant birth weight, we did not model pregnancy in our chips, and thus its usefulness for treatment of malnourished pregnant women requires further investigation through clinical trials.

FUNDING

The Bill and Melinda Gates Foundation, and the Wyss Institute for Biologically Inspired Engineering at Harvard University, and the HDDC Organoid Core of the P30 DK034854.

Effect of lactoferrin in oral nutrition supplement (ONS) towards IL-6 and IL-10 in failure to thrive children with infection

Background

Growth failure due to infection in children is a major health problem throughout the world. It provokes a systemic immune response, with increased interleukin (IL)-6 and reduced IL-10. Lactoferrin (Lf) is a multifunctional iron-binding protein that can be found in whey protein inside formula milk such as oral nutrition supplement (ONS), which is able to upregulate anti-inflammatory cytokines (IL-10) and modulate pro-inflammatory cytokines. We conducted this study to investigate the effect of Lf supplementation in ONS on IL-6 and IL-10 levels in children with failure to thrive and infection.

Methods

We performed a quasi-experimental pre- and post-study in children aged 12-60 months old with failure to thrive due to infectious illness. The subjects received 400 ml of oral nutritional supplements (ONS, 1 ml equivalent to 1 kcal) each day for 90 days, and their parents received dietary advice and medication based on the underlying illness. Blood was drawn to measure IL-6 and IL-10 before and after the intervention.

Results

There were 75 subjects recruited and divided into group-1 and group-2 based on age. The incidence of undernutrition was 37.33%. Lf in ONS intervention improved body weight and body length. Lf also reduced IL-6, although there was not a significant difference before and after the intervention. However, the IL-6 reduction was significantly higher in subjects with undernutrition compared with subjects with weight faltering. Pre-intervention IL-6 levels were higher in children with stunting than in children with normal stature. There was a greater change in IL-6 in children with severe stunting than in children with normal stature or stunting. IL-10 was significantly reduced after the intervention.

Conclusions

In addition to improving body weight and length, Lf supplementation in ONS improved immune response homeostasis by balancing IL-6 and IL-10 levels and by improving the IL-6/IL-10 ratio.ClinicalTrials.gov number ID: NCT05289674, dated May 3 rd 2022.

Associations of the Geriatric Nutritional Risk Index with high risk for prostate cancer: A cross-sectional study

OBJECTIVES

The geriatric Nutritional Risk Index (GNRI) is an effective tool to assess the nutritional status of the elderly. However, the relationship between the GNRI and the risk for prostate cancer (PCa) remains uncertain in middle-aged and older men. The aim of this study was to investigate the association between the GNRI and the risk for PCa by analyzing the serum total (tPSA) and free prostate-specific antigen (fPSA) levels (including percent fPSA [%fPSA]).

METHODS

Data for this study were obtained from 7396 men ≥40 y of age from the 2001-2010 National Health and Nutrition Survey (NHANES). We obtained the tPSA and fPSA and calculated the %fPSA and the GNRI. Participants with %fPSA >25% and tPSA <4 ng/mL were defined as high PCa risk. The relationship between the GNRI and serum PSA levels was investigated using a linear regression model. The odds ratios (ORs) and 95% confidence intervals (CIs) for the association between the GNRI and PCa risk were estimated by a logistic regression model. The non-linear relationship was also characterized by a restricted cubic spline regression model.

RESULTS

The median of tPSA, fPSA, and %fPSA was 0.90, 0.26, and 29%, respectively. The mean of the GNRI was 29. The proportion of participants in the low PCa- and high PCa-risk groups was 93% and 7%, respectively. There was a negative and linear correlation between the GNRI and serum tPSA and fPSA levels in all models. However, no association between the GNRI and the %fPSA was observed. In the adjusted model, lower GNRI was associated with higher PCa risk (OR, 0.570; 95% CI, 0.415-0.784; Ptrend = 0.001). The restricted cubic spline regression model showed a non-linear and negative association between the GNRI and PCa risk (Pnon-linearity = 0.020), with inflection points of 109.148.

CONCLUSION

The results of this study suggest that nutritional status, as represented by the GNRI, is associated with the risk for PCa.

Role of Malnutrition in Atrial Fibrillation: A Prospective Study including Individuals ≥ 75 Years of Age

BACKGROUND

Atrial fibrillation (AF) is the most common rhythm disorder in the elderly. The AF can cause life-threatening thromboembolic complications. Therefore, there is a need to determine the risk factors of AF. In this study, we aimed to examine the association of markers of malnutrition with AF in individuals aged 75 years and older and to find the factors that may affect mortality.

METHODS

In this prospective study, 358 consecutive individuals aged 75 years and older presenting to the cardiology outpatient clinic were included. All participants were divided into AF and sinus rhythm (SR) groups. In addition, a questionnaire and scoring system were used to assess malnutrition status. Information was obtained from all patients through outpatient clinic visits or telephone interviews for one year. Death from any cause was considered as the endpoint.

RESULTS

AF was observed in 71 (19.8%) patients. Death was higher in patients with AF (p < 0.001), high CONUT score (p = 0.018), and GLIM malnutrition (p = 0.018). GLIM malnutrition caused a 2.8-fold increase in the development of AF.

CONCLUSIONS

Screening for malnutrition in the elderly is essential. According to GLIM criteria, malnutrition may play a role in the development of AF and increase one-year mortality in the elderly.

Immune modulation by nutritional intervention in malnourished children: Identifying the phenotypic distribution and functional responses of peripheral blood mononuclear cells

Malnourished children are susceptible to an increased risk of mortality owing to impaired immune functions. However, the underlying mechanism of altered immune functions and its interaction with malnutrition is poorly understood. This study investigates the immune function and evaluates the effect of a particular nutritional intervention on the immune cells of undernourished children. Stunted (LAZ <-2) and at-risk of being stunted (length-for-age Z-scores, LAZ <-1 to -2) children aged between 12 and 18 months were enrolled and were provided with the daily nutritional intervention of one egg and 150 mL cow's milk for 90 days. Peripheral blood mononuclear cells (PBMCs) were isolated at enrolment and upon completion of the intervention. Phenotypic profiles for CD3+ cells, CD4+ cells, CD8+ cells, NKT cells, and B cells were similar in both cohorts, both before and after the intervention. However, activated B cells (CD25+) were increased after nutritional intervention in the at-risk of being stunted cohort. Several pro-inflammatory cytokines, IL-6, IFN-γ, and TNF-α, were elevated in the stunted children following the nutritional intervention. The results of the study indicate that nutritional intervention may have a role on activated B cells (CD25+) s in children who are at-risk of being stunted and may alter the capacity of PBMC to produce inflammatory cytokines in stunted children.

Changes in Nutritional Status during Induction Phase and Their Association with Fever and Minimal Residual Disease in Paediatric Acute Lymphoblastic Leukaemia

Background and objectives: Acute lymphoblastic leukaemia (ALL) is associated with a cytokine imbalance and oxidative stress, which can be aggravated by malnutrition. Malnutrition, defined by the World Health Organisation (WHO) as obesity or undernutrition, can affect treatment complications and outcomes. Therefore, we aimed to analyse the change in the body mass index (BMI) z-score during induction, as well as evaluate the impact of childhood malnutrition on fevers at an ALL presentation and early response to therapy. Methods: An observational cohort study of 50 consecutive children with ALL, diagnosed in 2019-2022, was performed. Patients were divided into age groups of 0-5, 6-11, and 12-17 years. BMI-for-age z-scores were used to define undernutrition and overnutrition according to WHO growth standards. Results: The number of patients with an abnormal BMI increased from 3 (6%) at diagnosis to 10 (20%) at the end of induction (from 2 (4%) to 6 (12%) in overweight/obese, and from 1 (2%) to 4 (8%) in underweight patients). At the end of induction, all overweight/obese patients were 0-5 years old. On the other hand, a statistically significant decrease in the mean BMI z-score among patients aged 12-17 was observed (p = 0.005). The mean BMI z-score differed statistically significantly among children aged 0-5 presenting with and without fever (p = 0.001). The minimal residual disease (MRD) level at the end of induction was not related to BMI at diagnosis. Conclusions: Despite the use of steroids, adolescents are prone to losing weight during an ALL induction, in contrast to preschool children, who tend to gain weight under the same treatment. BMI at diagnosis was related to a fever of ≥38 °C (at ALL presentation) in the 0-5 age group. The results emphasise the importance of careful nutritional status monitoring, with younger and older children as important target groups for weight gain and weight loss interventions, respectively.

Influence of Oxidative Stress and Inflammation on Nutritional Status and Neural Plasticity: New Perspectives on Post-Stroke Neurorehabilitative Outcome

Beyond brain deficits caused by strokes, the effectiveness of neurorehabilitation is strongly influenced by the baseline clinical features of stroke patients, including a patient's current nutritional status. Malnutrition, either as a pre-stroke existing condition or occurring because of ischemic injury, predisposes patients to poor rehabilitation outcomes. On the other hand, a proper nutritional status compliant with the specific needs required by the process of brain recovery plays a key role in post-stroke rehabilitative outcome favoring neuroplasticity mechanisms. Oxidative stress and inflammation play a role in stroke-associated malnutrition, as well as in the cascade of ischemic events in the brain area, where ischemic damage leads to neuronal death and brain infarction, and, via cell-to-cell signaling, the alteration of neuroplasticity processes underlying functional recovery induced by multidisciplinary rehabilitative treatment. Nutrition strategies based on food components with oxidative and anti-inflammatory properties may help to reverse or stop malnutrition and may be a prerequisite for supporting the ability of neuronal plasticity to result in satisfactory rehabilitative outcome in stroke patients. To expand nutritional recommendations for functional rehabilitation recovery, studies considering the evolution of nutritional status changes in post-stroke patients over time are required. The assessment of nutritional status must be included as a routine tool in rehabilitation settings for the integrated care of stroke-patients.

Clinical analysis of hospital acquired mycoplasma pneumoniae infection after cardiac surgery: a case series

Background

Mycoplasma pneumoniae (MP) is a common pathogen of community-acquired respiratory infections. The clinical characteristics hospital-acquired MP infections are rarely reported in the literature. Our ward is mainly responsible for the management of patients during the perioperative period of cardiac surgery. Several patients had fever during the improvement of their condition after cardiac surgery, and the effect of upgrading antibiotics and increasing the antibacterial spectrum was not good.

Methods

Using inpatient data of Guangdong Provincial People's Hospital, we conducted a retrospective case series study of hospital-acquired MP infection after cardiac surgery from January 2015 to December 2020 to investigate the clinical characteristics. Clinical data was extracted from patients with a confirmed diagnosis of MP infection after >48 hours of hospitalization. All analyses for this study were descriptive. Data were expressed as mean ± standard deviation (SD), median with range or number with percentage as appropriate.

Results

We totally included 22 patients. The time of onset of hospital-acquired MP infection after surgery was 23.32±12.57 days, and the duration of antibiotic use before the onset of infection was 4-40 days. Both fever and sore throat were the main symptoms of nosocomial MP infection, and the rash was the most common physical sign. Laboratory tests were normal for peripheral blood leukocyte count and procalcitonin in most patients (17 cases), while the lymphocyte count was decreased in 10 cases. A single serum anti-MP antibody titer ≥1:160 combined with clinical manifestations and imaging helped confirm nosocomial MP infection, although a double serum anti-MP antibody (four-fold change in titer) wasn't seen. With quinolone therapy, such as levofloxacin, all the patients' temperature gradually returned to normal and were discharged uneventfully.

Conclusions

Patients after cardiac surgery should be aware of the presence of hospital-acquired MP infection when they develop new fever accompanied by atypical bacterial infection signs such as sore throat and rash during treatment. In such cases, changes in MP antibody titers need to be monitored and anti-MP therapy is required.

Anemia Is a Strong Predictor of Wasting, Disease Severity, and Progression, in Clinical Tuberculosis (TB)

A typical trait of chronic tuberculosis (TB) is substantial weight loss that concurs with a drop in blood hemoglobin (Hb) levels, causing anemia. In this observational study, we explored Hb levels in 345 pulmonary TB patients. They were divided into anemic or non-anemic groups which related to clinical symptoms, anthropometric measurements, and immune status. Data was obtained in a randomized controlled trial that we previously conducted using nutritional supplementation of TB patients in Ethiopia. A post hoc analysis demonstrated that anemic patients have a higher composite clinical TB score at baseline than non-anemic patients. Consequently, Hb values were significantly lower in underweight patients with moderate to severe disease and/or cavitary TB compared to normal weight patients with mild disease or non-cavitary TB. Anemia was associated with a low body mass index (BMI), low mid-upper arm circumference (MUAC), lower peripheral CD4 and CD8 T cells counts and IFN-γ levels, and a higher erythrocyte sedimentation rate (ESR). Chronic inflammation and TB disease progression appeared to be driven by elevated systemic levels of pro-inflammatory IL-6 in anemic patients. Multivariable modeling confirmed that a low Hb and a low BMI were key variables related to an unfavorable TB disease status. Although Hb levels increased with successful chemotherapy, anemic TB patients maintained a slower clinical recovery compared to non-anemic patients during the intensive phase treatment (two months). In conclusion, anemia is a strong predictor of wasting, disease severity, inflammation, and slower recovery in patients with pulmonary TB.

The Impact of Malnutrition on the Hospital and Infectious Outcomes of Patients Admitted With Alcoholic Hepatitis: 2011 to 2017 Analysis of US Hospitals

GOALS

We specifically evaluate the effect of malnutrition on the infection risks of patients admitted with alcoholic hepatitis using a national registry of hospitalized patients in the United States.

BACKGROUND

Malnutrition is a common manifestation of alcoholic hepatitis that affects patient outcomes.

STUDY

2011 to 2017 National Inpatient Sample was used to isolated patients with alcoholic hepatitis, stratified using malnutrition (protein-calorie malnutrition, sarcopenia, and weight loss/cachexia) and matched using age, gender, and race with 1:1 nearest neighbor matching method. Endpoints included mortality and infectious endpoints.

RESULTS

After matching, there were 10,520 with malnutrition and 10,520 malnutrition-absent controls. Mortality was higher in the malnutrition cohort [5.02 vs. 2.29%, P<0.001, odds ratio (OR): 2.25, 95% confidence interval (CI): 1.93-2.63], as were sepsis (14.2 vs. 5.46, P<0.001, OR: 2.87, 95% CI: 2.60-3.18), pneumonia (10.9 vs. 4.63%, P<0.001, OR: 2.51, 95% CI: 2.25-2.81), urinary tract infection (14.8 vs. 9.01%, P<0.001, OR: 1.76, 95% CI: 1.61-1.91), cellulitis (3.17 vs. 2.18%, P<0.001, OR: 1.47, 95% CI: 1.24-1.74), cholangitis (0.52 vs. 0.20%, P<0.001, OR: 2.63, 95% CI: 1.59-4.35), and Clostridium difficile infection (1.67 vs. 0.91%, P<0.001, OR: 1.85, 95% CI: 1.44-2.37). In multivariate models, malnutrition was associated with mortality [P<0.001, adjusted odds ratio (aOR): 1.61, 95% CI: 1.37-1.90] and infectious endpoints: sepsis (P<0.001, aOR: 2.42, 95% CI: 2.18-2.69), pneumonia (P<0.001, aOR: 2.19, 95% CI: 1.96-2.46), urinary tract infection (P<0.001, aOR: 1.68, 95% CI: 1.53-1.84), cellulitis (P<0.001, aOR: 1.46, 95% CI: 1.22-1.74), cholangitis (P=0.002, aOR: 2.27, 95% CI: 1.36-3.80), and C. difficile infection (P<0.001, aOR: 1.89, 95% CI: 1.46-2.44).

CONCLUSION

This study shows the presence of malnutrition is an independent risk factor of mortality and local/systemic infections in patients admitted with alcoholic hepatitis.

Validation of a Feed Protocol in a Mouse Model That Mimics Marasmic Malnutrition

Host nutritional status directly interferes with immunity and/or susceptibility to infectious diseases. To understand the mechanisms behind this relationship, the use of animal models and feeding protocols is necessary. In the literature, studies reporting marasmic malnutrition in mice are not common. In this context, the objective of this study was to validate a feed methodology that mimics marasmic malnutrition, examining the nutritional, biochemical, and hematological status in BALB/c mice. Weaned BALB/c mice were or were not fed a Restricted diet (36.26% carbohydrate, 8.79% protein, 4.95% fat, and 7.62 kJ/100 g). Some malnourished mice underwent a refed process with a Control diet (65.93% carbohydrate, 24.18% protein, 9.89% fat, and 15.24 kJ/100 g). The nutritional status of the mice was evaluated through phenotypic markers and hematological and biochemical parameters. Our results showed that the Restricted diet was able to induce mild malnutrition in mice, resulting in mouse weight loss of 12%, which could be reversed after refeeding. Malnourished mice demonstrated slow body growth and low body mass index (BMI) values. Malnourished mice also showed physical and behavioral changes, a reduction of 47.5% in leukocyte counts and a 2-fold increase in cholesterol levels. In conclusion, our feeding protocol was able to generate mild malnutrition and cause changes in the nutritional status of mice that could be similar to those observed in marasmic malnutrition.

INTERGROWTH-21 Identifies High Prevalence of Low Symphysis-Fundal Height in Indigenous Pregnant Women Experiencing Multiple Infections, Nutrient Deficiencies, and Inflammation: The Maternal Infections, Nutrient Deficiencies, and Inflammation (MINDI) Cohort

BACKGROUND

In the absence of ultrasound, symphysis-fundal height (SFH) can assess maternal-fetal well-being as it is associated with gestational age, fetal weight, and amniotic fluid volume. However, other modifiers of SFH, including maternal infections, nutrient deficiencies, and inflammation (MINDI), have not been widely explored.

OBJECTIVES

Our objectives were 2-fold: 1) to assess prevalence of low SFH in indigenous Panamanian women using both Pan-American Health Organization (PAHO) and INTERGROWTH-21 standards and 2) to explore associations of SFH with maternal health indicators: infections (oral, skin, urogenital, nematode infections), nutrient deficiencies [protein and iron indicators (ferritin, serum iron, serum transferrin receptor, hepcidin), folate, and vitamins A, D, and B-12], and inflammation [leukocytes, C-reactive protein (CRP), cytokines].

METHODS

For this cross-sectional study, low-SFH-for-gestational-age was assessed using PAHO and INTERGROWTH <10th centile in 174 women at ≥16 weeks of gestation. Bootstrapping selected MINDI variables for inclusion in multivariable fractional polynomial (MFP) logistic regressions for low SFH. Associations of MINDI variables with hepcidin were also investigated.

RESULTS

Prevalence of low SFH was 8% using PAHO, but using INTERGROWTH, 50.6% had SFH <10th centile, including 37.9% <3rd centile. Both PAHO-SFH <10th centile and INTERGROWTH-SFH <3rd centile were associated with higher hepcidin (OR = 1.12, P = 0.008, and OR = 3.04, P = 0.001, respectively) and with lower TNF-α (OR = 0.73, P = 0.012, and OR = 0.93, P = 0.015, respectively). Wood-smoke exposure increased the odds of PAHO-SFH <10th centile (OR = 1.19, P = 0.009), whereas higher BMI decreased the odds of INTERGROWTH-SFH <3rd centile (OR = 0.87, P = 0.012). Lower pulse pressure (OR = 0.90, P = 0.009) and lower inflammatory responses [lower lymphocytes (OR = 0.21, P = 0.026), IL-17 (OR = 0.89, P = 0.011)] distinguished SFH <3rd centile from SFH ≥3rd to <10th centiles using INTERGROWTH-21 standards. The MFP regression for hepcidin controlling for SFH (adjusted R 2 = 0.40, P = 0.001) revealed associations with indicators of inflammation (CRP, P < 0.0001; IL-17, P = 0.012), acidic urinary pH (P = 0.008), and higher intake of supplements (P = 0.035).

CONCLUSIONS

Associations of low SFH with MINDI variables, including hepcidin, highlight its potential for early detection of multicausal in utero growth faltering.

The effect of malnutrition on the infectious outcomes of hospitalized patients with cirrhosis: analysis of the 2011-2017 hospital data

BACKGROUND

In patients with cirrhosis, there is a clinical concern that the development of protein-calorie malnutrition will affect the immune system and predispose these patients to increased infectious outcomes.

AIMS

In this study, we evaluate the effects of malnutrition on the infectious outcomes of patients admitted with cirrhosis.

MATERIALS AND METHODS

This study used the 2011-2017 National Inpatient Sample to identify patients with cirrhosis. These patients were stratified using malnutrition (protein-calorie malnutrition, cachexia, and sarcopenia) and matched using age, gender, and race with 1:1 nearest neighbor matching method. The endpoints included mortality and infectious outcomes.

RESULTS

After matching, there were 96 842 malnutrition-present cohort and equal number of controls. In univariate analysis, the malnutrition cohort had higher hospital mortality [10.40 vs. 5.04% P < 0.01, odds ratio (OR) 2.18, 95% confidence interval (CI) 2.11-2.26]. In multivariate models, malnutrition was associated with increased mortality [P < 0.01, adjusted odds ratio (aOR) 1.32, 95% CI 1.27-1.37] and infectious outcomes, including sepsis (P < 0.01, aOR 1.94, 95% CI 1.89-2.00), pneumonia (P < 0.01, aOR 1.68, 95% CI 1.63-1.73), UTI (P < 0.01, aOR 1.39, 95% CI 1.35-1.43), cellulitis (P < 0.01, aOR 1.09, 95% CI 1.05-1.13), cholangitis (P < 0.01, aOR 1.39, 95% CI 1.26-1.55), and clostridium difficile (P < 0.01, aOR 2.11, 95% CI 1.92-2.31).

CONCLUSION

The results of this study indicate that malnutrition is an independent risk factor of hospital mortality and local/systemic infections in patients admitted with cirrhosis.

How immune-cell fate and function are determined by metabolic pathway choice: The bioenergetics underlying the immune response

Immune cells are highly dynamic in their response to the tissue environment. Most immune cells rapidly change their metabolic profile to obtain sufficient energy to engage in defensive or homeostatic processes. Such "immunometabolism" is governed through intermediate metabolites, and has a vital role in regulating immune-cell function. The underlying metabolic reactions are shaped by the abundance and accessibility of specific nutrients, as well as the overall metabolic status of the host. Here, we discuss how different immune-cell types gain a sufficient energy supply. We then explain how immune cells perform various functions under challenged conditions and expend energy to sustain homeostasis. Finally, we speculate on how the immune-cell metabolic profile might be modulated in health and disease, by manipulating nutrient availability. By such intervention, the recovery of patient with dysregulated immune system responses might be sped up and the fitness of an individual efficiently restored.

Comparison of cricket diet with peanut-based and milk-based diets in the recovery from protein malnutrition in mice and the impact on growth, metabolism and immune function

Some evidence suggests that edible insects could be used to treat malnutrition following protein deficiency. However, additional studies are needed to better assess the potential of edible insects as a therapeutic food supplement and their long-term impact on recovery from malnutrition. The goals of this study were to investigate the effectiveness of a cricket-based diet in recovery from protein-malnutrition in early life, and to compare cricket protein to more traditional sources used for food fortification and supplementation. Protein-malnutrition was induced by administration of an isocaloric hypoprotein diet (5% protein calories) in young male mice for two weeks during puberty, followed by a six-week recovery period using a cricket-, peanut- or milk-based diet. We examined the impact of protein-malnutrition and subsequent recovery on body weight, growth and select biomarkers of inflammation and metabolism. Protein-malnutrition resulted in growth retardation, downregulation of inflammatory markers in spleen tissue, decreased levels of serum triglycerides, and elevated serum levels of leptin and adiponectin. The cricket-based diet performed equally well as the peanut- and milk-based diets in body weight recovery, but there were differences in immune and metabolic markers among the different recovery diets. Results suggest edible crickets may provide an alternative nutrient-dense protein source with relatively low environmental demands for combating the effects of early-life malnutrition compared to more traditional supplementation and fortification sources. Additional investigations are needed to examine the short and long term impacts of different recovery diets on metabolism and immune function.

The relationship between malnutrition risk and inflammatory biomarkers in outpatient geriatric population

PURPOSE

Malnutrition is an underestimated, but significant problem among older persons. It is described as a consequence of genetic and environmental factors, lack of physical activity, and co-morbidities. However, a key role of a geriatrician is to further explore the multidimensional complexity of this issue. The aim of this study was to identify the relationship between nutritional status and different factors, particularly focusing on inflammatory biomarkers.

METHODS

Nutritional status was assessed using Mini-Nutritional-Assessment with a score below 24 (out of 30) defined as malnutrition. Different serum biomarkers of inflammation were measured, such as High-Sensitivity-C-Reactive-Protein (hsCRP), Interleukin-6 (IL-6), Interleukin-8 (IL-8), Interleukin-18(IL-18), osteoprotegerin(OPG), and Soluble-Receptor-For-TNF-alfa(sTNFRII). Medical history, mental status (Mini-Mental-State-Examination, Geriatric-Depression-Scale) and activities of daily living (using Instrumental-Activities-of-Daily-Living-Scale) were used in the evaluation. The relationship between nutritional status and the factors listed was assessed.

RESULTS

The mean age of 76 examined persons (40.8% female) from the outpatient clinic was 71 years. Malnutrition risk was recognized in 29%. The following factors significant in univariate regression were used in stepwise regression analysis: age, sex, mental status (MMSE, GDS), valve disease, number of diseases, IADL. Stepwise regression revealed that the risk of malnutrition was increased by the presence of valve disease, number of diseases, and female sex. Factors that increased the risk of malnutrition were: logsTNFRII (OR = 3.09; 95% CI 1.07-8.96), IL-8 (OR = 1.09; 95% CI 1.00-1.18), and OPG (OR = 1.27; 95% CI 1.02-1.57). Risk of malnutrition was negatively associated with Il-18(OR = 0.995; 95% CI 0.991-0.999).

CONCLUSIONS

Chronic inflammation and immunologic process are likely contributors to the complex etiopathogenesis of malnutrition in older persons.

Nutrient Restriction has Limited Short-Term Effects on Gut, Immunity, and Brain Development in Preterm Pigs

BACKGROUND

Extrauterine growth restriction (EUGR) in preterm infants is associated with higher morbidity and impaired neurodevelopment. Early nutrition support may prevent EUGR in preterm infants, but it is not known if this improves organ development and brain function in the short and long term.

OBJECTIVE

Using pigs as models for infants, we hypothesized that diet-induced EUGR impairs gut, immunity, and brain development in preterm neonates during the first weeks after birth.

METHODS

Forty-four preterm caesarean-delivered pigs (Danish Landrace × Large White × Duroc, birth weight 975 ± 235 g, male:female ratio 23:21) from 2 sows were fed increasing volumes [32-180 mL/(kg·d)] of dilute bovine milk (EUGR group) or the same diet fortified with powdered bovine colostrum for 19 d (CONT group, 50-100% higher protein and energy intake than the EUGR group).

RESULTS

The EUGR pigs showed reduced body growth (-39%, P < 0.01), lower plasma albumin, phosphate, and creatine kinase concentrations (-35 to 14%, P < 0.05), increased cortisol and free iron concentrations (+130 to 700%, P < 0.05), and reduced relative weights of the intestine, liver, and spleen (-38 to 19%, all P < 0.05). The effects of EUGR on gut structure, function, microbiota, and systemic immunity were marginal, although EUGR temporarily increased type 1 helper T cell (Th1) activity (e.g. more blood T cells and higher Th1-related cytokine concentrations on day 8) and reduced colon nutrient fermentation (lower SCFA concentration; -45%, P < 0.01). Further, EUGR pigs showed increased relative brain weights (+19%, P < 0.01), however, memory and learning, as tested in a spatial T-maze, were not affected.

CONCLUSION

Most of the measured organ growth, and digestive, immune, and brain functions showed limited effects of diet-induced EUGR in preterm pigs during the first weeks after birth. Likewise, preterm infants may show remarkable physiological adaptation to deficient nutrient supply during the first weeks of life although early life malnutrition may exert negative consequences later.

The IL-33/ST2 Axis in Immune Responses Against Parasitic Disease: Potential Therapeutic Applications

Parasitic infections pose a wide and varying threat globally, impacting over 25% of the global population with many more at risk of infection. These infections are comprised of, but not limited to, toxoplasmosis, malaria, leishmaniasis and any one of a wide variety of helminthic infections. While a great deal is understood about the adaptive immune response to each of these parasites, there remains a need to further elucidate the early innate immune response. Interleukin-33 is being revealed as one of the earliest players in the cytokine milieu responding to parasitic invasion, and as such has been given the name "alarmin." A nuclear cytokine, interleukin-33 is housed primarily within epithelial and fibroblastic tissues and is released upon cellular damage or death. Evidence has shown that interleukin-33 seems to play a crucial role in priming the immune system toward a strong T helper type 2 immune response, necessary in the clearance of some parasites, while disease exacerbating in the context of others. With the possibility of being a double-edged sword, a great deal remains to be seen in how interleukin-33 and its receptor ST2 are involved in the immune response different parasites elicit, and how those parasites may manipulate or evade this host mechanism. In this review article we compile the current cutting-edge research into the interleukin-33 response to toxoplasmosis, malaria, leishmania, and helminthic infection. Furthermore, we provide insight into directions interleukin-33 research may take in the future, potential immunotherapeutic applications of interleukin-33 modulation and how a better clarity of early innate immune system responses involving interleukin-33/ST2 signaling may be applied in development of much needed treatment options against parasitic invaders.

Risk Factors for False-Negative Interferon-γ Release Assay Results in Culture-Confirmed Childhood TB

A negative interferon-γ release assay (IGRA) result might inappropriately lower the clinical suspicion for childhood tuberculosis (TB) and result in delayed treatment initiation. However, the risk factors associated with false-negative IGRA results in children remain unclear. Between May 2012 and January 2018, 156 culture-confirmed childhood TB patients who had received T-SPOT.TB test were included. Data, including demographic information and clinicopathological variables, were collected via questionnaires. Univariate and multivariate logistic regression analyses were performed to estimate the odds ratio (OR) and corresponding 95% CI of risk factors associated with false-negative T-SPOT.TB results. The positive rate of T-SPOT.TB test was 85.9% in childhood TB patients. Multivariate analysis revealed that younger age (≤ 9 years; OR = 4.782; 95% CI: 1.689, 13.539), weight for age (z-score > 0.37; OR = 4.256; 95% CI: 1.458, 12.428), and hypoproteinemia (total protein ≤ 68.4 g/L; OR = 7.131; 95% CI: 1.864, 27.271) were risk factors for false-negative T-SPOT.TB results in childhood TB. Younger age, overweight, and hypoproteinemia were found to be associated with false-negative T-SPOT.TB results in childhood TB. Health care professionals should consider these risk factors when evaluating suspected childhood TB with negative T-SPOT.TB results.

Immune Responses of the Critically Endangered Yangtze Finless Porpoises (Neophocaena asiaeorientalis ssp. asiaeorientalis) to Escalating Anthropogenic Stressors in the Wild and Seminatural Environments

Increasing anthropogenic stressors are potential threats to biodiversity conservation and management of Yangtze finless porpoises (YFPs). The objective of this study was to indirectly compare the habitat quality of a natural reserve, Poyang Lake and a seminatural reserve, the Tian-E-Zhou Oxbow (TZO) in terms of anthropogenic stressors by investigating different stress and immunological parameters in the blood of YFPs. Samples from a total of 74 YFPs from the TZO (n = 43) and Poyang Lake (n = 31) were collected and analyzed. The animals were divided into ontogenetic groups: male calf, female calf, juvenile female, juvenile male, and adult male, and reproductive groups: pregnant female, lactating female, and pregnant plus lactating. The blood from all the animals was analyzed for general stress (HSP14, SOD1, TXN, and FTL), metabolic stress (ACAT2 and THRA), and immunity-related genes (IL12p40, IFNγ, TNFα; IL1α, IL1ra, COX2, CRPL, IL4, and IL8) using qPCR. YFPs living in Poyang Lake showed an increased relative expression pattern for IFNγ, IL1ra, IL4, ACAT2, and CRPL across all the ontogenetic groups with significantly higher expression in adult males. In contrast, YFPs living in the TZO showed a significantly higher expression in 13 of 15 genes analyzed in the male calf group. Across the reproductive states for porpoises living in Poyang Lake, eight of the 15 genes in the pregnant female and three of the 15 genes in the pregnant plus lactating group had a significantly higher expression level. However, in YFPs living in the TZO, eight of the 15 genes showed significantly higher expression in the pregnant and lactating groups. There was significantly a higher expression of most of the genes in porpoises living in the TZO compared to the age-matched groups from porpoises living in Poyang Lake. The exception was the pregnant female group. The higher relative expression of stress and immune genes in the TZO porpoise population compared to porpoises living in Poyang Lake suggests the effects of worsening habitat quality, possibly indicating water pollution and lack of feeding resources.

Role of neutrophils in ischemic heart failure

Amplified innate leukocytes (neutrophils and monocytes/macrophages) are associated with advanced ischemic and non-ischemic heart failure (HF). Intensified neutrophilic leukocytosis (neutrophilia) and sustained activation of neutrophils is the predominant factor that determines over activated inflammation in acute HF and the outcome of long-term chronic HF. After heart attack, the first wave of innate responsive and short-lived neutrophils is essential for the initiation of inflammation, resolution of inflammation, and cardiac repair, however uncontrolled and long-term activation of neutrophils leads to collateral damage of myocardium. In the presented review, we highlighted the interactive and integrative role of neutrophil phenotypes in cellular and molecular events of ischemic HF. In addition, we discussed the current, nonimmune, immune, and novel paradigms of neutrophils in HF associated with differential factors with a specific interest in non-resolving inflammation and resolution physiology.

Current Understanding of Innate Immune Cell Dysfunction in Childhood Undernutrition

Undernutrition affects millions of children in low- and middle-income countries (LMIC) and underlies almost half of all deaths among children under 5 years old. The growth deficits that characterize childhood undernutrition (stunting and wasting) result from simultaneous underlying defects in multiple physiological processes, and current treatment regimens do not completely normalize these pathways. Most deaths among undernourished children are due to infections, indicating that their anti-pathogen immune responses are impaired. Defects in the body's first-line-of-defense against pathogens, the innate immune system, is a plausible yet understudied pathway that could contribute to this increased infection risk. In this review, we discuss the evidence for innate immune cell dysfunction from cohort studies of childhood undernutrition in LMIC, highlighting knowledge gaps in almost all innate immune cell types. We supplement these gaps with insights from relevant experimental models and make recommendations for how human and animal studies could be improved. A better understanding of innate immune function could inform future tractable immune-targeted interventions for childhood undernutrition to reduce mortality and improve long-term health, growth and development.

Strongyloides stercoralis hyperinfection syndrome: a deeper understanding of a neglected disease

Strongyloides stercoralis hyperinfection syndrome (SHS) is a life-threatening condition that warrants early detection and management. We describe the pathogenesis, organ-specific clinical manifestations, and risk factors associated to this condition. A comprehensive review of the literature was conducted in PubMed, LILACS, EBSCO and SciELO by using the keywords: "hyperinfection syndrome"; "Strongyloides stercoralis"; "disseminated strongyloidiasis"; "systemic strongyloidiasis", "pathogenesis" and "pathophysiology". Relevant articles on this topic were evaluated and included by consensus. Also, a secondary search of the literature was performed. Articles in English and Spanish language were included. SHS has been described in tropical and sub-tropical regions. However, there is growing evidence of cases detected in developed countries favored by increasing migration and the advance in immunosuppressive therapies for oncologic and inflammatory diseases. SHS is characterized by massive multiplication of larvae, typically in immunocompromised hosts. Clinical manifestations vary according to the organ involved and include diarrhea, intestinal bleeding, alveolar hemorrhages, heart failure, jaundice, bacteremia among others. Despite advances in the understanding of this condition, fatality rates are near 90%. Clinicians should consider SHS in the differential diagnosis of acutely ill patients with multiple organ damage and epidemiological risk factors. Adverse outcomes are common, especially with delayed anti-parasitic treatment.

An observational study of perioperative nutrition and postoperative outcomes in patients undergoing laparotomy at Queen Elizabeth Central Hospital in Blantyre, Malawi

Background

Nutritional status in patients undergoing surgery can influence their immune function, tissue repair and, hence, clinical outcomes. This study aimed to assess the perioperative nutrition and postoperative outcome of patients undergoing laparotomy at a tertiary hospital in Malawi.

Methods

A total of 25 patients were included in this prospective, observational study. The Subjective Global Assessment was used to classify each patient according to nutritional status. Handgrip strength was measured for each patient preoperatively and at day 3 postoperatively. Anthropometric measurements were also done. Protein and energy requirements for each participant were estimated and compared to the quantities provided by the hospital diet. Patients were followed up until discharge and outcome variables which included length of hospital stay and wound dehiscence or infectious complications were recorded.

Results

Of the study participants, 20% were well-nourished, 52% were moderately malnourished and 28% were severely malnourished. The median handgrip strength decreased at day 3 postoperatively from the preoperative handgrip strength. Well-nourished patients had higher handgrip strength than malnourished patients both preoperatively and postoperatively. Total energy and protein provided by the hospital diet were significantly lower than the estimated requirements for the patients. Severely malnourished patients had increased median length of hospital stay and increased rate of postoperative complications. Preoperative and postoperative day 3 handgrip strength correlated negatively with the number of postoperative complications and length of hospital stay.

Conclusion

This study showed high rates of malnutrition and inadequate in-hospital nutritional support which were associated with poor clinical outcomes, especially in severely malnourished patients. Proper nutritional assessment and provision of adequate nutritional support should be reinforced in surgical patients to promote favourable clinical outcomes postoperatively. Further studies with larger sample sizes in other patient populations and hospitals in Malawi are required in this area.

Effect of guava and vitamin C supplementation on experimental gingivitis: A randomized clinical trial

OBJECTIVE

To study the effect of guava and synthetic vitamin C on the development of gingival inflammation during experimental gingivitis.

MATERIAL AND METHODS

Participants were randomly assigned to three groups supplemented daily with either 200 g guava, 200 mg synthetic vitamin C or water. The study included a 14 days pre-experimental period with oral hygiene instructions, scaling, prophylaxis and supplementation. Thereafter, experiment gingivitis was initiated, while continuing supplementation. At baseline, Day 7 and Day 14 of experimental gingivitis, Plaque Index (PlI) and Gingival Index (GI) were assessed. During the entire study, dietary fruit/vegetables intake was minimal.

RESULTS

PlI increased in guava, vitamin C and control group (ΔPlI: 1.30, 1.61 and 1.79, respectively). However, the guava group developed significantly less plaque compared to the control group. The GI increase in both guava and vitamin C group was significantly less than the increase in the control group (ΔGI: 0.10, 0.24 and 0.87, respectively).

CONCLUSION

In a population of young nonsmoking adults, consumption of either 200 g guava/day or 200 mg synthetic vitamin C/day, prior to and during the oral hygiene abstention period, has a preventive effect on the development of experimental gingivitis as compared to the control group that developed the usual amount of experimental gingivitis.

Apolipoproteins C-II and C-III as nutritional markers unaffected by inflammation

BACKGROUND

Rapid turnover proteins (RTPs), such as transthyretin (TTR), retinol binding protein (RBP), and transferrin (Tf), provide an accurate assessment of nutritional status but are susceptible to inflammation. Lipid-related markers, which have short half-lives in serum, may be better suited for nutritional assessment. We sought to identify sensitive nutritional markers unaffected by inflammation.

METHODS

Fasting serum samples were collected from 30 malnourished inpatients and 25 healthy volunteers. Malnourished inpatients were divided into 2 groups: a low-C-reactive protein (CRP) group (CRP < 20 mg/l, n = 15) and a high-CRP group (CRP ≥ 20 mg/l, n = 15). Lipid-related markers, traditional nutritional markers, RTPs, micronutrients, and ketone bodies were measured and compared among the groups.

RESULTS

Apolipoprotein (Apo)C-II and ApoC-III concentrations were lower in malnourished inpatients than in the control group. There was no significant difference in ApoC-II and ApoC-III between the low- and high-CRP groups. Carnitine transporters and ketone bodies did not show a significant difference among the three groups. Albumin, TTR, RBP, and Tf concentrations were lowest in the high-CRP group, intermediate in the low-CRP group, and highest in the control group.

CONCLUSIONS

These results indicate that ApoC-II and ApoC-III are appropriate nutritional biomarkers unaffected by inflammation.

Nutritional metabolomics in critical illness

PURPOSE OF REVIEW

Disruption of metabolic homeostasis is universal in the critically ill. Macronutrients and micronutrients are major environmental regulators of metabolite production through their gene regulation effects. The study of large numbers of circulating metabolites is beginning to emerge through the comprehensive profiling of the critically ill. In the critically ill, metabolomic studies consistently show that changes in fatty acids, lipids and tryptophan metabolite pathways are common and are associated with disease state and outcomes.

RECENT FINDINGS

Metabolomics is now being applied in research studies to determine the critical illness response to nutrient deficiency and delivery. Nutritional metabolomics approaches in nutrient deficiency, malnutrition and nutrient delivery have included single time point studies and dynamic studies of critically ill patients over time. Integration of metabolomics and clinical outcome data may create a more complete understanding of the control of metabolism in critical illness.

SUMMARY

The integration of metabolomic profiling with transcription and genomic data may allow for a unique window into the mechanism of how nutrient deficiency and delivery alters cellular homeostasis during critical illness and modulates the regain of cellular homeostasis during recovery. The progress and the challenges of the study of nutritional metabolomics are reviewed here.

Severe childhood malnutrition

The main forms of childhood malnutrition occur predominantly in children <5 years of age living in low-income and middle-income countries and include stunting, wasting and kwashiorkor, of which severe wasting and kwashiorkor are commonly referred to as severe acute malnutrition. Here, we use the term 'severe malnutrition' to describe these conditions to better reflect the contributions of chronic poverty, poor living conditions with pervasive deficits in sanitation and hygiene, a high prevalence of infectious diseases and environmental insults, food insecurity, poor maternal and fetal nutritional status and suboptimal nutritional intake in infancy and early childhood. Children with severe malnutrition have an increased risk of serious illness and death, primarily from acute infectious diseases. International growth standards are used for the diagnosis of severe malnutrition and provide therapeutic end points. The early detection of severe wasting and kwashiorkor and outpatient therapy for these conditions using ready-to-use therapeutic foods form the cornerstone of modern therapy, and only a small percentage of children require inpatient care. However, the normalization of physiological and metabolic functions in children with malnutrition is challenging, and children remain at high risk of relapse and death. Further research is urgently needed to improve our understanding of the pathophysiology of severe malnutrition, especially the mechanisms causing kwashiorkor, and to develop new interventions for prevention and treatment.