Global view of vasomotor symptoms and sleep disturbance in menopause: a systematic review

Studies have shown racial/ethnic differences in the prevalence of vasomotor symptoms (VMS), sleep disturbance and VMS treatment in menopause. To assess the reproducibility of these differences, we systematically reviewed observational studies, published in 2000-2021, reporting the prevalence/incidence of VMS, sleep disturbance or treatment use in menopausal women stratified by race/ethnicity. We screened 3799 records from PubMed and Embase and included 27 papers (19 studies). No incidence data were found. Prevalence data varied widely, but some common patterns emerged. In all five studies comparing VMS between Black women and White, Hispanic and/or East Asian women, the prevalence was highest in Black women and lowest in East Asian women. The prevalence of sleep disturbance overall was compared among Black, White and East Asian women in two study populations, and was highest in White women in both papers. Sleep disturbance was more common than VMS in East Asian women. In all four studies comparing hormone therapy use between White women and Black and/or East Asian women, treatment use was more common in White women. These results highlight the need for individualized counseling and treatment, outreach to under-served minorities, and standardized definitions and outcome measures for VMS and sleep disturbance for future studies.

Mediterranean diet: a dietary pattern related to nutritional benefits for hemodialysis patients

INTRODUCTION

In adults with CKD, not on dialysis, there is a recent recommendation suggesting the prescription of a Mediterranean Diet pattern but there is still no evidence to suggest a specific dietary pattern for hemodialysis (HD) patients. The aim of this study was to identify dietary patterns in HD patients and analyze their relationship with nutritional status, physical activity, and survival.

METHODS

This was a longitudinal prospective multicenter study with 12 months of follow-up that included 582 HD patients from 37 dialysis centers. Clinical parameters, dietary intake and physical activity were assessed. Dietary patterns were derived from principal component analysis. A p-value lower than 0.05 was considered statistically significant.

RESULTS

Three different dietary patterns were identified: "Mediterranean", "Western" and "Low animal protein". Patients in the Mediterranean pattern group showed higher intakes of protein (p=0.040), omega 3 fatty acids (p< 0.001), vitamins B12 (p< 0.001), B6 (p< 0.001), C (p< 0.001), D (p< 0.001), folic acid (p< 0.001) and presented a higher practice of moderate physical activity (p=0.010). Despite the lower number of deaths that occurred in the Mediterranean dietary pattern group, we did not observe a statistically significant lower mortality risk (p=0.096).

CONCLUSION

The Mediterranean style pattern was associated with a better nutritional intake profile and in lifestyle related factors such as a higher practice of moderate physical activity in HD patients.

The 2009-2014 economic crisis and deaths by suicide in Portugal: time series analysis

Introduction

Population health, including mental health, is influenced by its socioeconomic context. After the 2008 global economic crisis, studies found contradicting results: some showed an increased risk for self-harm and suicidal behavior, while others found the opposite association. To the best of our knowledge, there is no research in Portugal on the subject. Thus, our aim was to estimate the impact of the Portuguese economic crisis of 2009-2014 on the death rate by suicide and self-inflicted injury in Portugal.

Methods

A retrospective ecological study with an interrupted time series analysis of deaths by suicide and self-inflicted injury (data from the National Statistics Institute) in mainland Portugal, in 2003-2014, was performed. Resident population data was also retrieved from the National Statistics Institute. Binomial negative generalized linear models were used to compare rates and trends before (2003-2008) and during (2009-2014) the economic crisis. All rates were stratified and adjusted for seasonality.

Results

The economic crisis was associated with 13% a step increase in the death rate due to suicide and self-inflicted injury, with unemployment playing a significant mediating role, being negatively associated to the outcome. Differences between groups exist, with males, working-age groups and the North and Centre regions being the most impacted, globally.

Conclusions

Economic downturns pose risks for suicidal behavior. Unemployment may play a role in this association. Employment protection schemes can prevent this impact, so urgent action is needed to prevent economic crisis leading to additional suicides, especially in the context of the COVID-19 pandemic and the economic crisis it caused.

Key messages

• The Portuguese economic crisis of 2009-2014 was associated with an increased death rate due to suicide, especially in males, working-age groups and the North and Centre regions.

• Unemployment may play a role in this association, and active labour market programmes can prevent the negative impacts of economic crisis leading to additional suicides.

Potassium Intake-(Un)Expected Non-Predictor of Higher Serum Potassium Levels in Hemodialysis DASH Diet Consumers

As high serum potassium levels can lead to adverse outcomes in hemodialysis (HD) patients, dietary potassium is frequently restricted in these patients. However, recent studies have questioned whether dietary potassium really affects serum potassium levels. The dietary approaches to stop hypertension (DASH) diet is considered a healthy dietary pattern that has been related to lower risk of developing end-stage kidney disease. The aim of this study was to analyze the association between a dietary pattern with high content of potassium-rich foods and serum potassium levels in HD patients. This was an observational, cross-sectional, multicenter study with 582 HD patients from 37 dialysis centers. Clinical and biochemical data were registered. Dietary intake was obtained using the Food Frequency Questionnaire. Adherence to the DASH dietary pattern was obtained from Fung’s DASH index. All statistical tests were performed using SPSS 26.0 software. A p-value lower than 0.05 was considered statistically significant. Patients’ mean age was 67.8 ± 17.7 years and median HD vintage was 65 (43−104) months. Mean serum potassium was 5.3 ± 0.67 mEq/L, dietary potassium intake was 2465 ± 1005 mg/day and mean Fung´s Dash Index was 23.9 ± 3.9. Compared to the lower adherence to the DASH dietary pattern, patients with a higher adherence to the DASH dietary pattern were older (p < 0.001); presented lower serum potassium (p = 0.021), serum sodium (p = 0.028), total fat intake (p = 0.001) and sodium intake (p < 0.001); and had higher carbohydrate intake (p < 0.001), fiber intake (p < 0.001), potassium intake (p < 0.001), phosphorus intake (p < 0.001) and body mass index (p = 0.002). A higher adherence to this dietary pattern was a predictor of lower serum potassium levels (p = 0.004), even in the adjusted model (p = 0.016). Following the DASH dietary pattern, which is rich in potassium, is not associated with increased serum potassium levels in HD patients. Furthermore, a higher adherence to the DASH dietary pattern predicts lower serum potassium levels. Therefore, generalized dietary potassium restrictions may not be adequate, at least for those with a DASH diet plan.

MO904: Potassium Intake Does Not Predict High Serum Potassium Levels in Haemodialysis Dash Diet Consumers

BACKGROUND AND AIMS

As high serum potassium levels can lead to adverse outcomes in haemodialysis (HD) patients, dietary potassium is frequently restricted in these patients. However, recent studies have questioned whether dietary potassium really affects serum potassium levels. Dietary approaches to stop hypertension (DASH) emphasizes the consumption of potassium rich foods, specially from plant sources, such as: fruits, vegetables, whole grains, nuts and seeds. The aim of this study was to analyze the association between the DASH dietary pattern and serum potassium levels.

METHOD

This was an observational cross-sectional multicentre study with 582 HD patients from 37 dialysis centers. Clinical and biochemical data were registered. Dietary intake was obtained using the Food Frequency Questionnaire. Adherence to DASH dietary pattern was obtained from Fung´s DASH index (8–40 points). For the statistical analysis, Fung´s DASH index was categorized into terciles and mean differences were analyzed with one-way ANOVA. Linear regression was used to analyze the relationship between serum potassium and adherence to the Dash dietary pattern. The multivariate model was adjusted to age, gender, presence of diabetes mellitus, energy intake, dietary potassium intake, residual diuresis, dialysis adequacy (Kt/V), dialysis vintage and intake of potassium binders. All statistical tests were performed using SPSS 26.0 software. A P-value lower than 0.05, was considered statistically significant.

RESULTS

Patients’ mean age was 67.8 ± 17.7 years and median HD vintage was 65 (43–104) months. Mean serum potassium was 5.3 ± 0.67 mEq/L,  dietary potassium intake was 2465 ± 1005 mg/day and mean Fung´s Dash Index was 23.9 ± 3.9. Of the whole sample, 36.4% of the patients presented low adherence to the DASH dietary pattern (0–22 points), 39.0% presented a moderate adherence (23–26 points) whereas 24.6% a high adherence (≥27 points).

Comparing to the lower adherence, patients with a higher adherence to the DASH dietary pattern were older (P &lt; 0.005), presented lower serum potassium (P = 0.021), serum sodium (P = 0.028), albumin (P = 0.030), creatinine (P &lt; 0.005), energy intake (P = 0.006), protein intake (P = 0.010), total fat intake (P = 0.001), sodium intake (P &lt; 0.005), lean tissue index (P = 0.006) and higher carbohydrates intake (P = 0.007), fiber intake (P &lt; 0.005), potassium intake (P &lt; 0.005), body mass index (P = 0.002) and fat tissue index (P &lt; 0.005). No differences were observed in potassium binders, Kt/V, C-reactive protein nor haemoglobin. A higher adherence to this dietary pattern was a predictor of lower serum potassium levels (P = 0.004), even in the adjusted model (P = 0.016).

CONCLUSION

Most of the patients presented a moderate adherence to the DASH dietary pattern. Following this dietary pattern, which is rich in potassium, is not associated with increased serum potassium levels in HD patients. What is more, a higher adherence to the DASH dietary pattern predicts lower serum potassium levels. Therefore, tight dietary potassium restrictions may not be adequate, at least for those with a DASH diet plan as a more flexible diet, especially regarding plant-based foods rich in potassium, may promote other health benefits and reduce patient´s dietary plan limitations.

Zinc Deficient Intake in Hemodialysis Patients: A Path to a High Mortality Risk

BACKGROUND

Zinc is essential for human nutrition and plays an important role in hemodialysis (HD) patients. The aim of this study is to analyze the relationship between zinc intake and mortality in HD patients.

METHODS

This is a longitudinal, prospective, multicenter study with 582 HD patients from 37 dialysis centers. We recorded clinical and body composition parameters. Dietary intake and physical activity data were obtained using the Food Frequency Questionnaire and International Physical Activity Questionnaire. All statistical tests were performed using SPSS 24.0 software. A P value lower than 0.05 was considered statistically significant.

RESULTS

Patients' mean age was 67.8 ± 17.7 years and median HD vintage was 65 (43-104) months. About 53.6% of the patients presented a deficient daily intake of zinc. Patients with the highest zinc intake were those who had a higher lean tissue index (P = .022), energy (P < .001), and protein (p = .022) intakes. Zinc intake was positively correlated with energy (r = 0.709) and protein intake (r = 0.805) and negatively correlated with the malnutrition screening tool score (r = -0.087). A higher energy, protein, and lower carbohydrates intake, as well as lower HD vintage and higher lean tissue index were predictors of zinc intake. A higher mortality risk was observed in patients with zinc intake below the recommended values, even after the adjustment for age, presence of diabetes, gender, dialysis vintage, albumin, lean tissue index, energy intake/kilogram, and level of physical activity (P = .021).

CONCLUSION

There is a high prevalence of HD patients with an inadequate zinc intake, which is related to worse nutritional and body composition parameters and with a higher mortality risk.

MO904DIETARY PATTERNS IN HEMODIALYSIS PATIENTS: RELATIONSHIP WITH CLINICAL AND NUTRITIONAL PARAMETERS

Background and Aims

Nutritional recommendations for hemodialysis (HD) patients focus on the achievement of a sufficient energy and protein intake without exceeding phosphorus, potassium, sodium and/or fluids intake limits. This study aimed to identify different dietary patterns of HD patients and analyze their relationship with clinical and nutritional parameters.

Method

This was a longitudinal prospective multicenter study with 582 HD patients from 37 dialysis centers. Dry weight, Kt/V, serum potassium, phosphorus, calcium, sodium, creatinine and C-reactive protein were measured. Dietary intake was obtained using the Food Frequency Questionnaire. Dietary patterns were derived from principal component analysis based on 20 food groups which were adjusted for total energy intake. Linear regression was used to analyze patterns and the variables of interest. All statistical tests were performed using SPSS 26.0 software. A p-value lower than 0.05, was considered statistically significant.

Results

Patients’ mean age was 67.8±17.7 years and median HD vintage was 65 (43-104) months. Three different dietary patterns were identified: “Western” (31.3% of the patients) with high intake of soft drinks, home-made fried potatoes, caffeinated drinks, red and processed meat, and low intake of fruit and vegetables soup; “Mediterranean” (33.5% of the patients) with high intake of vegetables, beans, fish, olive oil, eggs, and low intake of milk and milk products. Finally, “Low animal protein” (35.2% of the patients) with high intake of whole grain bread, cookies and sweets, vegetables soup and low intake of white bread, rice, pasta and potatoes. Regarding clinical parameters, the Mediterranean pattern was predictor of a higher dry weight (p=0.001), higher creatinine (p=0.032) and lower serum calcium (p=0.024), whereas Western pattern predicted higher phosphorus (p=0.006), sodium (p=0.014) and creatinine (p=0.001). Low animal protein pattern predicted lower creatinine levels (p=0.011). After adjusting for age, gender, presence of diabetes, HD vintage and Kt/V, serum calcium was the only parameter which remained statistical significant within the Mediterranean pattern. Comparing the nutritional parameters studied, the Mediterranean pattern was the strongest predictor of a higher intake of protein (%) (p&lt;0.001), folate (p&lt;0.001), vitamin B12 (p&lt;0.001), vitamin B6 (p&lt;0.001), vitamin C (p&lt;0.001), vitamin D (p&lt;0.001), potassium (p=0.015) and omega 3 fatty acids (p&lt;0.001) and a lower intake of carbohydrates (%) (p&lt;0.001), calcium (p&lt;0.001) and sodium (p=0.006).

Conclusion

Three different dietary patterns were identified in these HD population. The pattern which was closer to the well-known Mediterranean diet was associated with a better nutritional intake profile, which, at least theoretically, are associated with better clinical outcomes.

The difficult journey to treatment for women suffering from heavy menstrual bleeding: a multi-national survey

PURPOSE

Up to 30% of women of reproductive age experience HMB, which has a substantial impact on their quality of life. A clinical care pathway for women with HMB is an unmet need, but its development requires better understanding of the factors that characterise current diagnosis and management of the condition.

MATERIALS AND METHODS

This observational, survey-based study assessed the burden, personal experiences, and path through clinical management of women with HMB in Canada, the USA, Brazil, France and Russia using a detailed, semi-structured online questionnaire. After excluding those reporting relevant organic pathology, responses to the questionnaire from 200 women per country were analysed.

RESULTS

Around 75% of women with HMB had actively sought information about heavy periods, mostly through internet research. The mean time from first symptoms until seeking help was 2.9 (Standard deviation, 3.1) years. However, 40% of women had not seen a health care professional about the condition. Furthermore, 54% had never been diagnosed or treated. Only 20% had been diagnosed and received appropriate treatment. Treatment was successful in 69% of those patients currently receiving treatment. Oral contraceptives were the treatment most commonly prescribed for HMB, although the highly effective levonorgestrel-intrauterine system was used by only a small proportion of women.

CONCLUSIONS

This study provides insight into the typical journey of a woman with HMB which may help patients and health care professionals improve the path to diagnosis and treatment, although further research with long-term outcomes is needed.

Impact of the 2009-2014 economic crisis on suicide attempts and self-harm in Portugal

Background

Following the worldwide economic crisis of 2008, studies have found an increased risk for self-harm and suicide attempts, many of which need hospital care. There is no research in Portugal on the matter. Therefore, our goal was to estimate the impact of the Portuguese economic crisis of 2009-2014 on the hospital admission rates by attempted suicide and self-harm in Portugal.

Methods

A retrospective ecological study, with an interrupted time series analysis of hospital admissions by suicide attempts (data from the national Hospital Mobility Database) in mainland Portugal, between 2003 and 2014, was performed. Resident population data over 15 years old was retrieved from the National Statistics Institute. Poisson regression models were used to compare rates and trends before (2003-2008) and during (2009-2014) the Portuguese economic crisis. All rates were adjusted for seasonality.

Results

A total of 35,077 hospital admission episodes by suicide attempt were retrieved. The mean admission rate was 2.947 per 100 000 inhabitants per month before the crisis, falling to 2.798 during the crisis period. Before the crisis, the total admission rate was decreasing 1% per year. After the crisis erupted, there was a level change, with a sudden increase of 7.9%. The suicide and self-harm admission rate, after 2008, was constant and approximately 38.8% higher than expected if the earlier trend had continued.

Conclusions

There was an increase in the total hospital admission rate by suicide attempts and self-harm during the economic crisis period in Portugal, when compared to the previous period.

Key messages

Economic crisis can pose considerable suicide risks. Urgent action is needed to prevent economic crisis leading to additional suicides.

P0928PHYSICALLY ACTIVE PATIENTS IN HEMODIALYSIS: DO THEY HAVE A DIFFERENT EATING PATTERN AND BODY COMPOSITION?

Background and Aims

Body composition influences outcomes in hemodialysis (HD) patients. These patients need to follow specific nutritional recommendations and physical activity has been highly encouraged. The aim of this study was to evaluate if there are differences in body composition and in dietary patterns between physically active and no physically active HD patients.

Method

This was a multicenter observational cross-sectional study where 582 HD patients from 38 dialysis centers were enrolled. Clinical parameters were recorded and body composition analysis was performed with the Body Composition Monitor®. Dietary intake and physical activity were obtained respectively from the Food Frequency Questionnaire and from the International Physical Activity Questionnaire, both validated for the Portuguese population. For the analysis, patients were divided in 2 groups: physically active (PA), if they follow the World Health Organization recommendations, and no physically active (NPA). T-student and non-parametric tests were performed to compare means and medians respectively. A p&lt;0.05 was considered significant.

Results

Mean age was 67.8 ±17.7 years, 41.4% were female, 31.6 % had diabetes mellitus and median HD vintage was 65 (Interquartil range:43-104) months. PA patients were younger (p&lt;0.001) and had a higher energy intake (p= 0.017), protein (p=0.016), total fat (p=0.023) and omega 3 fatty acids (p=0.006). Regarding body composition; higher total body water (p=0.027), intracellular water (p=0.002), lean tissue index (p=0.002), % lean tissue mass (p=0.001), body cell mass (p=0.001) and lower % fat (p=0.003) was found in PA patients. Urea pre-dialysis (p=0.013), albumin (p=0.026), creatinine (p&lt; 0.001) and 6 months weight gain (p=0.047) were higher in PA patients whereas age-adjusted Charlson comorbidity index (p&lt;0.001) was lower in these patients. No statistically significant differences were observed among other nutrients or parameters studied nor in body mass index, HD vintage or overhydration.

Conclusion

These data shows that, after comparing PA patients with NPA, differences were observed in body composition and clinical parameters related to a better nutritional status. Moreover, the PA patients` dietary intake was more approximated to the existing recommendations for this population, namely for energy and protein daily intake.

P0925EFFECTS OF A NUTRITION INTERVENTION IN ADDITION TO AN INTRADIALYTIC EXERCISE PROGRAM IN HEMODIALYSIS PATIENTS

Background and Aims

Physical inactivity and low protein intake are related with protein-energy wasting syndrome. This is a very common condition in hemodialysis (HD) patients and is related with poor survival. Both, intradialytic exercise programmes (IEP) and nutrition interventions, are proposed as strategies to increase lean tissue mass in these population. The aim of this study was to analyze the effect of specific nutritional counseling in nutrition, body composition parameters and in eating habits, in patients undergoing HD with an IEP.

Method

This was a multicenter longitudinal intervention study with 3 months of follow-up. We enrolled 88 patients already performing intradialytic exercise (aerobic and strength training) for more than 3 months. These patients had an appointment with the dietitian and received specific nutritional counseling (NC) and a flyer with focus on nutrition recommendations for exercise. Eating habits were obtained through a questionnaire and body composition with bioimpedance spectroscopy (Body Composition Monitor®). Potassium and phosphorus were collected at baseline and 3 months after. Statistical tests were performed with SPSS, version 26.0. A p &lt; 0.05 was considered significant.

Results

Patient’s mean age was 63.5±1.5 years and median HD time was 34 (Interquartil range (IQR): 20-58) months. 61.4% (n=54) were male and 26.1% (n=23) were diabetics. Results pre and pos intervention for the parameters studied were, respectively: Body Mass Index (BMI) 25.4[IQR: 23.7-28.4] Kg/m2 vs. 25.6[IQR: 23.4-28.9] Kg/m2; Fat Tissue Mass 12.6±5.0 Kg/m2 vs. 12.5±4.8 Kg/m2; Lean Tissue Mass 13.5[IQR: 11.5-15.3] Kg/m2 vs. 13.4[IQR: 12.1-15.3] Kg/m2; Body Cell Mass 20.1[IQR: 15.7-25.1] Kg/m2 vs. 20.4[IQR: 16.4-24.8] Kg/m2; % Interdialytic Weight Gain 2.7±1.1 Kg/m2 vs. 2.8±1.1 Kg/m2; potassium 5.1±0.7 mEq/L vs. 5.2±0.8 mEq/L and phosphorus 4.6±1.3 mg/dl vs. 4.8±1.2 mg/dl. No statistically significant differences were observed between baseline and follow-up. Concerning eating habits, the intake of protein sources from meat and fish before the HD session increased after the 3 months (17% vs. 20.5%; p=0.002). About 23% of the patients reported having made changes in their diet after the NC and 60% felt positive changes in performance and fatigue.

Conclusion

We can conclude that NC contributed to increase the consumption of high biological value protein-rich foods and to improve the patient´s perception of fatigue and performance. Moreover, this intervention did not have a worrying effect on potassium and phosphorus levels. Longer follow up studies are needed to analyze the effect on body composition.

Risk and limits in dental practice: a Portuguese approach to medical-legal evaluation and professional liability

Patient safety and quality of healthcare delivery systems are an objective of WHO. This study aims to present and analyse Portuguese clinical data on risk and malpractice in dental practice. Data from the Forensic Dentistry Laboratory (Faculty of Medicine, University of Coimbra) was analysed, between the years of 2013 to 2018. One hundred and seven technical reports were selected, and seventy nine files were included in the iatrogenic sequelae group. Data included the analysis of the performance of dental professionals. Sequelae were divided in descending order of occurrence:1) mandibular dysfunction (53,2%)[(42)79]; 2) neurological deficit (39,2%)[(31)79]; 3) tooth loss (6,3%)[(5)79]; and 4) opening deficit (1,3%)[(1)79].Three major areas with significant expression in the field of expert evaluations were analysed: 1) orthodontic treatment (51,9%), implant rehabilitation (29,1%), and oral surgery. Given the prevalence of malpractice, the need to assess its causes and recognise standards for its prevention is necessary.

Low body cell mass index in hemodialysis patients: Association with clinical parameters and survival

INTRODUCTION

Body cell mass (BCM) is a useful nutritional marker and is not affected by changes in the hydration status that commonly occur in hemodialysis (HD) patients. This study aimed to examine the association between body cell mass index (BCMI) and nutritional parameters, as well as its relationship with long-term survival in these patients.

METHODS

This longitudinal prospective multicenter study followed a cohort of patients in HD for 24 months. The clinical parameters of 2527 patients (mean age 70.3 ± 14.6 years, 55.8% male and mean HD vintage 58 (IQR:33-95) months) were measured and their body composition parameters were assessed by a body composition monitor before the HD session. BCM was converted to BCMI (BCM/height² ) and, taking into account the mean value (6.4 ± 2.1 kg/m² ), we split our study population into 2 groups: G1 (BCMI <6.4 kg/m² ; n = 1366) and G2 (BCMI ≥ 6.4 kg/m² ; n = 1161). All statistical tests were performed using SPSS 20.0 software. A P value lower than 0.05 was considered statistically significant.

FINDINGS

Patients with a BCMI <6.4 kg/m² displayed higher age (P < 0.001), dialysis adequacy (Kt/V) (P < 0.001), total cholesterol (TC) (P = 0.033), high-density lipoprotein cholesterol (HDL-C) (P < 0.001), relative overhydration (overhydration/extracellular water [OH/ECW]) (P < 0.001), CRP (P < 0.001), fat tissue index (FTI) (P < 0.001) and lower normalized protein equivalent of nitrogen appearance (nPNA) (P < 0.001), albumin (P < 0.001), serum creatinine (P < 0.001), creatinine index (P < 0.001), potassium (P < 0.001), phosphorus (P < 0.001), calcium/phosphorus product (Ca X P) (P < 0.001), lean tissue index (LTI) (P < 0.001) and body mass index (BMI) (P = 0.046). The Kaplan-Meier survival curve showed a significantly better survival in female and male patients with BCMI ≥6.4 kg/m² (P = 0.001 and P < 0.001, respectively). In the cox regression analysis, a significantly higher mortality risk was observed in G1 patients (P = 0.001).

DISCUSSION

Our study showed that a low BCMI was a mortality predictor and was associated with worse nutritional parameters in patients undergoing HD.

Evaluating haemodialysis patient's nutritional status: Body mass index or body cell mass index?

OBJECTIVE

Evaluate which of two combinations of parameters based on International Society of Renal Nutrition and Metabolism recommendations could better identify patients with protein-energy wasting (PEW) and to compare the relationship of these two combinations with other clinical and body composition parameters.

METHODS

This was a multicentre longitudinal study with 24 months of follow-up. The PEW patients were characterized by: Group A (G_A ) - normalized protein catabolic rate (nPCR) < 1.0 g/kg per day, albumin <3.8 g/dL and body cell mass index (BCMI) < 6.4 kg/m² (n = 203); Group B (G_B ) - nPCR <1.0 g/kg per day, albumin <3.8 g/dL and body mass index (BMI) <23 kg/m² (n = 109). All the patients who did not meet these requirements were considered "well-nourished" (G_A : n = 1818; G_B : n = 3292).

RESULTS

When compared to the well-nourished patients, PEW patients in the G_A presented higher age, Kt/V, C-reactive protein, relative overhydration, fat tissue index (FTI); lower creatinine, albumin, nPCR, PTH, haemoglobin, phosphorus, calcium X phosphorus product, potassium, dry weight, BMI, BCMI, lean tissue index, %IDWG . In the G_B , well-nourished patients FTI was significantly higher. In Cox analysis, the combination with BCMI was a strong independent predictor of mortality in these patients (hazard ratio: 1.48; confidence interval: 1.00-2.19; P = 0.048), even after adjustment. Although G_B combination seemed to be also a predictor of death (hazard ratio: 2.67; confidence interval: 1.92-3.71; P < 0.001), when adjusted, the association remained no longer significant.

CONCLUSION

A new combination of parameters including protein intake, albumin and BCMI demonstrated significant associations with other nutrition and inflammation parameters as well as with mortality.

Hypophosphatemia: nutritional status, body composition, and mortality in hemodialysis patients

PURPOSE

The aim of the present study was to investigate the relationship between serum phosphate levels, clinical parameters, body composition, and mortality.

METHODS

Multicenter longitudinal observational study of a cohort of 3552 patients in hemodialysis (HD) from 34 Nephrocare dialysis units in Portugal with 24 months of follow-up. Patients were divided into three groups depending on their serum phosphorus (<3.5; 3.5-5.5; >5.5 mg/dL). Statistical tests were performed with SPSS, version 20.0. A p < 0.05 was considered significant.

RESULTS

On the one hand, hypophosphatemia was significantly associated with better dialysis adequacy, higher age and overhydration. On the other hand, it was associated with lower albumin, protein intake, creatinine, hemoglobin, calcium, potassium, magnesium, body mass index (BMI), body cell mass index, fat tissue index and lean tissue index. These patients had lower survival rates compared with those with normo- and hyperphosphatemia. Hypophosphatemia was a predictor of death when adjusted for age, diabetes, HD vintage, gender, and Kt/V. Comparing the mortality predictors in hypo- and hyperphosphatemia, we found that low albumin, BMI, and high overhydration increased the mortality risk in the hypophosphatemic group, whereas in hyperphosphatemic patients data were not statistically significant.

CONCLUSION

Currently, a high prevalence of hypophosphatemia exists in Portuguese HD patients. This condition is associated with worst nutritional and body composition parameters. In the context of additional indices of malnutrition (low albumin, low BMI or severe overhydration), hypophosphatemic patients presented higher mortality risk.

Body Composition and Mortality Predictors in Hemodialysis Patients

OBJECTIVE

To evaluate how different compartments of body composition can affect survival in hemodialysis (HD) patients.

DESIGN

Multicenter longitudinal observational study of a cohort of patients in HD with 12 months of follow-up.

SETTING

Patients from 34 Nephrocare dialysis units in Portugal were included.

SUBJECTS

A total of 697 patients on maintenance HD during 4 hours 3 days per week were enrolled.

INTERVENTION

Dry weight, presence of diabetes, body mass index (BMI), lean tissue index (LTI), fat tissue index (FTI), body cell mass index (BCMI), albumin and hydration status were recorded at baseline. In all patients, the assessment of body composition was carried out using the Body Composition Monitor (BCM; Fresenius Medical Care a Deutschland GmbH, Germany).

MAIN OUTCOME MEASURE

Survival during a 12-month period of follow-up.

RESULTS

Patient's mean (±standard deviation) age was 65.4 ± 14.3 years, and median (interquartile range) HD vintage was 41 (19-81) months. Patients who died during the study period, had higher age (P < .001), lower dry weight (P = .001), BMI (P < .001), albumin (P < .001), LTI (P = .015), and also lower BCMI (P = .046). Patients with diabetes (P = .045), BMI < 18.5 kg/m(2) (P < .001), albumin < 4.0 g/dL (P < .001), relative overhydration ≥ 15% (P = .001), low FTI (P = .019), and also those in the lowest tertile of BCMI (P = .022) displayed a significantly worse survival. In the Cox regression analysis, the overall mortality of patient was related to low FTI, relative overhydration, BMI < 18.5 kg/m(2), BCMI ≤ 5.2 kg/m(2), and albumin < 4.0 g/dL.

CONCLUSIONS

Several body composition parameters demonstrated to have an important role in predicting 1-year mortality in HD patients. Albumin, FTI, and BMI were useful predictors of mortality in these patients.

Luria's neuropsychological evaluation in the nordic countries

The publication of Luria's Neuropsychological Investigation (LNI) by Christensen in 1975 introduced Luria's evaluation procedures to worldwide neuropsychology. The LNI demonstrated the benefit of a thorough qualitative analysis of an individual patient's functioning as well as the usefulness of a comprehensive theory of brain functioning. This article reviews the experiences that led to the development of the LNI, discusses its use and extension in Scandinavian countries, and presents clinical and research applications of the LNI in diagnosis and rehabilitation. A series of case examples provides justification and validity for the continued use of the LNI and related procedures. Discussion of the advantages and disadvantages of the LNI and consideration of possible modifications of the procedures and interpretative methods provide the rationale for continued development of Luria's approach.

Psychopathological symptomatology in brain-injured patients before and after a rehabilitation program

The Symptom Checklist-90 revised (SCL-90-R) was used to evaluate subjective experience of psychopathological symptomatology in 30 patients before and after an intensive four-month neuropsychological rehabilitation program and again one year after completion of the program. The patients were all adults and had suffered acute brain injury as a result of head injury (37%), cerebro vascular accident (37%), anoxia (16%) or other causes (10%). Most had entered the program within two years after injury and at that time they showed slight to moderate elevation on all ten scales of the SCL-90-R. At program completion eight of the scales showed significant or near significant reductions. There were only small and non-significant changes in the scales between program completion and one year follow-up. Among the individual items of the SCL-90-R, the most common complaints related to cognitive difficulties and depression. The same pattern of sustained improvement was largely found for these items. Overall the results suggest, first, that the subjectively perceived distress in the brain-injured patient is diminished by the rehabilitation program, and second, that this reduction sustained at least up to one year following the completion of the program.