Mini Nutritional Assessment in patients with Parkinson's disease: correlation between worsening of the malnutrition and increasing number of disease-years

Abstract

Objective: To monitor the nutritional status of patients with Parkinson's disease using the Mini Nutritional Assessment (MNA) questionnaire.

Patients and methods: This was a 3-year longitudinal study conducted in a national referral centre for Parkinson's disease and other movement disorders. The cohort included 61 Parkinson's disease patients, 37 men and 24 women, mean age of 70.5 ± 5.5 years, mean duration of disease 9 ± 6.3 years; 35 patients were followed-up after 3 years.

Results: MNA score diminished from 24.9 ± 1.6 to 24 ± 2.5 (P = 0.02); the proportion of patients at risk of malnutrition increased from 22.9% to 34.3%. A linear correlation was observed between MNA score and the duration of disease (P = 0.0096). The dietary assessment subscore significantly diminished (8.6 versus 8.1; P = 0.0009) as did body mass index (25.9 ± 3.5 kg/m² versus 27.1 ± 3.1 kg/m²; P = 0.001).

Conclusions: The evaluation of nutritional status should be part of the routine work-up of a Parkinson's disease patient. Dietary education should be included amongst the therapeutic measures designed to improve the general conditions in Parkinson's disease.     

Association between Dietary Conjugated Linoleic Acid and Bone Mineral Density in Postmenopausal Women

Objective: To determine if dietary conjugated linoleic acid (CLA) is associated with bone mineral density (BMD) of different skeletal sites in postmenopausal women.

Methods: A cross-sectional analysis in 136 Caucasian, healthy, postmenopausal women, mean age 68.6 years. BMD and soft tissue were assessed by dual energy x-ray abosorptiometry (DXA). Energy, calcium, protein, fat, CLA and other relevant nutrients were estimated using 3 day dietary records. Supplement use was recorded as well. Current and past physical activity were determined using the Allied Dunbar National Fitness Survey for older adults.

Results: CLA (63.1 ± 46.8 mg, mean ± SD) was a significant predictor of Ward’s triangle BMD (p = 0.040) in a multiple regression model containing years since menopause (18.5 ± 8.4 y), lean tissue, energy intake (1691 ± 382 kcal/day) dietary calcium (873 ± 365 mg), protein (70.6 ± 18.6 g), fat (57.9 ± 23.9 g), zinc (19.2 ± 13.6 mg), and current and past physical activity, with R²_adj = 0.286. Subjects were also divided into groups below (Group 1) and above (Group 2) the median intake for CLA. Group 2 had higher BMD in the forearm, p = 0.042, and higher BMD in the hip, lumbar spine and whole body, however statistical significance was not reached.

Conclusion: These findings indicate dietary CLA may positively benefit BMD in postmenopausal women. More studies are warranted examining the relationship between dietary CLA and BMD.     

Dietary Intakes of Patients with Alcohol Use Disorder During a 4-Week Protocol on an Inpatient Treatment Unit Found to Meet Dietary Reference Intakes for Macronutrients,but Have Variability in Energy Balance and Adequacy of Micronutrient Intake

BackgroundDespite literature supporting the importance of diet during rehabilitation, minimal research quantifies dietary intake during treatment for alcohol use disorder (AUD).ObjectiveThe aim was to quantify dietary intake and energy balance of patients with AUD during inpatient treatment.DesignThis was a secondary analysis of data from a 4-week observational protocol. Participants self-selected food from a room service menu. Dietary intake was recorded by patients and reviewed by nutrition staff. To quantify nutrient and food group intake, data were coded into Nutrition Data Systems for Research software, versions 2016 and 2017. Daily average intake was calculated for all dietary variables.Participants/settingParticipants (n = 22) were adults seeking treatment for AUD at the National Institutes of Health Clinical Center (Bethesda, MD) between September 2016 and September 2017 and who were enrolled in a study examining the microbiome during AUD rehabilitation. Four participants discontinued protocol participation before study week 4 and were not included in analyses examining change over time.Main outcome measuresWeight change, daily energy, and macronutrient and select micronutrient intakes were the main outcome measures included.Statistical analyses performedMean differences in intake and weight were assessed using nonparametric tests.ResultsSixty-four percent of participants were male; mean ± SD age was 46.3 ± 13.0 years, mean ± SD body mass index (calculated as kg/m²) was 23.9 ± 2.5, and mean intake was 2,665 kcal/d (consisting of 45.9% carbohydrate, 34.9% fat, and 19.1% protein). Eighty percent or more of this sample met the Estimated Average Requirement for 10 of 16 micronutrients assessed. Male participants consumed more energy than estimated needs (P = .003) and gained a mean ± SD of 2.67 ± 1.84 kg (P = .006) when an outlier with weight loss and acute pancreatitis was removed from analysis. Female participants did not gain weight or consume more than estimated energy needs.ConclusionsOverall macronutrient intake was within recommended ranges, but intake of other dietary components and weight gain were variable, supporting the need for individualized nutrition care during AUD treatment.     

Dietary Management of Blood Glucose in Medical Critically Ill Overweight and Obese Patients: An Open‐Label Randomized Trial

Background: Enteral nutrition (EN) increases hyperglycemia due to high carbohydrate concentrations while providing insufficient protein. The study tested whether an EN formula with very high‐protein‐ and low‐carbohydrate‐facilitated glucose control delivered higher protein concentrations within a hypocaloric protocol. Methods: This was a multicenter, randomized, open‐label clinical trial with parallel design in overweight/obese mechanically ventilated critically ill patients prescribed 1.5 g protein/kg ideal body weight/day. Patients received either an experimental very high‐protein (37%) and low‐carbohydrate (29%) or control high‐protein (25%) and conventional‐carbohydrate (45%) EN formula. Results: A prespecified interim analysis was performed after enrollment of 105 patients (52 experimental, 53 control). Protein and energy delivery for controls and experimental groups on days 1–5 were 1.2 ± 0.4 and 1.1 ± 0.3 g/kg ideal body weight/day (P = .83), and 18.2 ± 6.0 and 12.5 ± 3.7 kcals/kg ideal body weight/day (P < .0001), respectively. The combined rate of glucose events outside the range of >110 and ≤150 mg/dL were not different (P = .54, primary endpoint); thereby the trial was terminated. The mean blood glucose for the control and the experimental groups were 138 (?SD 108, +SD 177) and 126 (?SD 99, +SD 160) mg/dL (P = .004), respectively. Mean rate of glucose events >150 mg/dL decreased (Δ = ?13%, P = .015), whereas that of 80–110 mg/dL increased (Δ = 14%, P = .0007). Insulin administration decreased 10.9% (95% CI, ?22% to 0.1%; P = .048) in the experimental group relative to the controls. Glycemic events ≤80 mg/dL and rescue dextrose use were not different (P = .23 and P = .53). Conclusions: A very high‐protein and low‐carbohydrate EN formula in a hypocaloric protocol reduces hyperglycemic events and insulin requirements while increasing glycemic events between 80–110 mg/dL.     

Serum Albumin at Diagnosis is an Independent Predictor of Early Mortality in Veteran Patients with Esophageal Cancer

Aims: To identify independent factors that could predict mortality within 6 months in a cohort of patients with esophageal cancer.

Methods: Esophageal cancer patients were grouped into early (≤6 months, n?=?41) and late (>6 months, n?=?81) mortality groups. 52 variables were analyzed by univariable analysis (UA). A multivariable (MVA) regression model was created to identify predictors of early mortality.

Results: When comparing early and late mortality groups, there was no difference in age, BMI, race, histology, or anatomic location between the two groups. UA demonstrated that the early mortality group had a lower mean albumin level (3.3?±?0.1?g/dl vs. 3.8?±?0.1?g/dl; P?<?0.001), poorer ECOG performance status (1.9?±?0.2 vs. 1.1?±?0.1, P?=?0.02), higher WBC count (9.6?±?0.7 K/µL vs. 8.2?±?0.3 K/µL, P?=?0.04), and were less likely to receive surgery (2.4% vs. 22.2%; P?=?0.003), neoadjuvant treatment (4.9% vs. 28.4%; P?=?0.009) and definitive chemoradiation (7.3% vs. 27.2%; P?=?0.01). MVA revealed that only low albumin at diagnosis was an independent predictor of survival (P?=?0.016).

Conclusion: Albumin level at diagnosis is an independent predictor of early mortality and might be used with other variables to provide prognostic information for patients and to guide treatment.     

Postoperative Hypoproteinemia in Cancer Patients Following Extensive Abdominal Surgery Despite Parenteral Nutritional Support

Determination of the predictors of hypoproteinemia among cancer patients following extensive surgery may enhance their nutritional management and clinical outcome. This study evaluated the predictive factors of postoperative hypoproteinemia among cancer patients following extensive abdominal surgery. An age- and gender-matched case-control study (n = 115) was conducted among cancer patients undergoing extensive (cases; n = 81) and moderate (controls; n = 34) abdominal surgery. Case patients received total parenteral nutrition (TPN), including 3 units of fresh frozen plasma and 200 mL 5% human albumin solution, for 8 postoperative days (POD). Case patients had lower mean total serum protein (TSP) levels throughout POD 8 (F value = 13.81; P = 0.001). Despite TPN, cases had greatest mean (±SD) TSP percent change on POD 1 (?24.6% ± 13.0, vs. ?12.6% ± 9.2; P < 0.0001) and did not regain preoperative levels (POD 8: ?14.3% ± 12.5 vs. 6.9% ± 13.4; P = 0.006). The likelihood of hypoproteinemia in this group was greatest on POD 3 (OR = 30.57; 95% CI 5.44–171.83). Multivariate regression analyses indicated that the determinants of postoperative hypoproteinemia were age [Adjusted OR (AOR) = 1.04; 95% CI 1.00–1.08), preoperative TSP (AOR = 0.46; 95% CI 0.23–0.92), and extensive surgery (AOR = 2.65; 95% CI 1.01–6.95). Tailored nutritional support, regarding extent of surgery, preoperative TSP, and patient age are needed to deter the occurrence of postoperative hypoproteinemia and consequent adverse surgical outcome among cancer patients.     

Do Flavonoid Intakes of Postmenopausal Women With Breast Cancer Vary on Very Low Fat Diets?

In the Women's Intervention Nutrition Study (WINS), a very low-fat eating pattern decreased breast cancer recurrence. We assessed whether the women's flavonoid intakes varied on the very low fat diet. A total of 550 randomly selected WINS participants who had been treated with conventional therapy (surgery, chemotherapy, and/or radiation) for primary breast cancer were randomized to either a very low fat diet (15% of calories from fat, N = 218) or their usual diets (30% calories from fat, N = 332). We compared their intakes of total flavonoids and 6 flavonoid classes (isoflavones, flavones, flavanones, flavonols, flavan-3-ols, and anthocyanins) for these 2 groups using the U.S. Department of Agriculture food flavonoid database and a flavonoid dietary supplement database on three 24-h dietary recalls at baseline and 12 mo after randomization. At baseline, neither mean fat intakes (31.7% ± 6.8 SD of calories, n = 332 in the usual diet group and 31.6% ± 6.8 SD of calories, n = 218 in the very low fat diet group; P = NS) nor flavonoid intakes (218 ± 283 SD mg/day, n = 332 in the usual diet group and 236 ± 393 SD mg/day, n = 218 in the very low fat diet group; P = NS) differed. Over half of the women's flavonoid intakes were from the flavan-3-ols. After 12 months of intervention, with 39 participants lost to follow-up, dietary fat intakes were 30.7 ± 8.4 SD calories (n = 316) among those on their usual diets but were significantly lower among those on the very low fat diet intervention: 21.4 ± 8.3 SD calories (n = 195), P = < 0.05. However, flavonoid intakes remained similar in both groups (201 ± 252 SD mg/day, n = 316 in the usual diet group vs. 235 ± 425 SD mg/day, n = 195 in the very low fat group; P = NS). In this random sample of WINS participants, neither total flavonoid intakes nor intakes of subclasses of flavonoids differed between those who had dramatically decreased their fat intakes and those who had not. Flavonoid intakes are therefore unlikely to account for WINS results on differences between the groups in cancer recurrence.     

Three Case Puzzles: One Diagnostic Solution

Practice Pearl

Acute decompensated heart failure (ADHF) leads to nearly I million hospital admissions annually. Recent research indicates that fluid diuresis by intravenous loop diuretics, either high dose or low dose and/or by either bolus or continuous infusion, are similarly effective and equally safe for therapeutic use in patients with ADHF. In addition, ultrafiltration is an effective and safe alternative therapy to loop diuretics for patients with ADHF as part of a strategy to reduce fluid overload.     

Chronic heart failure management in primary healthcare in Poland: Results of a nationwide cross-sectional study

Background: Organizational and educational activities in primary care in Poland have been introduced to improve the chronic heart failure (CHF) management.

Objectives: To assess the use of diagnostic procedures, pharmacotherapy and referrals of CHF in primary care in Poland.

Methods: The cross-sectional survey was conducted in 2013, involving 390 primary care centres randomly selected from a national database. Trained nurses contacted primary care physicians who retrospectively filled out the study questionnaires on the previous year’s CHF management in the last five patients who had recently visited their office. The data on diagnostic and treatment procedures were collected.

Results: The mean age?±?SD of the 2006 patients was 72?±?11 years, 45% were female, and 56% had left ventricular ejection fraction <50%. The percentage of the CHF patients diagnosed based on echocardiography was 67% and significantly increased during the last decade. Echocardiography was still less frequently performed in older patients (≥80 years) than in the younger ones (respectively 50% versus 72%, Ρ?<0.001) and in women than in men (62% versus 71%, P?<0.001). The percentage of the patients treated with β-blocker alone was 88%, but those with a combination of angiotensin inhibition 71%. The decade before, these percentages were 68% and 57%, respectively. Moreover, an age-related gap observed in the use of the above-mentioned therapy has disappeared.

Conclusion: The use of echocardiography in CHF diagnostics has significantly improved in primary care in Poland but a noticeable inequality in the geriatric patients and women remains. Most CHF patients received drug classes in accordance with guidelines.     

A Randomized Controlled Trial of Heart Failure Disease Management in Skilled Nursing Facilities

ObjectivePatients discharged from the hospital to a skilled nursing facility (SNF) are not typically part of a heart failure disease management program (HF-DMP). The objective of this study is to determine if an HF-DMP in SNF improves outcomes for patients with HF.DesignCluster-randomized controlled trial.ParticipantsThe trial was conducted in 47 SNFs, and 671 patients were enrolled (329 HF-DMP; 342 to usual care).MethodsThe HF-DMP included documentation of ejection fraction, symptoms, weights, diet, medication optimization, education, and 7-day visit post SNF discharge. The composite outcome was all-cause hospitalization, emergency department visits, or mortality at 60 days. Secondary outcomes included the composite endpoint at 30 days, change in the Kansas City Cardiomyopathy Questionnaire and the Self-care of HF Index at 60 days. Rehospitalization and mortality rates were calculated as an exploratory outcome.ResultsMean age of the patients was 79 ± 10 years, 58% were women, and the mean ejection fraction was 51% ± 16%. At 30 and 60 days post SNF admission, the composite endpoint was not significant between DMP (29%) and usual care (32%) at 30 days and 60 days (43% vs 47%, respectively). The Kansas City Cardiomyopathy Questionnaire significantly improved in the HF-DMP vs usual care for the Physical Limitation (11.3 ± 2.9 vs 20.8 ± 3.6; P = .039) and Social Limitation subscales (6.0 ± 3.1 vs 17.9 ± 3.8; P = .016). Self-care of HF Index was not significant. The total number of events (composite endpoint) totaled 517 (231 in HF-DMP and 286 in usual care). Differences in the 60-day hospitalization rate [mean HF-DMP rate 0.43 (SE 0.03) vs usual care 0.54 (SE 0.05), P = .04] and mortality rate (HF-DMP 5.2% vs usual care 10.8%, P < .001) were significant.Conclusions and ImplicationsThe composite endpoint was high for patients with HF in SNF regardless of group. Rehospitalization and mortality rates were reduced by the HF-DMP. HF-DMPs in SNFs may be beneficial to the outcomes of patients with HF. SNFs should consider structured HF-DMPs for their patients.     

Acute Effects of a Glucagon‐Like Peptide 2 Analogue,Teduglutide, on Gastrointestinal Motor Function and Permeability in Adult Patients With Short Bowel Syndrome on Home Parenteral Nutrition

Background: Glucagon‐like peptide 2 (GLP‐2) agonists decrease the need for parenteral nutrition (PN) in short bowel syndrome (SBS); mechanisms evaluated to date have focused on the intestinotrophic effect of GLP‐2 agonists such as increased absorptive capacity of the remnant intestine and increased citrulline levels. Other mechanisms may also play a role in effects of GLP‐2 agonists. Aim: To measure effects of a GLP‐2 agonist, teduglutide (TED), compared with placebo (PLA) on gastric emptying (GE), overall gut transit, fluid balance, intestinal monosaccharide absorption, and permeability in patients with SBS on home PN (HPN). Materials and Methods: In 8 adults with SBS on HPN, we compared daily subcutaneous TED (0.05 mg/kg) and PLA (crossover design, each treatment 7 days with a 14‐day washout) on gut transit, intestinal absorption, and permeability after oral mannitol (200 mg) and lactulose (1 g), as well as stool weight and urine volume over 8 hours. Analysis used the paired t test. Results: Of 8 patients, 4 were men, with a mean ± SD age of 54 ± 1 years, body mass index of 25 ± 4 kg/m², residual small intestine of 63 ± 12 cm, and 25% ± 15% of residual colon. The overall gut transit (% emptied at 6 hours) was 53.4% ± 15% for TED vs 62.4% ± 15.2% for PLA (P = .075), with no effect on GE (P = .74). TED increased urine mannitol excretion at 0–2 hours (16.2 ± 3.6 mg TED vs 11.3 ± 2.2 mg PLA, P = .20) and 0–8 hours (32.7 ± 5.9 mg PLA vs 48.8 ± 8.9 mg TED, P = .17). There were no differences in urine lactulose excretion or lactulose/mannitol ratio (0.024 ± 0.005 TED vs 0.021 ± 0.005 PLA). Over 8 hours, TED (vs PLA) numerically reduced stool weight (mean ± SEM, 77 ± 18 g TED vs 106 ± 43 g PLA, P = .42) and increased urine volume (408.9 ± 52.2 mL TED vs 365.7 ± 57.3 mL PLA, P = .34). Conclusion: Seven‐day TED treatment in 8 participants suggests beneficial effects on fluid balance and monosaccharide absorption, and it retarded overall gut transit with no effects on GE or mucosal permeability. Larger, longer, mechanistic studies of TED in SBS are warranted. This trial was registered at clinicaltrials.gov as NCT02099084.     

Point-of-Care Saliva Osmolarity Testing for the Screening of Hydration in Older Adults With Hypertension

ObjectivesOlder adults have an elevated risk of dehydration, a state with proven detrimental cognitive and physical effects. Furthermore, the use of diuretics by hypertensive patients further compounds this risk. This prospective study investigated the diagnostic accuracy of point-of-care (POC) salivary osmolarity (SOSM) measurement for the detection of dehydration in hypertensive adults with and without diuretic pharmacotherapy.DesignProspective diagnostic accuracy study.SettingHome visits to patients recruited from 4 community health centers in West Sulawesi, Indonesia.ParticipantsA total of 148 hypertensive older adults (57 men, 91 women). The mean ages of male and female patients were 69.4 ± 11.4 and 68.1 ± 7.8 years, respectively.MethodsHypertensive adults were divided into 2 groups based on the presence of diuretics in their pharmacotherapeutic regimen. First-morning mid-stream urine samples were used to perform urine specific gravity (USG) testing. Same-day SOSM measurements were obtained using a POC saliva testing system.ResultsBoth USG (P = .0002) and SOSM (P < .0001) were significantly elevated in hypertensive patients with diuretic pharmacotherapy. At a USG threshold of ≥1.030, 86% of diuretic users were classified as dehydrated compared with 55% of non-using participants. A strong correlation was observed between USG and SOSM measurements (r = 0.78, P < .0001). Using a USG threshold of ≥1.030 as a hydration classifier, an SOSM threshold of ≥93 mOsm had a sensitivity of 78.6% and a specificity of 91.1% for detecting dehydration.Conclusions and ImplicationsHypertensive patients on diuretics have significantly higher first-morning USG and SOSM values, indicating a higher likelihood of dehydration relative to those on other classes of antihypertensive medication. POC SOSM assessment correlates strongly with first-morning USG assessment, and represents a rapid and noninvasive alternative to urinary hydration assessment that may be applicable for routine use in populations with elevated risk of dehydration.     

Spontaneous neurocognitive retrieval of patients with sub-acute ischemic stroke is associated with dietary protein intake

Abstract

Objective: To document the relationship between neurocognitive recovery and macronutrient intake of patients suffering from ischemic strokes.

Design: Thirty day prospective study of 17 patients suffering from sub-acute stroke (> 14 days from the index event; 10 males, 7 females; mean age 75 ± 8 years) admitted to our rehabilitation unit.

Results: At admission (ADM), mean energy intake was inadequate (< 24 kcal/kg) for bodily needs, whereas protein (> 0.8 g/kg) and lipid (> 0.7 g/kg) intake was appropriate. Patients were moderately deficient for neurological (NIHSS 10.3 ± 3.5) and cognitive tests (MMSE 22.5 ± 3.3). NIHSS correlated negatively with proteins (r = ?0.47, P = 0.05 at ADM; r = ?0.52, P = 0.03 at 30 days) and positively with carbohydrate/protein ratio (CHO/protein; r = +0.45, P = 0.06 at ADM; r = +0.48, P = 0.05 at 30 days). However, MMSE correlated positively with proteins (r = +0.77, P = 0.0003 at ADM; r = +0.55, P = 0.02 at 30 days) and negatively with (CHO/Prot; r = ?0.57, P = 0.02 at ADM; not significant at 30 days). The relationship remained significant even when the data at ADM and at 30 days where pooled.

Conclusions: In sub-acute strokes, patient neurological and cognitive retrieval could positively be associated with protein intake.     

Randomized,double-blind,placebo-controlled trial to evaluate efficacy of ketodiet in predialytic chronic renal failure

ObjectiveTo assess whether a ketodiet, a combination of ketoanalogs of essential amino acids (KAs) and a very low-protein diet, retards progression of chronic renal failure and maintains nutritional status.DesignA prospective, randomized, double-blind, placebo-controlled trial.SettingNephrology outpatient department in Northern Railways Central Hospital, New Delhi, India.PatientsThirty-four patients in predialytic stages of chronic renal failure (CRF), randomized to 2 comparable groups in terms of age, sex distribution, blood pressure control, etiology, use of angiotensin converting enzyme inhibitors, serum creatinine, glomerular filtration rate (GFR), and body mass index (BMI).InterventionSubjects randomly received either 0.6 g/kg/d protein plus placebo (n = 16) or 0.3 g/kg/d protein plus tablets of KAs (Ketosteril; Fresenius Kabi, Germany) (n = 18) for 9 months. A dietician administered the diet as well as the KAs or the placebo to the patients.Outcome measuresChanges in GFR and renal and nutritional parameters were measured.ResultsMean (± SD) GFR measured by the ^99mTc-DTPA (99 m technetium diethylenetri-aminepenta-aceticacid) plasma sample method was unchanged in the ketodiet group: 28.1 ± 8.8 (before) and 27.6 ± 10.1 mL/min/1.73 m² (after the study) (P = .72). However, it significantly decreased from 28.6 ± 17.6 to 22.5 ± 15.9 mL/min/1.73 m² in the placebo group (P = .015). Serum creatinine before and after the study in the ketodiet group was 2.26 ± 1.03 mg/dL and 2.07 ± 0.8 mg/dL (P = .90) and in the placebo group was 2.37 ± 0.85 and 3.52 ± 2.9 mg/dL (P = .066), respectively. In both groups the mean BMI did not change from 25.4 ± 4.2 to 24.5 ± 4.2 kg/m² (P = .46) for ketodiet and from 25.0 ± 6.8 to 23.9 ± 4.1 kg/m² (P = .39) for the placebo group. Serum total proteins decreased significantly (P = .038) in the placebo group, and serum albumin showed a trend (P = .061) toward reduction, whereas both of these parameters were maintained in the ketodiet group.ConclusionOver a 9-month period, very low-protein diet supplemented with ketoanalogs helped CRF patients to preserve GFR and maintain BMI. KAs were safe and efficacious in retarding the progression of renal failure and preserving the nutritional status of CRF patients.     

Low serum citrulline concentration correlates with catheter-related bloodstream infections in children with intestinal failure

Background: Serum citrulline concentration is used as a biomarker of enterocyte mass and enteral tolerance, and low serum concentrations are correlated with bacteremia in immunosuppressed adults undergoing hematopoietic stem cell transplant. The authors sought to determine if citrulline was associated with the development of catheter‐related bloodstream infections (CRBSIs) in children with intestinal failure. Methods: Data were reviewed from 66 children treated in a multidisciplinary intestinal rehabilitation program, who had serum concentration citrulline measured between January 2007 and August 2009. All patients had a diagnosis of intestinal failure requiring parenteral nutrition (PN) support. Exclusion criteria included central venous catheter in situ <30 days, creatinine clearance <20 mL/minute, or a history of organ transplant/immunosuppression. Results: A total of 15 patients were excluded because of the above criteria. In this cohort of 51 patients, 26 (51%) developed CRBSIs. Both groups were similar in terms of gestational age, diagnosis, nutrition status, and biochemical liver function tests. The mean (± standard deviation [SD]) minimum serum citrulline concentration was significantly lower in patients who developed CRBSIs (6.7 ± 4.6 µmol/L) than in those who did not (11.3 ± 6.4 µmol/L, P = .004). Multivariate logistic regression analysis identified lower minimum serum citrulline concentration and longer central venous catheter duration as independently associated with CRBSI (P = .003 and P = .038, respectively). Conclusions: Low serum citrulline concentration and longer central venous catheter time are independently associated with CRBSI in children with intestinal failure. Serum citrulline concentration may be a useful biomarker to identify patients with intestinal failure who are at high risk of developing a CRBSI.     

Relationship Between Energy Balance and Complications After Subarachnoid Hemorrhage

Background: Subarachnoid hemorrhage patients are hypermetabolic and at risk for developing medical complications. A relationship was hypothesized between energy balance and complications following subarachnoid hemorrhage. Methods: Fifty‐eight consecutive poor‐grade subarachnoid hemorrhage patients (mean age, 58; range, 26–86; 66% women) were studied between 2005 and 2007. Caloric intake and energy expenditure were assessed. In‐hospital complications over the first 14 days posthemorrhage were defined as renal failure, fever (>38.3°C), any infection, anemia, hyperglycemia (>11 mmol/L), and myocardial infarction. Energy balance was calculated by subtracting energy expenditure from caloric intake. Results: Enteral nutrition was begun 1 day posthemorrhage (range, 0–5 days). Recommended (mean ± SD) caloric intake was 28 ± 3 kcal/kg/d, and the actual was 14 ± 5 kcal/kg/d. Enteral nutrition accounted for 67% of caloric intake; propofol and dextrose infusions accounted for 33% of caloric intake. Cumulative energy balance over the first 7 days was –117 ± 53 kcal/kg. The average energy balance during the first 7 days after subarachnoid hemorrhage significantly correlated with the total number of infectious complications (r = –0.5, P < .001) but not medical complications (r = –0.2, P = .1). After adjustment for Hunt‐Hess grade, fever, hyperglycemia, and anemia, negative energy balance during the first 7 days after subarachnoid hemorrhage correlated with the number of infectious complications (P = .01). Conclusions: Infectious complications after subarachnoid hemorrhage are associated with negative energy balance. Studies are needed to better understand the impact of negative energy balance on outcome after subarachnoid hemorrhage.     

Adherence to treatment in children and adolescent patients with cystic fibrosis

PurposeThe purpose of this study was to monitor medication adherence in cystic fibrosis (CF) patients and its correlation with disease severity and patient age.MethodsChildren less than 12 years of age (group 1) and adolescents 12 years of age and older (group 2) were recruited from the University of Michigan CF Center. The study duration was 3 months. A total of 22 patients per group were enrolled. Adherence to ADEKs, an oral multivitamin, and dornase alfa, a nebulized mucolytic medication, was monitored. Adherence to ADEKs was monitored by using the Medication Event Monitoring System (MEMS) SmartCaps (APREX, AARDx, Inc., Union City, California). Dornase alfa adherence rate was monitored by counting empty medication vials.ResultsThirty-three patients completed the study, 15 patients in group 1 and 18 patients in group 2. The overall mean adherence rates for ADEKs and dornase alfa were (± SD) 63.6% ± 24.0% and 66.5% ± 31.2%, respectively. The median ADEKs and dornase alfa adherence rate for group 1 was 84.6% and 79.1%, respectively (p = .08); and for group 2 was 56.7% vs. 78.4%, respectively (p = .07). There was a trend toward significance, suggesting that the adherence rate for ADEKs was higher than for dornase alfa (p = .08) in group 1. Group 2 showed a trend toward adherence to dornase alfa than to ADEKs (p = .07). There was a trend for ADEKs adherence between groups 1 and 2 (p = .09), but not for dornase alfa (p = .93).ConclusionParental supervision and disease severity are likely to play a major role in adherence to medical management. Partnership with patients and families about the treatment plan might be important for improving adherence rate. The MEMS SmartCaps is an electronic monitoring technology that should be used to measure drug adherence objectively both in further larger clinical trials and in the outpatient setting.     

Associations of smoking with cardiometabolic profile and renal function in a Romanian population-based sample from the PREDATORR cross-sectional study

Background: The impact of smoking on morbidity is well known, but in Romania, limited data are available regarding the smoking prevalence and relationship with cardiometabolic profile and kidney function.

Objectives: To assess the association of smoking with cardiometabolic traits and kidney function, in a Romanian population-based sample from the PREDATORR study.

Methods: PREDATORR was an epidemiological cross-sectional study. Between 2012 and 2014, participants were randomly selected from the lists of general practitioners and enrolled if they were aged 20 to 79 years, born and living in the past 10 years in Romania. Sociodemographic and lifestyle characteristics were collected through interviewer-administered questionnaires.

Results: Overall, 2704 participants were included in the analysis, 18% of them being current smokers and 30.8% former smokers. Current smokers compared to non-smokers had higher total cholesterol (220.6?±?50.4 versus 213.9?±?86.8?mg/dl, P?=?0.017), LDL-cholesterol (137.8?±?45.2 versus 130.7?±?83.7?mg/dl, P?=?0.004) and glomerular filtration rate (96.9?±?16.8 versus 90.7?±?19.1?ml/min/1.73?m², P?<0.001) in women and higher triglycerides (170.7?±?129.8 versus 144.3?±?94.2?mg/dl, P?=?0.007), glomerular filtration rate (97.6?±?17 versus 90.3?±?18?ml/min/1.73?m², P?P?=?0.002) in men. Active smoking was associated with hypercholesterolaemia [OR: 1.40 (95% CI: 1.01–1.96), P?=?0.04] and low HDL-cholesterolaemia [OR: 1.39 (95% CI: 1.01–1.91), P?=?0.04] and negatively associated with overweight/obesity [OR: 0.67 (95% CI: 0.48–0.94), P?=?0.02]. Male former smokers had higher prevalence of abdominal obesity (82.4% versus 76.4%, P?=?0.02), hypertriglyceridaemia (43.6% versus 35.6%, P?=?0.01), hypertension (64% versus 56.4%, P?=?0.01) and ischaemic vascular disease (40.5% versus 30.9%, P?=?0.003) than male non-smokers.

Conclusion: The PREDATORR study showed a high prevalence of smoking in the adult Romanian population providing data on the association of smoking with cardiometabolic traits.     

The MacNew Heart Disease Health-Related Quality of Life Questionnaire in Patients with Angina and Patients with Ischemic Heart Failure

ObjectivePatient-reported outcomes including health-related quality of life are important in clinical care and research studies. The MacNew Heart Disease health-related quality of life questionnaire has been validated in English-speaking patients with myocardial infarction. The aim of this study was to validate the MacNew in English-speaking patients with angina or ischemic heart failure.MethodsCanadian and American patients with angina or ischemic heart failure completed the MacNew, the Short Form-36 Health Survey, and the Hospital Anxiety and Depression Scale.ResultsWe administered questionnaires to 276 patients with angina (mean age, 65.9 years) and 155 patients with ischemic heart failure (mean age, 70.3 years). The mean ± SD MacNew global score in patients with ischemic heart failure (5.1 ± 1.2) was statistically (P < 0.001), but not clinically, poorer than in patients with angina (5.3 ± 1.1). The three-factor measurement model explained 46.1% of the observed variance in the MacNew in patients with angina and 46.5% in patients with ischemic heart failure. Internal consistency was ≥0.90, and test-retest reliability was ≥0.70 for each MacNew scale and the a priori convergent and discriminative validity hypotheses were confirmed in both diagnoses. The MacNew was highly accepted by patients with little respondent or administrative burden.ConclusionsThe English version of the MacNew is reliable and valid in patients with angina or ischemic heart failure. This permits health-related quality of life outcome comparisons in patients with angina, ischemic heart failure, and myocardial infarction with the MacNew and provides a better understanding of the full range of health-related quality of life outcomes.