Search

The article focuses on evaluating a new scoring system for diagnosing protein energy wasting (PEW) in children with chronic kidney disease (CKD), particularly emphasizing the importance of lean body mass (LBM) measured by dual-energy x-ray absorptiometry (DEXA) as diagnostic biomarker. Topics include the criteria and biomarkers for diagnosing PEW, the utility of LBM measurement by DEXA in detecting subclinical PEW, and considerations regarding the limitations and practicality of using DEXA.

Background: The current diagnosis of protein energy wasting (PEW) is based on scoring systems that lack precision in measuring muscle deficits. We undertook this cross-sectional study to determine the prevalence of PEW in children with chronic kidney disease (CKD) using a scoring system that included dual energy x-ray absorptiometry (DEXA) for measuring lean body mass (LBM) and to determine the prevalence of selected markers in PEW. Methods: Thirty CKD and 20 healthy children (1–18 years) were evaluated for (1) reduced dietary protein intake (DPI); (2) BMI < fifth centile for height age (BMI/HA); (3) serum albumin < 3.8 g/dl, cholesterol < 100 mg/dl, or CRP > 3 mg/L; (4) LBM < fifth centile for height age [LBMr] on DEXA. PEW was scored as minimal—one parameter positive in 2/4 categories; standard—one parameter positive in 3/4 categories; or modified—standard plus height < 2 SD. Results: Twenty children with CKD (66.7%) had PEW, (5/9) 55% in CKD 3, and (15/21) 71% in advanced CKD; minimal 12, standard 1, and modified 7. LBMr was seen in 20 (100%), reduced DPI in 16 (80%), and BMI/HA in 6 (30%) children with PEW. LBMr had 100% sensitivity and BMI/HA 100% specificity. LBMr was seen in 8 who had no other criteria for PEW. None of the parameters were positive in controls (p < 0.01). Conclusions: PEW prevalence in CKD was high. Both prevalence and severity were higher in advanced CKD. LBMr was a highly sensitive marker to detect PEW. LBMr seen in some children with CKD who were negative for other markers could represent subclinical PEW. [ABSTRACT FROM AUTHOR]

Background: Protein energy wasting (PEW), a state of deficient protein storage, is not well understood in children and adolescents with chronic kidney disease (CKD). We aimed to re-define PEW using pediatric malnutrition guidelines from the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition (AND/ASPEN), and to describe the relationship between PEW, malnutrition, and kidney function. Methods: This was a retrospective review of outpatients ≤ 20 years old with a diagnosis of CKD from January 1, 2013, to August 31, 2018. Malnutrition was diagnosed by a licensed dietitian, and PEW was diagnosed using an updated definition incorporating AND/ASPEN malnutrition guidelines. Logistic regression and linear mixed effects modeling were performed on the relationship of malnutrition and PEW to estimated glomerular filtration rate (eGFR). Results: The 142 patients included in this analysis had a median age of 11.1 years and median eGFR of 57 ml/min/1.73 m2 at initial visit. Malnutrition was diagnosed in 50% of patients in at least one visit, and 17.6% met ≥ 2 PEW criteria. Patients with eGFR < 30 ml/min/1.73 m2 had significantly increased risk of malnutrition [OR 2.5, 95% CI 2.0–3.3] (p < 0.001) and PEW [OR 4.9, 95% CI 3.0–8.0] (p < 0.001). A diagnosis of malnutrition or PEW was associated with worse eGFR by logistic regression (p = 0.01 and p = 0.001, respectively) and more rapid eGFR decline by linear mixed effects model (p = 0.002 and p < 0.001, respectively) compared to those without these diagnoses. Conclusions: Malnutrition and PEW are prevalent in pediatric CKD and are associated with significantly lower eGFR and more rapid decline in eGFR, emphasizing the need to address nutritional status. [ABSTRACT FROM AUTHOR]

Few regular national clinical data are available for individuals with Down's syndrome (IDS) bearing in mind that they are subject to countries variations in medical termination of pregnancy and screening. Individuals < 65 in 2019 were selected in view of the low number of older IDS. Thus, 98% of 52.4 million people with correct data were included from the national health data system. IDS (35,342) were identified on the basis of the International Classification of Diseases 10th revision code (Q90). Risk ratios (RR) were calculated to compare the frequencies in 2019 between IDS and individual without Down's syndrome (IWDS) of use of health care. The prevalence of IDS was 0.07% (48% women), comorbidities were more frequent, especially in younger patients (24% < 1 year had another comorbidity, RR = 20), as was the percentage of deaths (4.6%, RR = 10). Overall, tumours were less frequent in IDS compared with IWDS (1.2%, RR = 0.7) except for certain leukaemias and testicular tumours (0.3%, RR = 4). Cardiac malformations (5.2%, RR = 52), dementia (1.2%, RR = 29), mental retardation (5%, RR = 21) and epilepsy (4%, RR = 9) were also more frequent in IDS. The most frequent hospital diagnoses for IDS were: aspiration pneumonia (0.7%, RR = 89), respiratory failure (0.4%, RR = 17), sleep apnoea (1.1%, RR = 8), cryptorchidism (0.3%, RR = 5.9), protein-energy malnutrition (0.1%, RR = 7), type 1 diabetes (0.2%, RR = 2.8) and hypothyroidism (0.1%, RR = 72). IDS were more likely to use emergency services (9%, RR = 2.4), short hospital stay (24%, RR = 1.6) or hospitalisation at home (0.6%, RR = 6). They consulted certain specialists two to three times more frequently than IWDS, for example cardiologists (17%, RR = 2.6). This study is the first detailed national study comparing IDS and non-IDS by age group. These results could help to optimize prenatal healthcare, medical and social support. [ABSTRACT FROM AUTHOR]

Background: The increasing prevalence of bariatric procedures has led to a surge in revisional surgeries. Failure of bariatric surgery can be attributed to inadequate weight loss or complications necessitating revisional surgery. In this study, we investigated the indications and outcomes of revisional surgery due to complications following primary bariatric surgery. Materials and Methods: A retrospective study was conducted using data from the Tehran Obesity Treatment Study, which included patients who underwent revisional bariatric surgery between March 2013 and September 2021 due to complications following primary bariatric surgery. Results: Of the 5382 patients who underwent primary bariatric surgery (sleeve gastrectomy, one-anastomosis gastric bypass, and Roux-en-Y gastric bypass), 203 (3.70%) required revisional surgery, with 37 cases performed due to surgical complications. The indications of revisional operations were gastroesophageal reflux disease (GERD) (n=17, 45.9%), protein-calorie malnutrition (PCM) (n=14, 37.8%), unexplained abdominal pain (n=5, 13.5%), and phytobezoar (n=1, 0.03%). In the postoperative follow-up, most patients exhibited improvement in signs and symptoms related to underlying causes. However, eight patients experienced early or late complications of grade III or higher according to the Clavien-Dindo classification, with one death resulting from liver failure. Conclusion: Revisional bariatric surgery may effectively address complications from primary bariatric surgery, with the majority of patients experiencing improvements in symptoms. While the overall incidence of revisional surgery due to complications is relatively low, our findings suggest that GERD and PCM are the most common indications for revisional surgery. [ABSTRACT FROM AUTHOR]

Monoamine oxidase inhibitors (MAOIs) prevent the breakdown of tyramine in the body, and can cause a sudden increase in blood pressure with significant tyramine build up. This phenomenon, when it occurs, is known as tyramine pressor response. It is unknown if tyrosine administered in parenteral nutrition (PN) leads to tyramine build-up with concomitant use of MAOIs. It is also unknown if PN patients who are taking MAOI are at risk for the tyramine pressor response. This is a theoretical possibility as tyrosine endogenously undergoes decarboxylation to produce tyramine. We describe our experience with a 67-year-old woman with severe depression who was on the MAOI, transdermal selegiline. Her clinical course was complicated by an inability to take adequate per oral (PO) intake and she met criteria for unspecified severe protein-calorie-malnutrition in the context of social or environmental circumstances. Therefore, she required PN initiation. PlenamineTM (B. Braun, Bethlehem, PA, USA) was used as the amino acid source in the PN, which contains 39 mg of tyrosine per 100 ml of solution. The patient was monitored closely for any signs of hypertensive crisis while on PN and selegiline. She safely tolerated the combined therapy without any side effects. This is the first documented report of co-administration of PN containing tyrosine along with a MAOI. Our findings suggest that the dose of selegiline used in this patient can be co-administered safely in the setting of PN. However, further study is needed to verify our findings beyond this one patient. In conclusion, we recommend initiating PN and increasing it to goal in patients taking MAOIs, gradually, while monitoring for hypertensive crisis given the theoretical possibility of the tyramine pressor response. [ABSTRACT FROM AUTHOR]

The article explores the link between malnutrition and cognitive development in children, particularly in India where malnutrition rates are high. It emphasizes that malnourished children are more likely to have lower IQ scores and struggle with cognitive tasks. Early intervention and proper nutrition are crucial for promoting cognitive development. The article suggests efforts to combat malnutrition and prioritize nurturing care for early childhood development. By addressing malnutrition, future generations of children may avoid cognitive impairment. The article references several studies that likely delve into the developmental potential of children in developing countries, the significance of nurturing care for early childhood development, and the risk factors for stunting, wasting, and underweight among under-five children in Bangladesh. [Extracted from the article]

Background: Nutritional status assessment in children with nephrotic syndrome (NS) is critical for identifying patients who are at risk of protein-energy wasting (PEW) and for determining their nutritional needs and monitoring nutritional intervention outcomes. Methods: In a case–control study, we enrolled 40 children (age range: 2–16 years) with NS and 40 apparently healthy children (age and sex-matched) as a control group. Anthropometric data, as well as demographic, clinical, and laboratory data, were collected. A dietary intake assessment using a 3-day food intake record was done, and the quadriceps rectus femoris thickness (QRFT) and quadriceps vastus intermedius thickness (QVIT) were assessed using B-mode ultrasound and compared between both groups. Results: Children with NS had lower QRFT and QVIT measurements than control groups (p < 0.001). Inadequacy in protein intake occurred in 62.5% and 27.5% of the NS and control groups, respectively (p = 0.002). The thickness of the rectus and vastus muscles by ultrasound was significantly associated with the percentage of protein intake (p < 0.001). The ROC curve revealed that the best cutoff value of QRFT for the prediction of the patient at risk of malnutrition was ≤ 1.195 with an area under curve of 0.907, with p < 0.001. Conclusion: In children with NS, skeletal muscle ultrasound is a simple and easy-to-use bedside technique for the identification of patients at risk of malnutrition. [ABSTRACT FROM AUTHOR]

Patients with hematological malignancies (HM) are at risk of acute respiratory failure (ARF). Malnutrition, a common association with HM, has the potential to influence ICU outcomes. Geriatric nutritional risk index (G-NRI) is a score derived from albumin and weight, which reflects risk of protein-energy malnutrition. We evaluated the association between G-NRI at ICU admission and ICU mortality in HM patients with ARF. We conducted a single center retrospective study of ventilated HM patients between 2014 and 2018. We calculated G-NRI for all patients using their ICU admission albumin and weight. Our primary outcome was ICU mortality. Secondary outcomes included duration of mechanical ventilation and ICU length of stay. Two hundred eighty patients were admitted to the ICU requiring ventilation. Median age was 62 years (IQR 51–68), 42% (n = 118) were females, and median SOFA score was 11 (IQR 9–14). The most common type of HM was acute leukemia (54%) and 40% underwent hematopoietic cell transplant. Median G-NRI was 87 (IQR 79–99). ICU mortality was 51% (n = 143) with a median duration of ventilation of 4 days (IQR 2–7). Mortality across those at severe malnutrition (NRI < 83.5) was 59% (65/111) compared to 46% (76/164) across those with moderate-no risk (p = 0.047). On multivariable analysis, severe NRI (OR 2.34, 95% CI 1.04–5.27, p = 0.04) was significantly associated with ICU mortality. In this single center, exploratory study, severe G-NRI was prognostic of ICU mortality in HM patients admitted with respiratory failure. [ABSTRACT FROM AUTHOR]

To assess the role of protein-energy malnutrition on perioperative outcomes in patients with pancreatic cancer undergoing open pancreaticoduodenectomy. We conducted a retrospective observational cohort study and investigated patients ≥ 18 years old with pancreatic cancer undergoing open pancreaticoduodenectomy within the National inpatient sample database during 2012–2014. The study population was divided into two groups based on the presence of protein-energy malnutrition. In-hospital mortality, length of stay, cost of hospitalization, and in-hospital complications were compared between the two groups. Logistic and linear regression analyses were used to adjust for potential confounders. A trend analysis was further conducted on the in-hospital outcomes. Of the 12,785 patients aged ≥ 18 years undergoing open pancreaticoduodenectomy during years 2012–2014, 9865 (77.0%) had no protein-energy malnutrition and 2920 (23.0%) had protein-energy malnutrition. Patients with protein-energy malnutrition were found to have significantly higher mortality rate, longer length of hospital stay, and higher total hospital cost compared to those without protein-energy malnutrition. The risks of gastroparesis, small bowel obstruction, intraoperative and postoperative hemorrhage, infectious complications, and several systemic complications were found to be significantly higher in the protein-energy malnutrition group in a multivariate regression model. A study of trends from 2009 to 2012 revealed an increasing prevalence of protein-energy malnutrition, a declining trend in mortality and length of stay and a stable total hospital cost in the protein-energy malnutrition group. Protein-energy malnutrition was found to be associated with higher mortality, longer length of hospital stay and greater hospital cost in pancreatic cancer patients undergoing open pancreaticoduodenectomy, as well as increased occurrence of various systemic complications. Attention should be paid to patients' nutritional status, which can be corrected before surgery as an effective means to optimize postoperative results. [ABSTRACT FROM AUTHOR]

Background: The data on specific comorbidities in children with dyskinetic cerebral palsy (DCP) is limited. We evaluated the pattern of comorbidities and health related quality of life (HRQOL) in these children and compared them between etiological and motor impairment subgroups. Methodology: This cross-sectional study was conducted over 18 months in children with DCP of both sex, and age between one and 14 years. Comorbidities were assessed using standardized scales such as gross motor functioning scale (GMFCS), developmental profile-3 (DP-3), developmental behaviour checklist, sleep behaviour questionnaire (SBQ), and caregiver questionnaire. Results: Sixty-five children with DCP were evaluated (hyperbilirubinemia n = 43, 66% and perinatal asphyxia n = 19, 29%). The majority of children were severely affected in gross motor functioning (level IV 29.2% and level V 53.8%). Epilepsy was seen in 21.5% of cases (19% in hyperbilirubinemia and 32% in asphyxia, p = 0.4). The mean age of onset of seizures was 15.4 + 20.6 months (range 2–72). Visual problems were seen in 54% of cases and included upgaze palsy, squint, refractive error, optic atrophy and cortical blindness. A significant proportion of children with hyperbilirubinemia had upgaze palsy as compared to those with perinatal asphyxia (70% vs. 32%, p 0.01). Rest of the visual problems were not significantly different between the two etiological subgroups. Drooling (87.6%), protein-energy malnutrition (66.6%), and reflux (57%) were the most common gastrointestinal problems in children with DCP. Children with DCP showed problems in social relating (33.8%), anxiety (26.2%), and self-absorbed behaviour (7.7%). However, there were no statistically significant differences between the etiological, motor impairment and age-based subgroups. Children with DCP had high scores on SBQ, suggesting sleep problems. Sleep scores were similar in the hyperbilirubinemia and perinatal asphyxia subgroups. Greater sleep problems were noted in children aged < 4y (70.6 + 10.1 vs. 56.5 + 11.3, p < 0.05 as compared to children above 4y of age) and severe motor impairments (68.2 + 11.3 vs. 57.2 + 13.1, p 0.008 as compared to mild-moderate motor impairment). Poor overall developmental scores were seen in 61.5% children and were significantly associated with GMFCS (p 0.04). The majority of children showed impairments in physical (58.5%), adaptive behaviour (58.5%), social-emotional (50.8%), cognitive (60%) and communication (52%) subscales of DP-3. Cognitive impairment was similar in the etiological (hyperbilirubinemia vs. perinatal asphyxia, p = 0.3), and motor impairment (mild-moderate vs. severe, p = 0.9) subgroups. HRQOL was significantly affected by motor impairment in positioning-transfer (p value 0.0001), and interaction-communication domains (p value 0.0001), however, there was no difference based on the etiology of hyperbilirubinemia and asphyxia. Conclusion: Children with DCP demonstrate several comorbidities and impaired quality of life. These are similar in hyperbilirubinemia and perinatal asphyxia cohorts, expect for significant proportion of upgaze palsy in DCP secondary to hyperbilirubinemia. Younger children have more problematic behaviour and impaired sleep quality. Severe motor disability influences the developmental outcomes, cognition, sleep and HRQOL in children with DCP. [ABSTRACT FROM AUTHOR]

Purposes: There is no consensus regarding the optimal bariatric procedure in patients with super obesity [body mass index (BMI) ≥ 50 kg/m2]. This study compared the outcomes of one-anastomosis gastric bypass (OAGB) with those of sleeve gastrectomy (SG) in these patients. Methods: This retrospective study was conducted based on the prospectively maintained data in a cohort of 557 patients with super obesity, who underwent either SG (n = 348) or OAGB with a 200-cm BPL (n = 154) or a 160-cm BPL (n = 55) by the same surgical team from March 2013 to 2017. Results: Patients undergoing OAGB had greater weight loss in comparison to those managed by SG during the first, second, and third years of follow-up. Comparing the OAGB and SG groups within 3 years after surgery, the total weight loss was 36.5 vs. 33.2% (P < 0.001) and the ΔBMI was 20.1 vs. 18.1 kg/m2 (P < 0.001), respectively. The resolution of diabetes mellitus, hypertension and dyslipidemia were similar after the two procedures. The operative time and length of hospital stay were longer in the OAGB group, and incidence of complications, requiring either readmission or reoperation, was significantly higher after OAGB, in comparison to SG. There was no significant difference in the postoperative weight loss results, resolution of comorbidities, or the incidence of complications between the OAGB-160 and OAGB-200 groups, with the exception of protein–calorie malnutrition requiring revision surgery, which was exclusively observed in the OAGB-200 group. Conclusion: Although OAGB provides superior mid-term weight loss, SG remains the first option for patients with super obesity, due to the safer surgical profile and comparable metabolic improvement. [ABSTRACT FROM AUTHOR]

Purposes: There is no consensus regarding the optimal bariatric procedure in patients with super obesity [body mass index (BMI) ≥ 50 kg/m2]. This study compared the outcomes of one-anastomosis gastric bypass (OAGB) with those of sleeve gastrectomy (SG) in these patients. Methods: This retrospective study was conducted based on the prospectively maintained data in a cohort of 557 patients with super obesity, who underwent either SG (n = 348) or OAGB with a 200-cm BPL (n = 154) or a 160-cm BPL (n = 55) by the same surgical team from March 2013 to 2017. Results: Patients undergoing OAGB had greater weight loss in comparison to those managed by SG during the first, second, and third years of follow-up. Comparing the OAGB and SG groups within 3 years after surgery, the total weight loss was 36.5 vs. 33.2% (P < 0.001) and the ΔBMI was 20.1 vs. 18.1 kg/m2 (P < 0.001), respectively. The resolution of diabetes mellitus, hypertension and dyslipidemia were similar after the two procedures. The operative time and length of hospital stay were longer in the OAGB group, and incidence of complications, requiring either readmission or reoperation, was significantly higher after OAGB, in comparison to SG. There was no significant difference in the postoperative weight loss results, resolution of comorbidities, or the incidence of complications between the OAGB-160 and OAGB-200 groups, with the exception of protein–calorie malnutrition requiring revision surgery, which was exclusively observed in the OAGB-200 group. Conclusion: Although OAGB provides superior mid-term weight loss, SG remains the first option for patients with super obesity, due to the safer surgical profile and comparable metabolic improvement. [ABSTRACT FROM AUTHOR]

Background: The prevalence of severe acute malnutrition among children (< 5 years) due to low energy-protein density of local complementary foods and poor feeding practices is a great concern in developing countries, Nigeria inclusive. Hence, the aimed of this study was to formulate and evaluate the chemical composition, functional, antioxidant and organoleptic properties of low-cost complementary foods from locally accessible food material using household technologies. Using UNCEF guidelines, three complementary foods were formulated and their nutritional characteristics were compared with local complementary food (100% sorghum) and ready-to-using therapeutic food. Results: Protein (g/100 g) and energy values (kcal./100 g) of formulated complementary foods varied from 16.16 to 16.93 and 418.08 to 474.13, respectively, and were significantly (p < 0.05) higher than OG (7.72; 378.71) (a 100% sorghum flour), but lower than P0 (539.8) (a read-to-eat therapeutic food). Mineral elements (mg/100 g) in the food samples were K (4175–6350.5), Ca (341.5–949), Fe (23.5–50.5) Zn (28–38.5), P (3855.6–4501), and Na (343.5–950.5), and were significantly lower than in P0, but higher in K, Fe and Zn than for OG. Sodium/Potassium and Calcium/Phosphorous molar ratios of the complementary foods ranged from 0.16 to 0.92 and 0.07 to 0.16 and were lower than P0 (0.64, 0.19) and OG (1.71, 0.2), respectively. Total essential amino acids (g/100 g protein) of the food samples varied from 23.53 to 25.94, and were comparable to OG (28.40) and P0 (32.74). Predicted biological value and essential amino acid index of P2 sample (53.53%, 59.85%) had the highest values, while P1 (46.0%, 52.94%) had the lowest, and these values were comparatively lower than P0 (67.53%, 72.69%), OG (55.91%, 62.03%), and recommended value (> 70%). Functional properties varied from 0.61 to 0.83, 124.2 to 176.2, 102.2 to 257.19, 0 to 1 and 164.7 to 373.3 for bulk density, oil absorption capacity, water absorption capacity, least gelation and swelling capacity, respectively. Antioxidant activity of formulated complementary foods ranged from 2.07 to 3.24%, 8.61 to 9.87 mg/g, 21.6 to 40.95% and 62.42 to 87.0% for DPPH, FRAP, Fe-chelation and OH-free radicals, respectively, and were significantly (p < 0.05) higher than in OG and PO. Sample P1 was significantly (p < 0.05) rated highest in appearance, aroma, taste, texture and overall acceptability above P2 and P3. Conclusion: The formulated complementary foods had enough nutrient and energy values to meet the requirements for infants as recommended for complementary foods and for amelioration of severe acute malnutrition in children. Nutritional and sensory evaluation revealed that addition of full fat milk to the P1 sample significantly improved its nutrient composition and organoleptic quality and contributed to its high acceptance compared to other formulations. Therefore, this complementary food is potentially suitable for use as complementary food and diet to manage severe acute malnutrition in Nigeria and other developing countries. However, there is a need for biological evaluation. [ABSTRACT FROM AUTHOR]

Edible insects have a varied nutritional value and have been a part of the human diet since the early ages. Protein-energy malnutrition (PEM) remains a challenge, particularly in developing regions, because of prevalent poverty and food insecurity and the high prices of conventional animal protein sources. There is an urgent need to find alternative affordable sources of quality protein. This study determined the nutritional composition of some commonly consumed insect species: cricket, palm weevil, termite and grasshopper. Protein was the most abundant macronutrient in all the insect species, it ranged from 36.5 % in palm weevil to 60.2 % in termite. The fat percentage was lowest in cricket (17.5 %) and highest in palm weevil (39.5 %). The analysed insects proved to be a good source of fibre which is mainly represented by chitin found in the insect exoskeleton. The fibre content ranged between 3.2 % in palm weevil to 5.2 % in termite and grasshopper. Total ash content ranged between 4.1 % (grasshopper) to 5.7 % (palm weevil). The carbohydrate content of termite was the lowest at 5.2 %, while cricket recorded the highest at 16.1 %. Amino acids were present in substantial amounts in all insects, including lysine and methionine. All insect species were rich in magnesium, copper, iron, and zinc and the levels were comparable to the FAO/WHO/UN recommended daily intakes (mg/day) for minerals. [ABSTRACT FROM AUTHOR]

Background: The one anastomosis gastric bypass (OAGB) was first described in 2001 as a safe and effective procedure that meets the criteria for the "ideal" weight loss operation. However, revisions for malnutrition and liver failure were reported. Case Report: We report a patient who was transferred to our institution with protein calorie malnutrition and liver failure after undergoing OAGB. Methods: A 42-year-old morbidly obese female patient underwent a laparoscopic sleeve gastrectomy (LSG) in 2012 followed by conversion to OAGB in 2018 for weight regain at another institution. Nine months after conversion, she was transferred to our institution with dehydration, vomiting, dysphagia, generalized edema, and steatorrhea (7 times/day). She had become wheelchair bound. On examination, there was gross edema, protein–calorie malnutrition, dermatitis, and muscle wasting. She had anemia (8 g/dl) reference range (11.5–15.5 g/dl), bilirubin (1.8 mg/dl) (0.2–1.2 mg/dl), hypoalbuminemia (1.4 g/dl) (3.5–5 g/dl), and elevated international normalized ratio (INR). The patient was admitted to the hospital and was started on total parenteral nutrition (TPN), with thiamine, vitamins, iron injections, and trace mineral replacement. Her course was complicated by multiple episodes of line sepsis and bacteremia. After 6 weeks, we succeeded in raising her albumin to 2.9 g/dl and proceeded with surgery. Technique: Laparoscopic exploration started with identifying the anatomy and measuring the biliopancreatic limb (BPL = 430 cm) and the common channel (CC = 380 cm). First, we restored the continuity of the small bowel. Then the long gastric pouch was trimmed. Finally, the patient was converted to a Roux-en-Y gastric bypass (RYGB) with a 30 cm BP limb and 70 cm Roux limb. The patient had an uneventful recovery and was discharged home on the fourth postoperative day. At 3 months of follow-up, her symptoms resolved, her laboratory work up normalized, and she regained mobility. Conclusion: Malnutrition and liver failure after OAGB are not uncommon. It is encountered with configurations of longer BP limb. BPL length of 150 to 200 cm seems to reduce such complications. Preoperative nutritional optimization is key. Conversion to a proximal RYGB is a safe and feasible approach. [ABSTRACT FROM AUTHOR]

Background: Single-anastomosis sleeve ileal (SASI) bypass is a simplification of sleeve gastrectomy with transit bipartition. Both share a metabolic foundation through early postprandial ileal brake, and SASI bypass has the advantages of shorter operative time and less incidence of internal herniation. This study evaluates the safety and outcome of SASI bypass with 2-year follow-up. Methods: A retrospective cohort study of all patients who underwent SASI bypass in the period between June 2016 and January 2019. The primary outcome was weight loss and diabetic remission. Results: Three hundred twenty-two patients underwent SASI bypass with a mean age of 37.4 ± 15 years and a mean body mass index of 50.1 ± 7.7 kg/m2. Thirteen patients (4%) had early major postoperative complications. The 1-year percentage of excess weight loss (%EWL) was 86.9 ± 9.2, and diabetic remission rate was 98.2%. The 2-year %EWL was 96.7 ± 5, and diabetic remission rate was 97.9%. Twenty-six patients had gastroesophageal reflux that improved in 21 (80.7%) patients, remained stationary in 4 (15.4%) patients, and worsened in one patient who required reversal. One patient (0.3%) had severe protein-energy malnutrition and is prepared for reversal. Technical variations had no significant impact on %EWL or diabetic remission. Conclusion: SASI bypass had a promising outcome in terms of 2-year %EWL, diabetic remission, and improvement of preoperative GERD. However, stationary or progressive course of GERD is a substantial possibility. Although the double-outlet for the gastric content allows duodenal access, it may be an obstacle to the standardization of postoperative care. The double-outlet is not a guarantee for absence of malnutrition. [ABSTRACT FROM AUTHOR]

Purpose: One-anastomosis gastric bypass (OAGB) has raised concerns about nutritional complications possibly attributed to the biliopancreatic limb (BPL) length. We aimed to assess the results of a conservative approach of OAGB compared with the original OAGB and Roux-en-Y gastric bypass (RYGB) in a 1-year follow-up study. Materials and Methods: This retrospective study was conducted based on prospectively maintained data in a cohort of patients who underwent either RYGB with a Roux limb of a 150 cm and a BPL of 50 cm (n = 145), OAGB with a 200-cm BPL (n = 272), or OAGB with a 160-cm BPL (n = 383), from March 2013 to 2017 at three university hospitals by a single surgical team. Results: Groups were comparable regarding age and sex. Mean preoperative body mass indexes of the RYGB, OAGB-160, and OAGB-200 groups were 44.5 ± 5.8, 45.6 ± 6.3, and 46.7 ± 6.4 kg/m2, respectively. One-year follow-up rates were 83.4%, 85.3%, and 82.5% for the RYGB, OAGB-200, and OAGB-160 groups, respectively. One-year percent total weight loss values were 33.8 ± 6.7 after OAGB-160 and 35.3 ± 6.9 after OAGB-200 (P = 0.056), which were significantly greater compared with 30.9 ± 8.9 after RYGB (P < 0.001). All groups were comparable regarding remission of type 2 diabetes mellitus, hypertension, dyslipidemia, and fatty liver. Mean operative time was longer with RYGB than with either OAGB techniques. Groups were comparable for postoperative complications except for the incidence of protein-calorie malnutrition (PCM), occurring in 11 patients (4.7%) after OAGB-200, 7 of whom required revisional surgery, in one patient (0.3%) after OAGB-160 who responded to parenteral alimentation, but in no patients after RYGB. Conclusion: After 1 year, OAGB with a 160-cm BPL was as effective as OAGB with a 200-cm BPL and RYGB, but safer than OAGB-200. This approach also avoided the need for revisional surgery following postoperative malnutrition. [ABSTRACT FROM AUTHOR]

Background: Children with mild to moderate chronic kidney disease are at an increased risk for cardiovascular sequelae, the leading cause of death in children with end-stage renal disease. We aimed to establish the prevalence of aortic dilatation, a newly recognized cardiovascular sequelae of renal disease, within a cohort of pediatric patients with mild to moderate kidney disease. Methods: A total of 501 children enrolled in the Chronic Kidney Disease in Children study contributed imaging data between April 2011 and February 2015. Aortic dilatation was defined as a dimension exceeding a z-score of 2 at any of three locations: aortic root, sinotubular junction, or the ascending aorta. Results: At baseline echocardiographic evaluation, 30 (6%) children were identified to have aortic dilatation in at least one of the three locations. Multivariate analysis demonstrated an increased odds ratio for the presence of aortic dilatation associated with the following variables: high diastolic blood pressure z-scores, low weight z-score, and low body mass index z-score. Presense of protein energy wasting (modified definition, OR 2.41, 95%CI 1.23, 4.70) was the strongest independent predictor of aortic dilatation. Conclusion: In conclusion, aortic dilatation does occur early in the course of chronic kidney disease and associates with markers of poor nutrition. Future studies should continue to evaluate these risk factors longitudinally as the kidney disease progresses. [ABSTRACT FROM AUTHOR]

Protein-energy malnutrition (PEM)/undernutrition and frailty are prevalent, overlapping conditions impacting on functional and health outcomes of older adults, but are frequently unidentified and untreated in community settings in the United States. Using the World Health Organization criteria for effective screening programs, we reviewed validity, reliability, and feasibility of data-driven screening tools for identifying PEM and frailty risk among community-dwelling older adults. The SCREEN II is recommended for PEM screening and the FRAIL scale is recommended as the most promising frailty screening tool, based on test characteristics, cost, and ease of use, but more research on both tools is needed, particularly on predictive validity of favorable outcomes after nutritional/physical activity interventions. The Malnutrition Screening Tool (MST) has been recommended by one expert group as a screening tool for all adults, regardless of age/care setting. However, it has not been tested in US community settings, likely yields large numbers of false positives (particularly in community settings), and its predictive validity of favorable outcomes after nutritional interventions is unknown. Community subgroups at highest priority for screening are those at increased risk due to prior illness, certain demographics and/or domiciliary characteristics, and those with BMI < 20 kg/m2 or < 22 if > 70 years or recent unintentional weight loss > 10% (who are likely already malnourished). Community-based health professionals can better support healthy aging by increasing their awareness/use of PEM and frailty screening tools, prioritizing high-risk populations for systematic screening, following screening with more definitive diagnoses and appropriate interventions, and re-evaluating and revising screening protocols and measures as more data become available. [ABSTRACT FROM AUTHOR]

Key summary points: Aim: To summarize the main scientific results achieved during the 2-year Joint Action Malnutrition in the Elderly (MaNuEL) project and to outline the recommendations derived. Findings: Four systematic reviews, six secondary data analyses of existing cohort and intervention studies, two web-based surveys and one Delphi study were performed. In addition, a scoring system to rate malnutrition screening tools and a theoretical framework (DoMAP) on the aetiology of malnutrition in older persons were developed. Message: The MaNuEL Toolbox was made available to effectively distribute and disseminate the MaNuEL results and recommendations, which will support researchers, healthcare professionals, policy-makers as well as educational institutes to advance their efforts in tackling the increasing problem of protein–energy malnutrition in the older population. Purpose: The Joint Action Malnutrition in the Elderly (MaNuEL) Knowledge Hub was established to extend scientific knowledge, strengthen evidence-based practice, build a sustainable, transnational network of experts and harmonize research and clinical practice in the field of protein–energy malnutrition in older persons. This paper aims to summarize the main scientific results achieved during the 2-year project and to outline the recommendations derived. Methods: 22 research groups from seven countries (Austria, France, Germany, Ireland, Spain, The Netherlands and New Zealand) worked together on 6 relevant domains of malnutrition—i.e. prevalence, screening, determinants, treatment, policy measures and education for health care professionals—making use of existing datasets, evidence and expert knowledge. Results: Four systematic reviews, six secondary data analyses of existing cohort and intervention studies, two web-based surveys and one Delphi study were performed. In addition, a scoring system to rate malnutrition screening tools and a theoretical framework on the aetiology of malnutrition in older persons were developed. Based on these activities and taking existing evidence into consideration, 13 clinical practice, 9 research and 4 policy recommendations were developed. The MaNuEL Toolbox was created and made available to effectively distribute and disseminate the MaNuEL results and recommendations. Conclusions: The MaNuEL Knowledge Hub successfully achieved its aims. Results and recommendations will support researchers, healthcare professionals, policy-makers as well as educational institutes to advance their efforts in tackling the increasing problem of protein–energy malnutrition in the older population. [ABSTRACT FROM AUTHOR]

Introduction: One-anastomosis-mini-gastric bypass (OAGB-MGB) is the second most popular gastric bypass procedure with remarkable weight loss results and comorbidity resolution rates. However, some concerns remain regarding its postoperative complications, including protein-calorie malnutrition (PCM). We hereby report our experience with patients who returned with severe PCM after OAGB-MGB. Methods: Patients with severe obesity presenting to our referral bariatric center underwent OAGB-MGB surgery using a 200-cm biliopancreatic limb (BPL) by a single surgical team at three university hospitals from March 2014 to February 2016. Results: From 189 patients undergoing OAGB-MGB, seven patients (3.7%), all female, with a mean age of 46.4 ± 8.2 years and initial body mass index (BMI) of 44.2 ± 4.7 kg/m2, were readmitted for signs of PCM. Lower extremity edema, fatigue, excessive weight loss, hypoalbuminemia, anemia, and pancytopenia were the presenting symptoms and lab findings. Revisional surgery was performed at a mean 19 ± 9.7 months after OAGB-MGB after failure of supportive measures. The mean BMI at the time of revision was 22.5 ± 2.6 kg/m2 with an excess weight loss of 109.2 ± 22.1%. After revisional surgery, one patient developed profound liver failure and expired. Another patient developed severe steatohepatitis but ultimately recovered. In the remaining five, edema and fatigue completely resolved at 1 month and hypoalbuminemia and anemia normalized at 2 months. Conclusion: A one-fits-all BPL length of 200 cm is increasingly being questioned as it may result in an inadequate absorptive area and PCM in a subset of patients with shorter total bowel lengths, potentially placing them in danger and depriving them of bariatric surgery benefits. [ABSTRACT FROM AUTHOR]

Summary: Chronic inflammation and protein energy wasting (PEW) syndrome are common in kidney transplant recipients (KTR). The presence of inflammation and PEW syndrome can directly affect bone resorption and bone formation, leading to bone loss and fractures. We showed PEW is independently associated with new clinically detected bone fractures in prevalent KTR.Introduction: Kidney transplant recipients (KTR) have a 4-fold higher risk of fracture compared to the general population. Chronic inflammation and PEW syndrome are common in KTR and are associated with poor outcomes. We hypothesized that the Malnutrition-Inflammation Score (MIS), a validated measure of PEW, is associated with higher risk of bone fractures in KTR.Methods: This prospective cohort study included 839 prevalent KTR from a Central European academic center. MIS, a semiquantitative instrument of PEW, was calculated at the study entry. Self-reported history of fractures was recorded during the 2-year follow-up period. The association between MIS and bone fractures was examined in logistic regression analyses with adjustment for age, gender, eGFR, smoking habits, history of pre-transplant bone fractures, and acute rejection.Results: Mean age was 51 ± 13 years, and 56% of patients were males with median (interquartile range) transplant vintage 69 (38-112) months, estimated glomerular filtration rate 55 ± 21 ml/min/1.73 m2, and calculated MIS 3 (2-4) at enrollment. Fifty-five (7%) patients experienced self-reported bone fractures during the 2-year follow-up period. Higher MIS score showed linear association with increased risk of fracture. Each one-point higher MIS was associated with 23% higher risk of bone fractures (odds ratio (OR) and 95% CI 1.23, 1.12-1.34), which remained significant after multivariable adjustments (OR 1.17, 95% CI 1.06-1.29).Conclusion: The MIS is independently associated with new clinically detected bone fractures in prevalent KTR. [ABSTRACT FROM AUTHOR]

Protein-energy malnutrition (PEM) pre-existing at stroke onset is believed to worsen functional outcome, yet the underlying mechanisms are not fully understood. Since brain inflammation is an important modulator of neurological recovery after stroke, we explored the impact of PEM on neuroinflammation in the acute period in relation to stroke-initiated sensori-motor abnormalities. Adult rats were fed a low-protein (LP) or normal protein (NP) diet for 28 days before inducing photothrombotic stroke (St) in the forelimb region of the motor cortex or sham surgery; the diets continued for 3 days after the stroke. Protein-energy status was assessed by a combination of body weight, food intake, serum acute phase proteins and corticosterone, and liver lipid content. Deficits in motor function were evaluated in the horizontal ladder walking and cylinder tasks at 3 days after stroke. The glial response and brain elemental signature were investigated by immunohistochemistry and micro-X-ray fluorescence imaging, respectively. The LP-fed rats reduced food intake, resulting in PEM. Pre-existing PEM augmented stroke-induced abnormalities in forelimb placement accuracy on the ladder; LP-St rats made more errors (29 ± 8%) than the NP-St rats (15 ± 3%; P < 0.05). This was accompanied by attenuated astrogliosis in the peri-infarct area by 18% and reduced microglia activation by up to 41 and 21% in the peri-infarct area and the infarct rim, respectively (P < 0.05). The LP diet altered the cortical Zn, Ca, and Cl signatures (P < 0.05). Our data suggest that proactive treatment of pre-existing PEM could be essential for optimal post-stroke recovery. [ABSTRACT FROM AUTHOR]

Background: This study aimed to evaluate plasma concentrations of leptin and total ghrelin in children with chronic kidney disease (CKD) and assess their roles in protein-energy wasting (PEW).Methods: This study consisted of three different CKD populations [CKD group (20 patients with non-dialysis CKD), dialysis group (39 patients on dialysis), and kidney transplant (KTx) group (35 KTx recipients)] and control group (18 healthy children). Plasma leptin and total ghrelin levels were measured. Multi-frequency bioimpedance analysis was used for the assessment of fat and lean mass. PEW was defined using criteria including body mass, muscle mass, growth, serum albumin level, and protein intake.Results: While plasma leptin levels did not differ among the study groups, total ghrelin levels were significantly higher in the dialysis group (P < 0.001). Seven dialysis patients (18%) and one CKD patient (5%) but none of the KTx recipients met the criteria of PEW. Dialysis patients with PEW had lower plasma leptin levels compared to their counterparts (P = 0.018); however, total ghrelin levels did not differ between the two groups (P = 0.10). Low leptin level in dialysis patients was independently associated with lower fat mass index (P < 0.001) and lower height-specific SD scores of BMI (P = 0.019).Conclusions: PEW is prevalent in dialysis patients. Low levels of leptin seem to be associated with PEW. Our result suggests that low leptin levels may be a consequence rather than a cause of PEW. Longitudinal studies are required to investigate this complex relationship between leptin and PEW in pediatric dialysis patients. [ABSTRACT FROM AUTHOR]

We are very grateful to Liagre et al. for their interest in our article demonstrating our experience with 150-cm and 200-cm biliopancreatic limb (BPL) one anastomosis gastric bypass (OAGB) [[1]]. Effect of biliopancreatic limb length on weight loss, postoperative complications, and remission of comorbidities in one anastomosis gastric bypass: a systematic review and meta-analysis. Impact of biliopancreatic limb length on severe protein-calorie malnutrition requiring revisional surgery after one anastomosis (mini) gastric bypass. [Extracted from the article]

The study investigated the effect of the following maize:legume (70:30) mixed crop silages: maize:cowpea, maize:velvet bean, and maize:lablab on milk production during the 2016 dry season. Using a 5 × 5 double Latin square design, five Holstein-Friesian crossbred cows in early lactation (30 ± 15 days) and five Jersey crossbred cows in early lactation (25 ± 10 days) were given the supplementary mixed crop silage diets at 0.5 kg/l of milk produced over 105 days. Commercial dairy meal and sole maize silage were used as positive and negative controls, respectively. Milk yield was significantly higher (P < 0.05) in cows given the dairy meal compared to mixed crop silages; however, milk yield was also significantly higher (P < 0.05) for cows given the three mixed crop silages compared to cows given sole maize silage. Cows given mixed crop silages produced milk of significantly higher protein content (P < 0.05) than those given sole maize silage. There was no significant difference (P > 0.05) in butterfat content of milk across all the dietary treatments. The dietary cost of producing 1 l of milk was highest at 0.31USD/l for cows given commercial dairy meal and lowest for cows given maize:velvet bean and maize:cowpea silage at 0.19USD/kg. The highest dietary gross margins of 68% were observed when cows were given maize:velvet mixed silage compared to commercial dairy meal (47%) and sole maize silage (57%). The 70:30 maize:legume mixed crop silages showed the capability to increase milk quantity and quality at very low production costs in smallholder dairy schemes. [ABSTRACT FROM AUTHOR]

Loss of lean body mass is a relevant component of the cachexia, or protein energy wasting (PEW), syndrome. Reduced muscle mass seems to be the most solid criterion for the presence of cachexia/PEW in patients with chronic kidney disease (CKD), and those with greater muscle mass loss have a higher risk of death. Children with CKD have many risk factors for lean mass and muscle wasting, including poor appetite, inflammation, growth hormone resistance, and metabolic acidosis. Mortality risks in patients with CKD increases as body mass index (BMI) and weight decreases. However, data regarding cachexia/PEW and muscle wasting in children with CKD is scarce due to lack of consensus in diagnostic criteria and an appropriate investigative methodology. Further research is urgently needed to address this important complication in the pediatric CKD setting, which may have fundamental impact on clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: An increasing number of surgeons worldwide are now performing one anastomosis/mini gastric bypass (OAGB/MGB). Lack of a published consensus amongst experts may be hindering progress and affecting outcomes. This paper reports results from the first modified Delphi consensus building exercise on this procedure. Methods: A committee of 16 recognised opinion-makers in bariatric surgery with special interest in OAGB/MGB was constituted. The committee invited 101 OAGB/MGB experts from 39 countries to vote on 55 statements in areas of controversy or variation associated with this procedure. An agreement amongst ≥ 70.0% of the experts was considered to indicate a consensus. Results: A consensus was achieved for 48 of the 55 proposed statements after two rounds of voting. There was no consensus for seven statements. Remarkably, 100.0% of the experts felt that OAGB/MGB was an 'acceptable mainstream surgical option' and 96.0% felt that it could no longer be regarded as a new or experimental procedure. Approximately 96.0 and 91.0% of the experts felt that OAGB/MGB did not increase the risk of gastric and oesophageal cancers, respectively. Approximately 94.0% of the experts felt that the construction of the gastric pouch should start in the horizontal portion of the lesser curvature. There was a consensus of 82, 84, and 85% for routinely supplementing iron, vitamin B, and vitamin D, respectively. Conclusion: OAGB/MGB experts achieved consensus on a number of aspects concerning this procedure but several areas of disagreements persist emphasising the need for more studies in the future. [ABSTRACT FROM AUTHOR]

The article focuses on the etiology of protein-energy malnutrition (PEM) caused by inadequate energy, protein, and nutrient intake. Topics discussed include complications of PEM including decreased cardiac, respiratory, hepatic, and immune function; decreased quality of life; and increased risk of hospitalization.

Backgrounds/objectives:Malnutrition is very common in acute hip fracture (HF) patients. Studies differ widely in their findings, with reported prevalences between 31 and 88% mainly because of small sample sizes and the use of different criteria. The aim of this study was to learn the prevalence of malnutrition in a large cohort of HF patients in an comprehensive way that includes the frequency of protein-energy malnutrition, vitamin D deficiency and sarcopenia.Subjects/methods: A 1-year consecutive sample of patients admitted with fragility HF in a 1300-bed public University Hospital, who were assessed within the first 72 h of admission. Clinical, functional, cognitive and laboratory variables were included. Energy malnutrition (body mass index (BMI) <22 kg/m2), protein malnutrition (serum total protein <6.5 g/dl or albumin <3.5 g/dl), vitamin D deficiency (serum 25-OH-vitamin D <30 ng/dl) and sarcopenia (low muscle mass plus low grip strength) were considered.Results: Five hundred nine HF patients were included. The mean age was 85.6±6.9 years and 79.2% were women. Ninety-nine (20.1%) patients had a BMI <22 kg/m2. Four hundred nine patients (81.2%) had protein malnutrition. Eighty-seven (17.1%) patients had both energy and protein malnutrition. Serum vitamin D was <30 ng/ml in 466 (93%) patients. The prevalence of sarcopenia was 17.1%.Conclusions: Protein malnutrition and vitamin D deficiency are the rule in acute HF patients. Energy malnutrition and sarcopenia are also common. A nutritional assessment in these patients should include these aspects together. [ABSTRACT FROM AUTHOR]

Reply to Letter to the Editor: Outcomes and Effects of 250-cm Biliopancreatic Limb One Anastomosis Gastric Bypass in Patients with BMI > 50 kg/m2 with Total Bowel Length > 6 m: a 2-Year Follow-Up Outcomes and effects of 250-cm biliopancreatic limb one anastomosis gastric bypass in patients with BMI > 50 kg/m2 with total bowel length > 6 m: a 2-year follow-up. I have gladly received the letter to the editor commenting on the article titled "Outcomes and effects of 250-cm biliopancreatic limb one anastomosis gastric bypass in patients with BMI > 50 kg/m2 with total bowel length > 6 m: a 2-year follow-up" [[1]]. [Extracted from the article]

Background In a study involving 175 malnourished frail older adults, a solid oral supplement (ONS) adapted to people with poor dental status allowed an increase of weight and appetite (Protibis ® cookies, France). There was a decrease of bedsores and diarrhea and a trend of a decrease of falls and infections (Pouysségur et al., 2015). Objectives To use the database of this randomized controlled trial for an economic assessment a posteriori. Methods 1) Estimation of the medical cost of bedsores, diarrhea, falls and infections (Delphi method). 2) Comparison of the average cost per participant of the Control group (no cookies) vs. Intervention group (cookies). 3) Sensitivity analysis (Monte Carlo simulations, Tornado diagrams). Results For an 18-week period of observation, the consumption of cookies during 6 weeks generated a cost minimization for Health Insurance. For 18 weeks, the cost cutting was confirmed, mainly in the treatment of falls, with savings due to the reduction of hospital stays (83.44 €) and medical consultations (85.37 €), and in the treatment of infections, with savings due to the reduction of hospital stays (58.90 €). Savings ranged from 1.52 to 2.48 € daily and per malnourished resident, in the case of standard or full protection, respectively. For the institution, it also reduced the working time of the nursing staff by 30 min daily and per malnourished resident. Conclusion The additional cost generated by this new solid ONS in the usual care was compensated with savings generated thanks to the improvement of the nutritional status of the residents. [ABSTRACT FROM AUTHOR]

Acute kidney injury (AKI) in critically ill children is frequently a component of the multiple organ failure syndrome. It occurs within the framework of the severe catabolic phase determined by critical illness and is intensified by metabolic derangements. Nutritional support is a must for these children to improve outcomes. Meeting the special nutritional needs of these children often requires nutritional supplementation by either the enteral or the parenteral route. Since critically ill children with AKI comprise a heterogeneous group of subjects with varying nutrient needs, nutritional requirements should be frequently reassessed, individualized and carefully integrated with renal replacement therapy. This article is a state-of-the-art review of nutrition in critically ill children with AKI. [ABSTRACT FROM AUTHOR]

Background: The relationship between protein-energy wasting and chronic kidney disease (CKD) progression is unknown. In the present prospective cohort study, we evaluated the hypothesis that a combination of low body mass index (BMI) and serum albumin level is associated with rapid CKD progression. Methods: The study cohort comprised 728 predialysis Japanese patients with CKD (stages 2-5) enrolled from 2010 to 2011. Patients were categorized into four groups according to their serum albumin levels and BMI: group 1, low serum albumin level (<4 g/dL) and low BMI (<23.5 kg/m); group 2, high serum albumin level (≥4 g/dL) and low BMI; group 3, low serum albumin level and high BMI (≥23.5 kg/m); and group 4, high serum albumin level and high BMI. The primary outcome was a 30 % decline in estimated glomerular filtration rate (eGFR) or start of dialysis within 2 years. The secondary outcome was an annual GFR decline (mL/min/1.73 m/year). Results: Logistic regression analysis adjusted for baseline characteristics (reference, group 4) showed that only group 1 was associated with a significant risk of CKD progression, with adjusted odds ratio of 3.51 [95 % confidence interval (CI) (1.63, 7.56)]. A multivariate linear regression analysis adjusted for baseline characteristics showed a significant difference in annual eGFR decline between groups 1 and 4 [coefficients β (standard error) −2.62 (0.75), p = 0.001]. Conclusion: This study suggests that combined effects of low BMI (<23.5 kg/m) and serum albumin level (<4 g/dL) are associated with CKD progression. [ABSTRACT FROM AUTHOR]

Background Protein–energy malnutrition is very common among patients with end-stage renal disease undergoing maintenance hemodialysis therapy. Aim The aim of this prospective randomized study was to compare the effect of enteral nutrition (EN) and intradialytic parenteral nutrition (IDPN) on malnourished hemodialysis patients receiving nutritional support admitted in the intensive care unit. Patients and methods A total of 135 patients between 18 and 60 years of age admitted in Ain shams University Hospitals’ intensive care units and on regular hemodialysis were randomly allocated to three groups of 45 each. Group A received enteral and IDPN (250 ml dextrose 25%, 250 ml intralipid 10%, 250 nephrosteril 7%, and trace elements and vitamins). Group B received enteral and IDPN (250 ml dextrose 25%, 250 ml intralipid 10%, 250 aminosteril N-Hepa 8%, and trace elements and vitamins). Group C received only EN. The following evaluations were carried out: biochemical evaluation, which included serum albumin, prealbumin, transferrin, and urinary urea nitrogen evaluation every 20, 4, 8, and 0 days, respectively, and after 6 weeks at the end of the study, and anthropometric parameter measurement, which included BMI, mid-arm circumference, and dialysis malnutrition score (DMS). Results Serum albumin, prealbumin, BMI, and DMS significantly increased (P≤0.001) at the end in all groups. Serum transferrin increased only in groups A and B (P≤0.001), and there was a nonsignificant increase in group C (P≤0.05). No significant difference was found at the end between group A and group B as regards serum albumin (P=0.056), serum prealbumin (0.062), serum transferrin (0.0942), BMI (0.455), and DMS (P=0.840). Serum albumin, prealbumin, transferrin, and BMI showed a significant difference (P≤0.001) in group C at the end of the study in comparison with groups A and B with lower SD. Conclusion IDPN, either aromatic or branched amino acid, in addition to EN showed the same and greater improvement compared with patients who received only EN. [ABSTRACT FROM AUTHOR]

Summary: Chronic protein malnutrition leads to child mortality in developing countries. Spirulina alga (Spi), being rich in protein and growing easily, is a good candidate as supplementation. We showed that Spi completely prevents bone growth retardation and liver disturbances observed in young rats fed a low protein diet. This supports Spi as a useful source of vegetable protein to fight against protein malnutrition. Introduction: Chronic malnutrition is a main factor of child mortality in developing countries. A low protein diet impairs whole-body growth and leads to fatty liver in growing rats. Spi has great potential as a supplementation as it has a 60 % protein content and all essential amino acids. However, its specific impact on bone growth and the related secretion of hepatokines have not yet been studied. Methods: To address this question, 6-week-old female rats were fed isocaloric diets containing 10 % casein, 5 % casein, or 5 % casein + 5 % protein from Spi during 9 weeks. Changes in tibia geometry, microarchitecture, BMC, BMD, and biomechanical properties were analyzed. Serum IGF-I, FGF21, follistatin, and activin A were assessed as well as their hepatic gene expressions in addition to those of Sirt1, Ghr, and Igf1r. Hepatic fat content was also assessed. Results: A low protein diet altered bone geometry and reduced proximal tibia BMD and trabecular bone volume. In addition, it increased hepatic fat content and led to hepatic GH resistance by decreasing serum IGF-I and increasing serum FGF21 without altering serum activin A and follistatin. Spi prevented low protein diet-induced bone, hepatic, and hormonal changes, and even led to higher biomechanical properties and lower hepatic fat content in association with specific InhbA and Follistatin expression changes vs. the 10 % casein group. Conclusions: Altogether our results demonstrate the preventive impact of Spi on bone growth delay and hepatic GH resistance in conditions of isocaloric dietary protein deficiency. [ABSTRACT FROM AUTHOR]

Fatal starvation is a rare cause of death in industrialized countries. However, it may have major medicolegal importance if death results from the deliberate withholding of food, especially from infants. In such cases, the task of the forensic pathologist and the medical examiner, respectively, is to clarify the cause of death and give an expert opinion on the degree and duration of starvation. Several classification systems have been developed to estimate protein-energy malnutrition in developing countries. Simpler classifications, such as the Gomez classification, use the weight expected for the respective age group as the standard. However, smaller infants will be lighter, and therefore the classification may not be accurate in this case. Following the Waterlow classification, the extent of stunted growth (referring to growth retardation in cases of chronic malnutrition) is calculated using the ratio of the measured body height to that expected for the age. Using such classification systems, grading of stunting and wasting can be achieved and may greatly help in the assessment of a given child's nutritional status in legal cases. The application of the Waterlow classification to the authors' case material and previously published cases in the literature is herein demonstrated. The Waterlow classification is not only of importance for grading the final stage of fatal starvation, but also for the chronological development of the nutritional status if anthropometrical data have been repeatedly recorded from the affected individual in vivo. [ABSTRACT FROM AUTHOR]

Background: Anemia and malnutrition are highly prevalent, frequently concomitant and associated with negative outcomes and mortality in the elderly. Objectives: To evaluate the association between these two entities, and test the hypothesis that protein-energy deficit could be etiology of anemia. Design: Prospective case-control study. Setting: Geriatric and Rehabilitation Hospital, Geneva University Hospitals, Switzerland. Participants: 392 patients (mean age 84.8 years old, 68.6% female). Main outcome measures: Hematological (hemoglobin (Hb)), chemical (iron work up, cyanocobalamin, folates, renal function, C-Reactive Protein (CRP)) and nutrition (albumin, prealbumin) parameters, and mini nutritional assessment short form (MNA-SF). Results: The prevalence of anemia (defined as Hb<120 g/l) was 39.3%. Anemic patients were more frequently malnourished or at risk of malnutrition according to the MNA-SF (p=0.047), with lower serum albumin (p <0.001) and prealbumin (p <0.001) levels. Thirty-eight percent of these patients had multiple causes and 14.3% had no cause found for anemia. Among the latter 90.9% of patients with unexplained anemia had albumin levels lower than 35g/l. After exclusion of iron,vitamin B12 and folic acid deficits, anemic patients had lower albumin (p<0.001) and prealbumin (p 0.007) levels. Albumin level explained 84.5% of the variance in anemia. In multivariate analysis albumin levels remain associated with Hb only in anemic patients, explaining 6.4% of Hb variance (adj R2) and 14.7% (adj R2) after excluding inflammatory parameters (CRP>10). Conclusions: Albumin levels are strongly associated with anemia in the elderly. Screening for undernutrition should be included in anemia assessment in those patients. Further prospective studies are warranted in order to explore the effect of protein and energy supplementation on hemoglobin level. [ABSTRACT FROM AUTHOR]

Background: Bariatric surgery is currently the treatment of choice for those patients with severe obesity, but the procedure of choice is not clearly established. We describe weight loss and nutritional parameters in severely obese patients after biliopancreatic diversion for 10 years of follow-up. Methods: Patients were followed by the same multidisciplinary team, and data are shown for 10 years. Bariatric Analysis and Reporting Outcome System (BAROS) questionnaire, data regarding the evolution of obesity-related diseases, and nutritional parameters are reported. Results: Two hundred ninety-nine patients underwent biliopancreatic diversion, 76.1 % women, initial BMI 50.1 kg/m (7.2). Weight loss was maintained throughout 10 years with EWL% around 65 % and EBMIL% around 70 %. More than 80 % of the patients showed EWL higher than 50 %. Blood pressure, glucose metabolism, and lipid profile clearly improved after surgery. Mean nutritional parameters remained within the normal range during follow-up. Protein malnutrition affected less than 4 % and anemia up to 16 %. Fat-soluble vitamin levels decreased along the time, with vitamin D deficiency in 61.5 % of patients. No significant differences were found either in nutritional parameters or weight loss regarding gastrectomy or gastric preservation, or common limb length longer or shorter than 55 cm Conclusions: Biliopancreatic diversion is an effective surgical procedure in terms of weight loss, quality of life, and evolution of obesity-related diseases. Nutritional deficiencies are less frequent than feared for a malabsorptive procedure, but must be taken into account, especially for fat-soluble vitamins. [ABSTRACT FROM AUTHOR]

Background: There are no clinical guidelines or published studies addressing excessive weight loss and protein calorie malnutrition following a standard Roux-en-Y gastric bypass (RYGB) to guide nutritional management and treatment strategies. This study demonstrates the presentation, clinical algorithm, surgical technique, and outcomes of patients afflicted and successfully treated with excessive weight loss following a standard RYGB. Methods: Three patients were successfully reversed to normal anatomy after evaluation, management, and treatment by multidisciplinary team. Lowest BMI (kg/m) was 18.9, 17.9, and 14.2, respectively. Results: Twelve-month post-operative BMI (kg/m) was 28.9, 22.8, and 26.1, respectively. Lowest weight (lbs) was 117, 128, and 79, respectively. Twelve-month post-operative weight (lbs) was 179, 161, and 145, respectively. Pre-reversal gastrostomy tube was inserted into the remnant stomach to demonstrate weight gain and improve nutritional status prior to reversal to original anatomy. Conclusion: We propose a practical clinical algorithm for the work-up and management of patients with excessive weight loss and protein calorie malnutrition after standard RYGB including reversal to normal anatomy. [ABSTRACT FROM AUTHOR]

Objectives: Fluid imbalance due to sodium retention and malnutrition can be characterized by the ratio of extracellular water (ECW) to intracellular water (ICW). We investigated whether the ECW/ICW ratio is a risk factor for adverse outcomes. Design: Retrospective cohort study. Setting and Participants: 149 patients with chronic kidney disease from 2005 to 2009, who were followed until August 2013. Measurements: Body fluid composition was measured by bioelectrical impedance analysis. Patients were categorized according to the ECW/ICW ratio tertile. Daily nutrient intake was estimated from 24-h dietary recall and analyzed using standard food composition tables. The main outcomes were adverse renal outcomes, as defined by a decline of 50% or more from the baseline glomerular filtration rate or initiation of renal replacement therapy, cardiovascular events, and all-cause mortality. Results: The ECW/ICW ratio increased with downward ICW slope with age and renal dysfunction besides ECW excess with massive proteinuria. Sodium intake, protein intake, and calorie intake were negatively correlated with the ECW/ICW ratios due to the steeper decreasing ICW content with the decreased dietary intake than the decreasing ECW content. During a median 4.9-year follow up, patients in the highest tertile had the worst adverse renal outcomes (15.9 vs. 5.1 per 100 patient-years, P <0.001), cardiovascular events (4.1 vs. 0.3 per 100 patient-years, P = 0.002), and mortality (11.2 vs. 1.3 per 100 patient-years, P <0.001). The adjusted hazard ratio (95% confidence intervals) for adverse renal outcomes, cardiovascular events, and mortality were 1.15 (1.03-1.26), 1.12 (0.93-1.31), and 1.29 (1.11-1.50), respectively. Conclusion: Fluid imbalance between ICW and ECW occurring in malnourished and elderly patients with chronic kidney disease may explain the reserve capacity for volume overload and is associated with adverse renal outcomes and all-cause mortality. [ABSTRACT FROM AUTHOR]

Objectives: To determine the association between early childhood caries and nutritional status in preschool children.Methods: Cross-sectional study among preschool children (N=550, age 8-60 mo) were selected in tribal, rural and urban health care units of Kerala. An oral examination for early childhood caries status was done using Deft index. The anthropometric measurements were recorded. Multiple logistic regression with other covariates was used to determine the association between the early childhood caries and nutritional status.Results: The mean (SD) Deft scores were 0.93 (1.73), 2.22 (2.92) and 3.40 (3.23) for children with normal nutritional status, borderline undernutrition and undernutrition, respectively. Children with borderline undernutrition (adjusted OR 2.05, 95% CI 1.20, 3.49) or undernutrition (adjusted OR 3.46, 95% CI 1.93, 6.29) had higher odds of dental caries in comparison to those with normal nutritional status.Conclusion: Undernutrition is associated with early childhood caries among preschool children. [ABSTRACT FROM AUTHOR]

The article presents a retrospective study of academic hospital patients who suffered malnutrition after undergoing obesity treatment surgery and required artificial nutritional supplies for their recovery. Topics discussed include protein malnutrition to be the most critical form of malnutrition after obesity surgery, details regarding the study's methods and its results.

Protein-energy malnutrition is frequently seen in patients with end-stage liver disease who undergo liver transplantation. This causes a deterioration of the patients' clinical condition and affects their post-transplantation survival. Accurate assessment of the nutritional status and adequate intervention are prerequisites for perioperative nutritional treatment. However, the metabolic abnormalities induced by liver failure make the traditional assessment of the nutritional status difficult. The methods that were recently developed for accurately assessing the nutritional status by body bioelectrical impedance may be implemented in pre-transplant management. Because preoperative malnutrition and the loss of skeletal muscle mass, called sarcopenia, have a significant negative impact on the post-transplantation outcome, it is essential to provide adequate nutritional support during all phases of liver transplantation. Oral nutrition is preferred, but tube enteral nutrition may be required to provide the necessary caloric intake. We herein discuss both bioelectrical impedance and the latest findings in the current perioperative nutritional interventions in liver transplant patients regarding synbiotics, micronutrients, branched-chain amino acid supplementation, the use of immune system modulating formulas, the fluid balance and the offering of nocturnal meals. [ABSTRACT FROM AUTHOR]

Protein-energy malnutrition (PEM) is originated by a cellular imbalance between nutrient/energy supply and body's demand. Induction of genetic damage by PEM was reported. The purpose of this study was to determine the genetic effect of the in vitro zinc sulfate (ZnSO) supplementation of cultured peripheral blood lymphocytes from children with PEM. Twenty-four samples from 12 children were analyzed. Anthropometric and biochemical diagnosis was made. For the anthropometric assessment, height-for-age index, weight-for-age index, and weight-for-height index were calculated (WHO, 2005). Micronutrient status was evaluated. A survey for assessed previous exposure to potentially genotoxic agents was applied. Results were statistically evaluated using paired sample t test and χ test. Each sample was fractionated and cultured in two separate flasks to performed two treatments. One was added with 180 μg/dl of ZnSO (PEMs/ZnSO) and the other remains non-supplemented (PEMs). Cytotoxic effects and chromosomal damage were assessed using the cytokinesis-block micronucleus assay (CBMN). All participants have at least one type of malnutrition and none have anemia, nor iron, folate, vitamin A, and zinc deficiency. All PEMs/ZnSO samples have a significant reduction in the micronucleus (MNi) frequency compared with PEMs ( t = 6.25685; p < 0.001). Nuclear division index (NDI) increase in PEMs/ZnSO ( t = −17.4226; p < 0.001). Nucleoplasmic bridge (NPBs) frequency was four times smaller in PEMs/ZnSO ( χ = 40.82; p < 0.001). No nuclear buds (NBuds) were observed. Cytotoxic effects and chromosomal damage observed in children suffering from PEM can be repaired in vitro with zinc sulfate supplementation. [ABSTRACT FROM AUTHOR]

Protein-energy wasting (PEW), a condition of decreased body protein and fat mass, is highly prevalent in patients with chronic kidney disease (CKD) and a potent predictor of mortality in this population. In adults with CKD, PEW has typically been defined on the basis of (1) deranged biochemical parameters, (2) reduced body mass, (3) reduced muscle mass, and (4) decreased dietary protein intake. Emerging data suggest that PEW may also commonly afflict children with CKD and have a negative impact on growth and development ('uremic failure to thrive'), yet it remains comparatively understudied and less well characterized in these patients. Given the challenges of applying adult-defined PEW criteria to the pediatric population, the authors of a recent study entitled 'Protein energy wasting in children with chronic kidney disease' [Abraham et al. (2014) Pediatr Nephrol 29:1231-1238] have sought to develop a scoring system and three alterative definitions for this condition using a combination of biochemical markers, clinical measurements, and subjective reporting in children in the CKiD cohort: (1) minimal PEW definition (≥2 adult-defined PEW criteria); (2) standard PEW definition (≥3 adult-defined PEW criteria); (3) modified PEW definition (≥3 adult-defined PEW criteria, plus short stature or poor growth). These authors observed that meeting the modified PEW definition was associated with a significantly increased risk of hospitalization in unadjusted analyses, i.e., a 2.2-fold higher risk, and trended towards increased risk in multivariable adjusted analyses, i.e., 2.0-fold higher risk. At the present time, future studies validating these findings and developing further refined definitions and/or scoring systems for the detection and management of PEW in children and uremic failure to thrive are urgently needed. [ABSTRACT FROM AUTHOR]

Protein-energy wasting (PEW) is defined as a state of decreased body protein mass and fuel reserves (body protein and fat mass) and is a common complication of chronic kidney disease (CKD). It is multifactorial: the main causative factors are hormonal imbalances and a low nutrient intake, but low residual renal function, inadequate dialysis dose, chronic inflammation and metabolic acidosis are other important contributory factors. Adult PEW has been defined, but there is no accepted definition of pediatric PEW and consequently no precise diagnostic criteria. Assessing nutritional status in children is also complicated by the absence of a gold standard, specific abnormalities in body composition, and the slowly progressive course of the disease. The evaluation of PEW should take into account all of its pathogenetic aspects, which include dietary assessment, clinical and anthropometric assessment (based on weight, height, and body mass index), a panel of biochemical parameters, and a normalized protein catabolic rate (in the case of adolescents on hemodialysis). Bioimpedance indices can be used in individual patients on a regular basis in centers with expertise. The longitudinal follow-up data relating to the above parameters are valuable for comparing patient and normative data. Given the complex nature of PEW, only a multidisciplinary approach can provide an accurate assessment of nutritional status and its derangements in children with CKD and on dialysis. [ABSTRACT FROM AUTHOR]

Background: In adults with chronic kidney disease (CKD), protein-energy wasting (PEW) is a risk factor for hospitalization and death. However, PEW in children with CKD is not well characterized or defined. Methods: Using data from the Chronic Kidney Disease in Children study, we assessed three alternate definitions of PEW using biochemical parameters, body and muscle mass measurements, and reported appetite as described in adults: (1) a minimal PEW definition (≥2 of the four criteria); (2) a standard PEW definition (≥3 of the four criteria); (3) a modified PEW definition (≥3 of the four criteria plus a pediatric-focused criterion of short stature or poor growth). Results: Of the 528 children analyzed in this study (median age 12 years, median glomerular filtration rate 45 mL/min/1.73 m, 39 % female, 18 % African American), 7-20 % met the spectrum of definitions for PEW. The unadjusted incidence rates for incident hospitalizations were 1.9-, 2.1-, and 2.2-fold higher for those children diagnosed with PEW using the minimal, standard, and modified definitions, respectively ( P = 0.08, 0.09 and 0.03). Following adjustment, only the modified PEW definition, which added short stature or poor growth as a criterion, showed modest significance ( P = 0.06). Conclusions: The inclusion of a criterion based on growth may augment the definition of PEW and improve risk discrimination in children with CKD. [ABSTRACT FROM AUTHOR]