Effects of perinatal protein restriction on the oxidative balance in the hypothalamus of 60-day-old rats / Efeitos da restrição proteica perinatal sobre o balanço oxidativo no hipotálamo de ratos de 60 dias de idade

ABSTRACT Objective Evaluate the effects of maternal low-protein diet on the oxidative stress in the hypothalamus of 60-day-old rats. Methods Male Wistar rats were divided into two experimental groups according to the mother's diet during pregnancy and lactation; control group (NP:17% casein n=6) and a malnourished group (LP:8% casein n=6). At 60 days of life, the rats were sacrificed for the collection of the hypothalamus for further biochemical analysis. Results Our results showed an increase in oxidative stress in malnourished group, observed through an increase in carbonyl content (p=0.0357), a reduction in the activity of the glutathione-S-transferase enzyme (p=0.0257), and a reduction in the non-enzymatic antioxidant capacity evidenced by the decrease in the ratio reduced glutathione/oxidized glutathione (p=0.0406) and total thiol levels (p=0.0166). Conclusion A low-protein diet during pregnancy and lactation is closely associated with increased oxidative stress and reduced antioxidant capacity in the hypothalamus of sixty-day-old rats.

RESUMO Objetivo Avaliar os efeitos da restrição proteica materna sobre o estresse oxidativo no hipotálamo de ratos de 60 dias de idade. Métodos Ratos Wistar machos foram divididos em dois grupos experimentais de acordo com a dieta da mãe durante a gestação e lactação: grupo controle (NP: 17% caseína n=6) e grupo desnutrido (LP: 8% caseína n=6). Aos 60 dias de vida, os ratos foram sacrificados para coleta do hipotálamo para posterior análise bioquímica. Resultados Os resultados demonstraram aumento do estresse oxidativo no grupo desnutrido, observado através do aumento do conteúdo de cabonilas (p=0,0357) e redução da atividade da enzima glutationa-S-transferase (p=0,0257) e da capacidade antioxidante não enzimática, evidenciada pela queda da razão glutationa reduzida/glutationa oxidada (p=0,0406) e dos níveis de tióis totais (p=0,0166). Conclusão Uma dieta com baixo teor de proteínas durante a gestação e lactação está intimamente associada ao aumento do estresse oxidativo e à redução da capacidade antioxidante no hipotálamo de ratos de 60 dias de vida.

Clinical features of frailty syndrome and its association with all-cause mortality in elderly patients undergoing maintenance hemodialysis / 中华肾脏病杂志

Objective:To investigate the clinical characteristics and risk factors of frailty syndrome in elderly patients undergoing maintenance hemodialysis (MHD) and the effect of frailty syndrome on all-cause mortality.Methods:This was a prospective cohort study. MHD patients aged≥60 years in 5 hemodialysis centers in Beijing from April to June 2017 were selected as the study subjects. Baseline data were collected and compared, and the patients were then classified into non-frailty, pre-frailty and frailty syndrome groups according to the Fried criteria and followed up until June 2018. The end point event was all-cause death. Multivariate logistic regression was used to analyze the independent risk factors of frailty syndrome. Kaplan-Meier survival analysis was used to compare the difference in the cumulative survival rate among the 3 groups. A multivariate Cox regression model was used to analyze the independent risk factors of all-cause mortality.Results:A total of 204 patients aged (71.65±5.89) years (60-81 years) were enrolled into this study, including 123 males (60.29%), 147 patients (72.06%) in the frailty syndrome group, 41 patients (20.10%) in the pre-frailty group, and 16 patients (7.84%) in the non-frailty group. Patients with frailty syndrome tended to be older, longer dialysis vintage, a higher proportion of diabetes, lower urea clearance index (Kt/V) and lower serum albumin level (all P<0.05). Multivariate Logistic regression showed that factors independently associated with frailty syndrome included age ( OR=1.393, 95% CI 1.241-1.563, P<0.001), history of diabetes ( OR=3.610, 95% CI 1.262-10.327, P=0.017), dialysis vintage ( OR=1.011, 95% CI 1.002-1.020, P=0.019), Kt/V ( OR=0.711, 95% CI 0.516-0.979, P=0.037), serum albumin ( OR=0.754, 95% CI 0.644-0.882, P<0.001) and intact parathyroid hormone (iPTH, OR=1.344, 95% CI 1.024-1.763, P=0.033). Kaplan-Meier survival analysis showed that the cumulative survival rate in frailty syndrome group was significantly lower than those of pre-frailty (Log-rank χ2=7.265, P=0.007) and non-frailty groups (Log-rank χ2=5.238, P=0.022). Multivariate Cox regression analysis indicated that frailty syndrome ( HR=3.832, 95% CI 1.116-13.157, P=0.033), age ( HR=1.074, 95% CI 1.014-1.136, P=0.014), history of diabetes ( HR=2.009, 95% CI 1.067-3.784, P=0.031), cognitive impairment (Montreal cognitive assessment<26, HR=2.627, 95% CI 1.142-6.042, P=0.023), Kt/V ( HR=0.701, 95% CI 0.545-0.902, P=0.006), serum albumin ( HR=0.891, 95% CI 0.806-0.986, P=0.025) and iPTH ( HR=1.226, 95% CI 1.100-1.367, P<0.001) were independently associated with all-cause mortality. Conclusions:The prevalence of frailty syndrome in elderly patients undergoing hemodialysis is high. Ageing, diabetes history, long dialysis vintage, low levels of Kt/V and serum albumin, and elevated iPTH level are independent risk factors for frailty syndrome in such patients. Frailty syndrome is independently associated with an increased risk of all-cause mortality.

Effect of low-dose esketamine on postoperative delirium in elderly frail patients undergoing laparoscopic radical resection of gastrointestinal tumor / 中华麻醉学杂志

Objective:To evaluate the effect of low-dose esketamine on postoperative delirium (POD) in elderly frail patients undergoing laparoscopic radical resection of the gastrointestinal tumor.Methods:Ninety-four American Society of Anesthesiologists physical status Ⅱ or Ⅲ frail patients of both sexes, aged 65-80 yr, with body mass index of 18.5-30.0 kg/m 2 and preoperative Fried frailty phenotype scale score≥3, scheduled for elective laparoscopic radical resection of the gastrointestinal tumor under general anesthesia, were divided into 2 groups ( n=47 each) using a random number table method: control group (group C) and low-dose esketamine group (group K). In group K, esketamine 0.5 mg/kg was given during induction of anesthesia, and esketamine 0.25 mg·kg -1·h -1 was continuously infused during operation until the end of operation.In group C, the equal volume of normal saline was given at the corresponding time point.After induction of anesthesia and before skin incision (T 1), at 1 day after operation (T 2) and at 3 days after operation (T 3), blood samples from the internal jugular vein were collected for determination of the concentrations of S100β protein and neuron-specific enolase (NSE) in serum by enzyme-linked immunosorbent assay.The intraoperative consumption of propofol, remifentanil and sufentanil and use of vasoactive drugs were recorded.POD was evaluated by Confusion Assessment Method within 3 days after operation. Results:Compared with the baseline at T 1, the concentrations of serum S100β and NSE were significantly increased at T 2, 3 in both groups ( P<0.05). Compared with group C, the incidence of POD was significantly decreased (30% vs.13%), the intraoperative consumption of propofol and remifentanil was decreased, and concentrations of serum S100β protein and NSE were decreased at T 2, 3 in group K ( P<0.05). Conclusions:Low-dose esketamine can decrease the occurrence of POD in elderly frail patients undergoing laparoscopic radical resection of gastrointestinal tumor.

Malnutrition in liver cirrhosis: Benefits from improving portal hypertension / 临床肝胆病杂志

Malnutrition is common in patients with liver cirrhosis, especially with a high incidence rate in the decompensated stage, which mainly manifests as protein-energy malnutrition and has a negative impact on the prognosis of patients. The main causes of malnutrition in liver cirrhosis are insufficient intake and increased consumption. Body composition assessment is an important method to evaluate the type of malnutrition in liver cirrhosis. European Society for Parenteral and Enteral Nutrition (ESPEN) guidelines suggest that Nutritional Risk Screening 2002 (NRS2002) should be used for nutritional risk screening, and cirrhotic patients with an NRS2002 score of ≥3 are considered at the risk of malnutrition. ESPEN guidelines recommend a daily energy intake of 30-35 kcal/kg and a daily protein intake of 1.2-1.5 g/kg for patients with liver cirrhosis. Transjugular intrahepatic portosystemic shunt can effectively reduce portal hypertension in patients with liver cirrhosis and help to improve their nutritional status.

Desgaste proteico energético en pacientes con enfermedad renal crónica en estadios III a IV en Caldas, Colombia / Protein Energy Wasting in Patients with Chronic Renal Disease in Stage III to IV Caldas (Colombia)

Resumen Introducción: la enfermedad renal crónica (ERC) es un problema de salud mundial con una prevalencia aproximada del 7,2 % en países desarrollados y del 10 % en todo el mundo; además, es un factor independiente de morbilidad y riesgo cardiovascular que se caracteriza por la pérdida progresiva de la función renal. Objetivo: evaluar la frecuencia de desgaste proteico energético (DPE) en pacientes con ERC en estadios III a IV. Materiales y métodos: estudio descriptivo y de corte transversal. Se realizó una evaluación de los registros de las base de datos de la Sociedad Internacional de Nutrición y Metabolismo Renal sobre pacientes con ERC que contaran con variables sociodemográficas, bioquímicas, valoración global subjetiva (VGS) y medidas antropométricas para el diagnóstico de DPE. Resultados: de 200 pacientes revisados en consulta externa de Nefrología, 60 cumplieron con los criterios de inclusión. El promedio de edad fue de 68,4 años, con una media de tasa de filtración glomerular (TFG) de 47,1 mL/min. Respecto a la ERC, el 61,66 % (n=37) de los participantes fue clasificado en estadio IIIa; el 31,6 % (n=19), en estadio IIIb, y el 6,66 % (n=4), en estadio IV. Ninguno de los pacientes cumplió con los criterios para el DPE. La evaluación de la VGS mostró que el 53,33 % (n=32) de los pacientes estaba en categoría VGS-A (bien nutridos), el 45 % (n=27) en VGS-B (malnutrición moderada) y solo un paciente en VGS-C (malnutrición grave). La mayor proporción de pacientes con bajos niveles de albúmina y colesterol estuvo en pacientes con ERC en estadio IIIb, y los pacientes con índice de masa corporal <23, en estadios IIIb y IV. Conclusión: según los criterios de la Sociedad Internacional de Nutrición y Metabolismo Renal, ningún paciente presentó DPE.

Abstract Introduction: Chronic kidney disease (CKD) is a condition that is recognized as a global health problem and has an approximate prevalence of 7.2% in developed countries, and 10% in the world population, it is also an independent factor of cardiovascular morbidity and risk characterized by progressive loss of kidney function. Objective: To evaluate the frequency of DPE in patients with CKD stages III to IV. Methods: Descriptive, cross-sectional study. Evaluation of a database of patients with CKD, which will have sociodemographic, biochemical variables, Subjective Global Assessment (VGS), and anthropometric measures, for the diagnosis of DPE of the International Society for Nutrition and Renal Metabolism. Results: Of 200 reviewed patients from the Nephrology outpatient clinic, 60 met the inclusion criteria. The average age was 68.4 years, with a mean glomerular filtration rate (GFR) of 47.1ml / min. Regarding CKD, 61.66% (37) of the patients classified in stage IIIa, 31.6% (19) in stage IIIb, and 6.66% (4) in stage IV. None of the patients met the criteria for DPE. The VGS evaluation showed that 53.33% (32) of the patients were in the VGS A category (well nourished), 45% (27) VGS B (moderate malnutrition) and only one patient was classified as VGS C (severe malnutrition). The highest proportion of patients with low levels of albumin and cholesterol was in patients with CKD stage IIIb, and patients with BMI less than 23 in stages IIIb and IV. Conclusion: According to the criteria of the International Society for Renal Nutrition and Metabolism, no patient had DPE. outpatient clinic in Caldas, with CKD stages III to IV-. METHODS: Descriptive, cross-sectional study. Evaluation of a database of patients with CKD, which will have sociodemographic, biochemical variables, Subjective Global Assessment (SGA), and anthropometric measures, for the diagnosis of PEW of the International Society for Nutrition and Renal Metabolism. RESULTS: Of200 reviewed patients from the Nephrology outpatient clinic, 60 met the inclusion criteria. The average age was 68.4 years, with a mean glomerular filtration rate (GFR) of 47.1ml / min. Regarding CKD, 61.66% (37) of the patients were classified in stage IIIa, 31.6% (19) in stage IIIb, and 6.66% (4) in stage IV. None of the patients met the criteria for PEW. The SGA evaluation showed that 53.33% (32) of the patients were in SGAA category (well nourished), 45% (27) SGA B (moderate malnutrition) and only one patient was classified as SGA C (severe malnutrition). The highest proportion of patients with low albumin and cholesterol levels was in patients with CKD in stage IIIb, and patients with BMI less than 23 in stages IIIb and IV. Conclusion: According to the criteria of the International Society for Nutrition and Renal Metabolism, no patient had PEW.

Desnutrição na cirrose: associação com a etiologia e disfunção hepatocelular / Malnutrition in cirrhosis: association with etiology and hepatocellular dysfunction

ABSTRACT BACKGROUND: The protein-energy malnutrition alters the prognosis of patients with cirrhosis. Its prevalence may vary according to the etiology of liver disease, it´s severity and the evaluation of the method applied. The infection by the hepatitis C virus (HCV) and alcoholism are the main etiologies of cirrhosis and result in a significant morbidity and mortality. OBJECTIVE: To evaluate the nutritional status of patients with cirrhosis according the liver disease etiology and severity. METHODS: It is a prospective study, in which the sample was for convenience and consisted of patients with cirrhosis, infected by HCV or alcoholic etiology. The nutritional status evaluation was carried out through anthropometry, food consumption, bioelectrical impedance (BIA) and subjective global assessment (SGA). The anthropometric data evaluated were weight, height, body mass index (BMI), triceps skinfold (TSF), circumference of the arm (CA), non-dominant handshake strength (FAM) and the adductor pollicis muscle thickness (APM). Patients were classified according to the severity of liver disease, using the Child-Pugh and Model for End-stage Liver Diseases (MELD) scores. RESULTS: Ninety patients with cirrhosis were evaluated, 47 with HCV and 43 with alcoholic etiology. The prevalence of protein-calorie malnutrition ranged from 10.9% to 54.3% in the HCV group and from 4.7% to 20.9% in the alcoholic group, depending on the method used for evaluation. The group with HCV infection presented a higher malnutrition prevalence in comparison to the alcoholic in the following evaluations: TSF (P<0.001), phase angle (PA) (P=0.016) and SGA (P=0.010). PA values were lower in patients with viral cirrhosis (5.68±1.05) when compared to those with alcoholic etiology (6.61±2.31) (P=0.016). When all patients were analyzed, regardless of etiology, an inversely correlation was observed among Child-Pugh score and PA values (P=0.018). CONCLUSION: HCV cirrhosis showed worse nutritional parameters in comparison to alcoholic etiology; however, the PA was associated with worse liver function in both etiologies.

RESUMO CONTEXTO: A desnutrição proteico-calórica altera o prognóstico dos pacientes com cirrose. Sua prevalência pode variar de acordo com a etiologia da hepatopatia, gravidade da doença e o método de avaliação empregado. A infeção pelo vírus da hepatite C (VHC) e o alcoolismo, estão entre as principais etiologias da cirrose e acarretam significativa morbidade e mortalidade. OBJETIVO: Avaliar o estado nutricional do paciente com cirrose de acordo com a etiologia e gravidade da hepatopatia. MÉTODOS: Estudo prospectivo, em que a amostra foi por conveniência constituída de pacientes com cirrose, infectados pelo vírus da hepatite C (VHC) ou etiologia alcoólica. A avaliação do estado nutricional foi realizada através da antropometria, consumo alimentar, bioimpedância elétrica (BIA) e da avaliação subjetiva global (ASG). Os dados antropométricos avaliados foram: peso, altura, índice de massa corporal (IMC), prega cutânea triciptal (PCT), circunferências do braço (CB), força do aperto de mão não dominante (FAM) e a espessura do músculo adutor do polegar (MAP). Os pacientes foram classificados de acordo com a gravidade da hepatopatia, através do escore Child-Pugh e Model for End-stage Liver Diseases (MELD). RESULTADOS: Foram avaliados 90 pacientes com cirrose, 47 com etiologia pelo VHC e 43 com etiologia alcoólica. A prevalência de desnutrição proteico-calórica variou de 10,9% a 54,3% no grupo do VHC e de 4,7% a 20,9% no grupo dos alcoolistas, dependendo do método utilizado para avaliação. O grupo com infecção pelo VHC apresentou maior prevalência de desnutrição em relação ao de etiologia alcoólica nas seguintes avaliações: PCT (P<0,001), ângulo de fase (AF) (P=0,016) e ASG (P=0,010). Os valores do AF foram menores nos pacientes com cirrose viral (5,68±1,05) quando comparados aos com etiologia alcoólica (6,61±2,31) (P=0,016). Quando analisados todos os pacientes, independente da etiologia da hepatopatia, observou-se uma correlação inversamente proporcional entre a classificação de Child-Pugh e os valores de AF (P=0,018). CONCLUSÃO: A cirrose pelo VHC demonstrou piores parâmetros nutricionais em relação à etiologia alcoólica; entretanto, em ambas etiologias o AF foi associado com pior função hepática em ambas etiologias.

Serum albumin and total protein level as plausible marker for diagnosis of protein energy malnutrition in children under age 5 years

Background: The circulating concentration of transport protein, traditionally albumin, has been used to define protein deficiency. However, few studies have been conducted to see if there is any correlation between serum total protein and albumin levels in children with PEM. Hence the study was planned to estimate serum total protein, serum albumin levels in children with PEM and healthy controls.Methods: All the children were divided in two groups. Case Group A consist of 250 children with protein energy malnutrition and control Group B consist of healthy 250 children. Venous blood of amount 3 ml was collected with full aseptic precautions. The blood was collected in the EDTA vacutainer and test tube. Serum total protein was estimated by Biuret method, serum albumin was estimated by Bromocresol green dye method (BCG dye).Results: When the mean serum levels of albumin levels and the total protein levels were measured in the controls as well as case groups, there was decrease in levels in case group as compared to control group. This difference of decrease when evaluated statistically it was found to be statistically significant. When the albumin/globulin ratio was calculated in both the groups, it was found to be statistically lower in case group as compared to control group. PEM children have low serum total protein and albumin levels as compared to healthy controls (p<0.001), this is probably due to decreased intake of proteins and reduced biosynthesis. PEM children have lower hemoglobin levels as compared to healthy controls; this is probably due to deficiency of iron and other micronutrients, which is often found in a child with malnutrition.Conclusions: Early diagnosis and prompt management of PEM and its complications can prevent development of permanent physical and mental retardation.

Etiología y mecanismos de desnutrición en el paciente cirrótico / Etiology and mechanisms of undernourishment in the cirrhotic patient

RESUMEN El hígado juega un rol en la homeostasis calórica; está comprometido en el proceso digestivo, y es frecuente encontrar desnutrición en la cirrosis, por incapacidad para satisfacer sus requerimientos de macro y micronutrientes. La patogénesis de desnutrición en la cirrosis es multifactorial, compleja y difícil de ser comprendida, incluye ingesta reducida de nutrientes, biosíntesis disminuida, aumento de la perdida de proteína, absorción intestinal deficiente, disturbios en la utilización del substrato, anormalidades en el metabolismo de carbohidratos, lípidos y proteínas así como aumento de citoquinas pro inflamatorias, resultando en hipermetabolismo y aumento del gasto proteína-energía y de los requerimientos. La evaluación nutricional es trascendental para un enfoque clínico-terapéutico, por su implicancia pronóstica y la respuesta al trasplante hepático. Aún con la evidencia de la prevalencia de desnutrición en cirróticos, continúa poco reconocida, poco diagnosticada y muy poco tratada. Existe controversia si la desnutrición puede ser revertida en cirróticos; aunque hay un acuerdo sobre la necesidad de mejorar la ingesta de alimentos evitando las limitaciones y restricciones no basadas en la evidencia.

ABSTRACT The liver plays a role in the caloric homeostasis; it is involved in the digestive process, so it is not surprising to find malnutrition in cirrhosis, because they have an inability to meet their macro and micronutrient requirements. The pathogenesis of malnutrition is multifactorial and complex and frequently difficult to understand and includes reduced nutrient intake, decreased protein biosynthesis and increased loss, poor intestinal absorption, disturbances in the use of the substrate, abnormalities in the metabolism of carbohydrates, lipids and proteins and increased of pro-inflammatory cytokines resulting in a hypermetabolic state as well as increase in protein-energy expenditure and requirements. The evaluation of nutritional status is transcendental for a clinical-therapeutic approach, due to its influence on the prognosis and response to liver transplantation. Despite the evidence on the prevalence of malnutrition in liver cirrhosis, this condition remains poorly recognized, poorly diagnosed and poorly treated. It is controversial, if malnutrition can be reversed in cirrhotic; there is an agreement about the need to improve the food intake, avoiding limitations and restrictions that are not based on evidence.

Anorexia nervosa con desenlace fatal: a propósito de un caso / Anorexia nervosa with fatal outcome: A case report

Resumen La Anorexia Nervosa (AN) es el trastorno psiquiátrico con mayor nivel de mortalidad directa y, a la vez, causa de múltiples y riesgosas complicaciones somáticas tales como: bradicardia, hipotensión ortostática, arritmias cardiacas, hipoglicemia, falla hepática, alteraciones hidroelectrolíticas y hormonales, osteopenia, dilatación gástrica y, finalmente, muerte súbita por diferentes causas. A pesar de su prevalencia relativamente baja, afecta a personas jóvenes con larga expectativa de vida. Su manejo, cuando llega a niveles de gravedad severa (IMC < 15), es complejo, pues requiere trabajo conjunto de psiquiatría y otras especialidades médicas y puede tener consecuencias ominosas. Se presenta y discute el caso de una paciente mujer de 19 años cuyo IMC llegó a 11 y que, lamentablemente, falleció mientras recibía atención hospitalaria. Se revisan las principales complicaciones médicas de la AN, remarcándose la necesidad de considerar los parámetros pertinentes para una atención hospitalaria oportuna que pueda evitar desenlaces fatales.

Summary Anorexia Nervosa (AN) is the psychiatric disorder with the highest direct mortality level and, at the same time, the cause of multiple and risky somatic complications such as bradycardia, orthostatic hypotension, cardiac arrhythmias, hypoglycemia, liver failure, hydro-electrolytic and hormonal disorders, osteopenia, gastric dilation and, finally, sudden death from different causes. Despite its relatively low prevalence, it affects young people with a long life expectancy. Its medical management, when reaching a high severity level (BMI <15), is complex as it requires joint work between psychiatry and other medical specialties, and can even have ominous consequences. The case of a 19-year-old woman whose BMI was around 11, and who unfortunately died while receiving hospital care, is discussed. The main complications of AN are reviewed, and the need to consider the relevant parameters for a timely hospital care are highlighted, in order to avoid fatal outcomes.

Zinc Supplementation for Promoting Growth in Children Under 5 years of age in Low- and Middle-income Countries: A Systematic Review

Objective: To study the effect of zinc supplementation in children under 5 years of age from low- and middle-income countries (LMICs) onanthropometry and prevalence of malnutrition.Design: Systematic review of randomized controlled trials and cluster randomized trials.Setting: Low- and middle-income countries.Participants: 63 trials with zinc supplementation, incorporating data on 27372 children. Trials conducted exclusively in specificallydiseased participants and in children with severe acute malnutrition were excluded.Intervention: Zinc supplementation, provided either as medicinal supplementation or through food fortification.Outcome Measures: (i) Anthropometry: weight, height, weight-for-height, mid-arm circumference, head circumference; (ii) Prevalenceof malnutrition.Results: There was no evidence of effect on height-for-age Z score at the end of supplementation period (25 trials; 9165 participants;MD= 0.00 Z; 95% CI -0.07, 0.07; P=0.98; moderate quality evidence) with significant heterogeneity (I² = 57%; P<0.001) related to doseand duration of zinc between trials. There was little or no effect on change in height-for-age Z score (13 trials; 8852 participants; MD= 0.11Z; 95% CI -0.00, 0.21; P=0.05), but the heterogeneity was considerable (I²=94%; P<0.001). There was no evidence of effect on length(6303 participants; MD= 1.18 cm; 95% CI -0.63, 2.99 cm, P=0.20; moderate quality evidence; considerable heterogeneity, I²=99%) but alittle positive effect on change in length (19 trials; 10783 participants; MD= 0.43 cm; 95% CI 0.16, 0.70, P=0.002; moderate qualityevidence; considerable heterogeneity, I²=93%). There was no evidence of effect on weight-for-age Z score or change in weight-for-age Zscore but a little positive effect on weight (19 trials; 8851 study participants; MD= 0.23 kg; 95% CI 0.03, 0.42; P=0.02; considerableheterogeneity, I²=91%) and change in weight (kg) (23 trials; 10143 study participants; MD= 0.11 kg; 95% CI 0.05, 0.17, P<0.001,substantial heterogeneity, I²=80%). There was no evidence of effect on weight-for-height Z score, and mid upper arm circumference at theend of supplementation period, but there was a little positive effect on change in mid-arm circumference from baseline (8 trials; 1724participants; MD = 0.09 cm; 95% CI 0.01, 0.16; P=0.03; no heterogeneity, I²=0%). Head circumference in zinc supplemented group wasmarginally higher compared to control (2966 study participants; MD= 0.39 cm; 95% CI 0.03, 0.75; P=0.03; substantial heterogeneity,I²=67%). There was no evidence of benefit in stunting (10 trials; 11838 study participants; RR= 1.0; 95% CI 0.95, 1.06; P=0.89; moderatequality evidence; no significant heterogeneity, I²=11%), wasting (7 trials; 8988 study participants; RR= 0.94; 95% CI 0.82, 1.06; P=0.31;moderate quality evidence; no significant heterogeneity, I²=13%) or underweight (7 trials; 8677 study participants; RR= 1.08; 95% CI 0.96,1.21; P=0.19; moderate quality evidence; substantial heterogeneity, I²=73%).Conclusion: Available evidence suggests that zinc supplementation probably leads to little or no improvement in anthropometric indicesand malnutrition (stunting, underweight and wasting) in children under five years of age in LMICs. Advocating zinc supplementation as apublic health measure to improve growth, therefore, appears unjustified in these settings with scarce resources.

Indigenously Prepared Ready-to-use Therapeutic Food (RUTF) in Children with Severe Acute Malnutrition

Objective: To compare efficacy of indigenous Ready-to-useTherapeutic Food (Medical Nutrition Therapy) with StandardNutrition Therapy in children with Severe acute malnutrition.Design: Two facility-based and two community-based models:(i) Open prospective randomized controlled trial comparingIndigenous Ready-to-use Therapeutic Food (Medical NutritionTherapy) with Standard Nutrition Therapy; (ii) Only IndigenousReady-to-use Therapeutic Food (Medical Nutrition Therapy); (iii)Doorstep Child Care Centre; and (iv) Community-basedManagement of Acute Malnutrition.Setting: (i) Urban Health Center, Dharavi, Mumbai; (ii) Two daycare centers of Non-governmental Organization SNEHA –Mumbai; (iii) Urban slums, M East and L Ward, MumbaiParticipants: 1105 children aged 6-60 months in community orhospital inpatient/ outpatient department diagnosed as SevereAcute Malnutrition by WHO definition.Intervention: All subjects received either Indigenous Ready-to-use Therapeutic Food (Medical Nutrition Therapy) or StandardNutrition Therapy (protein calorie rich diet) for eight weeks andfollowed up for next four months.Main outcome measures: Mean rate of weight gain (g/kg/day), target weight, change in nutritional status.Results: Rate of weight gain was higher (P<0.05) at 2 weeks onindigenous Ready-to-use Therapeutic Food (Medical NutritionTherapy) (5.63 g/kg/day) as compared to Standard NutritionTherapy (3.43 g/kg/day). 61.2% subjects achieved target weightcompared to 47.7% controls. At 8 weeks, 82.8% subjectsrecovered from Severe Acute Malnutrition compared to 19.3%controls (P<0.005). The results obtained in community werecomparable to facility-based indigenous Ready-to-useTherapeutic Food (Medical Nutrition Therapy). The morbidity wasless in study group at follow-up.Conclusions: Indigenous Ready-to-use Therapeutic Food(Medical Nutrition Therapy) appeared to be superior to StandardNutrition Therapy in promoting weight gain in children with SevereAcute Malnutrition.Keywords:Medical Nutrition Therapy, Micronutrients, Nutritionalrehabilitation, Protein energy malnutrition. Ready-to-use-food

Prevalence of protein energy malnutrition among children: a cross sectional study

Background: In the world, hunger and malnutrition are most significant threat. Malnutrition is global risk factor for significant death among infants and pregnant woman. malnutrition increases the chances of several infections.Methods: A cross sectional study was undertaken in children age group of 1 to 18 years, suffering from protein energy malnutrition, attending Department of Paediatrics, tertiary care hospital, Bangalore during the period January 2016 to December 2016.'Results: In the present study, maximum number of cases (44) belongs to age group of 1-5 years, followed by 32 cases belongs to 6-12-year age group and 24 cases belong to 13-18-year age group. Maximum cases (59) belongs to female with male female ratio is 1:1.4. In the present study out of 100 cases, 81 cases came positive for protein energy malnutrition. Out of 81 cases positive for PEM, 34 cases belong to grade I followed by 24 cases belongs to grade II, 13 cases belong to grade III and 1o cases belongs to grade IV protein-energy malnutrition (PEM).Conclusions: Malnutrition is like an iceberg, most people in the developing countries live under the burden of malnutrition.

Estado nutricional e evolução clínica de idosos em terapia nutricional enteral domiciliar: uma coorte retrospectiva / Nutritional status and clinical evolution of the elderly in home enteral nutritional therapy: a retrospective cohort study / Estado nutricional y evolución clínica de ancianos en terapia nutricional enteral domiciliaria: cohorte retrospectiva

Objetivo avaliar a evolução clínica e nutricional de idosos que recebem terapia nutricional enteral domiciliar. Método estudo observacional do tipo coorte retrospectiva. A coleta de dados foi realizada por meio de análise de prontuários dos registros clínicos e nutricionais. Foram analisadas as variáveis demográficas, nutricionais e clínicas. A amostra foi constituída por pacientes idosos em uso de terapia nutricional enteral domiciliar por via sonda ou estomia. Para a análise estatística, utilizou-se o programa Statistical Package for the Social Sciences, adotando-se o nível de significância de 5%. Resultados a amostra foi de 218 participantes, com uma média de idade de 76±10,12 anos, sendo 54,1% do sexo feminino. A principal morbidade foi a sequela por acidente vascular encefálico. A desnutrição foi o diagnóstico nutricional e a avaliação subjetiva global, o principal instrumento de avaliação nutricional. A via de administração da dieta mais prevalente foi a sonda nasoentérica/nasogástrica, contudo, após um ano de acompanhamento, a gastrostomia passou a ser a principal via. Constatou-se o predomínio de manutenção do estado geral e o desfecho clínico mais prevalente foi o óbito. Conclusão a maioria dos pacientes em terapia de nutrição enteral domiciliar apresentou manutenção e/ou melhora do quadro clínico e nutricional. Logo, essa terapia pode contribuir com uma melhor evolução clínica e nutricional.

Objective to evaluate the clinical and nutritional evolution of elderly patients receiving home enteral nutritional therapy. Method retrospective cohort observational study. Data collection was performed through the analysis of clinical and nutritional records. The demographic, nutritional and clinical variables were analyzed. The sample consisted of elderly patients using home enteral nutritional therapy via the probe or the stomach. For the statistical analysis, the Statistical Package for the Social Sciences program was used, adopting the level of significance of 5%. Results the sample was 218 participants, with a mean age of 76 ± 10.12 years, of which 54.1% were female. The main morbidity was the stroke sequelae. Malnutrition was the nutritional diagnosis and the overall subjective assessment, the main instrument of nutritional evaluation. The route of administration of the most prevalent diet was the nasoenteric/nasogastric tube, however, after one year of follow-up, gastrostomy became the main route. It was observed the predominance of general condition maintenance and the most prevalent clinical outcome was death. Conclusion the majority of patients in home enteral nutrition therapy presented maintenance and / or improvement of clinical and nutritional status. Therefore, this therapy may contribute to a better clinical and nutritional evolution.

Objetivo evaluar la evolución clínica y nutricional de ancianos que reciben terapia nutricional enteral domiciliaria. Método estudio observacional tipo cohorte retrospectiva. La recogida de datos fue realizada por medio de análisis de los registros clínicos y nutricionales. Fueron analizadas las variables demográficas, nutricionales y clínicas. La muestra estuvo constituida por pacientes ancianos que usaban terapia nutricional enteral domiciliaria por vía de sonda o gastrostomía. Para el análisis estadístico, se utilizó el programa Statistical Package for the Social Sciences, adoptando el nivel de significación de 5% Resultados: la muestra estuvo compuesta de 218 participantes con una media de edad de 76±10,12 años, siendo 54,1% del sexo femenino. La principal morbilidad fue la secuela por accidente vascular encefálico. La desnutrición fue el diagnóstico nutricional y la evaluación subjetiva global el principal instrumento de evaluación nutricional. La vía de administración de la dieta más prevalente fue la sonda nasoenteral/nasogástrica; sin embargo, después de un año de acompañamiento, la gastrostomía pasó a ser la principal vía. Se constató el predominio de manutención del estado general y el resultado clínico más prevalente fue la muerte. Conclusión la mayoría de los pacientes en terapia de nutrición enteral domiciliaria presentó manutención y/o mejoría del cuadro clínico y nutricional. Luego, esa terapia puede contribuir con una mejor evolución clínica y nutricional.

Association of Undernutrition and Early Childhood Dental Caries

Objectives: To determine the association between early childhood caries and nutritionalstatus 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. Anoral examination for early childhood caries status was done using Deft index. Theanthropometric measurements were recorded. Multiple logistic regression with othercovariates was used to determine the association between the early childhood caries andnutritional 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) orundernutrition (adjusted OR 3.46, 95% CI 1.93, 6.29) had higher odds of dental caries incomparison to those with normal nutritional status. Conclusion: Undernutrition is associatedwith early childhood caries among preschool children.

Outcomes of Children with Severe Acute Malnutrition in a Tribal Day-care Setting

Objective: To describe the nutritional outcomes of children with severe acute malnutrition(SAM) in a village-level intervention. Methods: This observational longitudinal study on 179children aged <3 years was conducted in seven tribal blocks of Central and Eastern India withSAM managed in a comprehensive day care program. Results: 76% children with SAMshowed improvement over a 4-6 months period, with 37% shifting to normal anthrometricstatus. There was a significant shift in Z scores. Conclusion: This community-basedintervention showed fair results for management of children with SAM at village level.

Incidence of maintenance hemodialysis patients with fatigue and its related factors / 中华肾脏病杂志

Objective To investigate the incidence of fatigue in maintenance hemodialysis(MHD)patients and its related factors.Methods A total of 289 patients on MHD between January 2016 and March 2017 in hemodialysis centers of the First Affiliated Hospital of Xinjiang Medical University,Xinjiang Yili Kazak Autonomous Prefecture Friendship Hospital,and Yili Prefecture Hospital were enrolled.Internationally standard fatigue rating scale(FAI)was applied to assess the incidence of fatigue in MHD patients,and subjective comprehensive nutrition assessment(SGA)protein energy wasting rating scale was used to assess protein energy wasting(PEW)conditions.All patients were divided into the fatigue group and the non-fatigue group according to the FAI score.The clinical data and the blood biochemical indicators in two groups were compared.The risk factors of fatigue in MHD patients were analyzed by logistic regression method.Results The incidence of fatigue was 83.0％in MHD patients,and the rate of PEW was 62.6％.Blood total cholesterol in the fatigue group was lower than that of the non-fatigue group(P ＜ 0.05).The difference between SGA scores of two groups had statistical significance(P ＜ 0.001).Single factor logistic regression analysis results showed that higher SGA score(OR=1.312,95％CI:1.163-1.481,P ＜ 0.001),lower blood total cholesterol(OR=0.661,95％CI:0.496-0.880,P=0.005)were risk factors of fatigue in MHD patients.Multivariable logistic regression analysis results showed that higher SGA score(OR=5.286,95％CI:2.078-13.442,P ＜ 0.001)was an independent risk factor of fatigue in MHD patients.Conclusions The incidence of fatigue and PEW are high in MHD patients.PEW is an independent risk factor of fatigue in MHD patients.

Prognóstico e avaliação nutricional de doentes com doença hepática crônica com recurso à antropometria e avaliação global subjetiva / Outcome and nutritional assessment of chronic liver disease patients using anthropometry and subjective global assessment

ABSTRACT BACKGROUND: Protein-calorie malnutrition is common in chronic liver disease (CLD) but adequate clinical tools for nutritional assessment are not defined. OBJECTIVE: In CLD patients, it was aimed: 1. Characterize protein-calorie malnutrition; 2. Compare several clinical, anthropometric and functional tools; 3. Study the association malnutrition/CLD severity and malnutrition/outcome. METHODS: Observational, prospective study. Consecutive CLD ambulatory/hospitalised patients were recruited from 01-03-2012 to 31-08-2012, studied according with age, gender, etiology, alcohol consumption and CLD severity defined by Child-Turcotte-Pugh. Nutritional assessment used subjective global assessment, anthropometry, namely body-mass index (BMI), triceps skinfold, mid upper arm circumference, mid arm muscular circumference and handgrip strength. Patients were followed during two years and survival data was recorded. RESULTS: A total of 130 CLD patients (80 men), aged 22-89 years (mean 60 years) were included. Most suffered from alcoholic cirrhosis (45%). Hospitalised patients presented more severe disease ( P <0.001) and worst nutritional status defined by BMI ( P =0.002), mid upper arm circumference ( P <0.001), mid arm muscular circumference ( P <0.001), triceps skinfold ( P =0.07) and subjective global assessment ( P <0.001). A third presented deficient/low handgrip strength. Alcohol consumption ( P =0.03) and malnutrition detected by BMI ( P =0.03), mid upper arm circumference ( P =0.001), triceps skinfold ( P =0.06), mid arm muscular circumference ( P =0.02) and subjective global assessment ( P <0.001) were associated with CLD severity. From 25 patients deceased during follow-up, 17 patients were severely malnourished according with triceps skinfold. Malnutrition defined by triceps skinfold predicted mortality ( P <0.001). CONCLUSION: Protein-calorie malnutrition is common in CLD patients and alcohol plays an important role. Triceps skinfold is the most efficient anthropometric parameter and is associated with mortality. Nutritional assessment should be considered mandatory in the routine care of CLD patients.

RESUMO CONTEXTO: A desnutrição calórico-proteica é frequente na doença hepática crônica (DHC), no entanto, ferramentas clínicas adequadas para avaliação nutricional destes doentes não estão definidas. OBJETIVO: Em doentes com DHC, pretendeu-se: 1. Caracterizar a desnutrição calórico-proteica; 2. Comparar diferentes ferramentas clínicas, antropométricas e funcionais de avaliação nutricional; 3. Estudar a associação desnutrição/gravidade da DHC e desnutrição/prognóstico. MÉTODOS: Estudo observacional e prospetivo. Foram recrutados doentes ambulatórios/hospitalizados de 01-03-2012 a 31-08-2012 e estudados tendo em conta a idade, gênero, etiologia, consumo alcoólico e gravidade da DHC definida pelo score Child-Turcotte-Pugh. A avaliação nutricional incluiu a utilização da avaliação global subjetiva, antropometria nomeadamente índice de massa corporal (IMC), perímetro braquial, circunferência muscular do braço, prega cutânea tricipital e dinamometria. Os doentes foram seguidos durante 2 anos e foi registada a respectiva sobrevida. RESULTADOS: Foram incluídos 130 doentes com DHC (80 homens) com idade 22-89 anos (média 60 anos). A maioria apresentava cirrose alcoólica (45%). Os doentes hospitalizados apresentaram doença hepática mais severa ( P <0,001) e pior estado nutricional, definido pelo IMC ( P =0,002), perímetro braquial ( P <0,001), circunferência muscular do braço ( P <0,001), prega cutânea tricipital ( P =0,07) e avaliação global subjetiva ( P <0,001). Um terço apresentava força de preensão manual deficiente/baixa. O consumo alcoólico ( P =0,03) e a desnutrição detetada pelo IMC ( P =0,03), perímetro braquial ( P =0,001), prega cutânea tricipital ( P =0,06), circunferência muscular do braço ( P =0,02) e avaliação global subjetiva ( P <0,001) encontraram-se associados à gravidade da DHC. Dos 25 doentes que faleceram durante o seguimento, 17 apresentavam desnutrição severa definida pela prega cutânea tricipital. A desnutrição definida pela prega cutânea tricipital revelou ser um fator preditivo de mortalidade ( P <0,001). CONCLUSÃO: A desnutrição calórico-proteica é comum na DHC para a qual o álcool desempenha um papel importante. A prega cutânea tricipital é o parâmetro antropométrico mais eficiente e encontra-se associado à mortalidade. A avaliação nutricional deve ser considerada mandatória na abordagem rotineira de doentes com DHC.

Incidencia de falla anastomótica en intestino delgado, colon y recto, Bogotá, Colombia / Incidence of anastomotic failure in small bowel, colon and rectum, Bogotá, Colombia

Introducción. La falla anastomótica es una de las principales complicaciones de las cirugías gastrointestinales, que se presenta en 3,4 a 15 % de los pacientes, aproximadamente. En Colombia, no se conoce con exactitud la incidencia de falla anastomótica. Objetivo. Determinar la incidencia de falla anastomótica en cirugías intestinales en dos hospitales de IV nivel de Bogotá. Métodos. Se llevó a cabo un estudio prospectivo de cohorte que incluyó pacientes sometidos a anastamosis y a quienes se les hizo seguimiento hasta de 30 días. Se realizó un análisis descriptivo de la información, asociaciones entre variables mediante la prueba de ji al cuadrado y, además, se emplearon gráficas de KaplanMeier para determinar el tiempo hasta el evento. Los datos se analizaron en Stata 13®. Resultados. Se incluyeron 195 pacientes. El 47,1 % era de sexo masculino y la mediana de la edad fue de 60 años (rango intercuartílico, RIC: 48 a 70). La incidencia de falla anastomótica fue de 10,8 % y la tasa de incidencia fue de 10,2 por 1.000 personas/año. El 29,7 % de los pacientes presentaron complicaciones posoperatorias y se presentó una mortalidad de 9,7 %. La mediana de la estancia hospitalaria fue de 8 días (RIC: 5 a 16). Conclusiones. La incidencia de fístula de la anastomosis que se presentó estuvo acorde con lo reportado en la literatura científica a nivel mundial. El antecedente de cirugía abdominal así como la cirugía de urgencia fueron los factores frecuentes entre los pacientes que presentaron falla anastomótica

Introduction: Anastomotic leak is one of the main complications of patients submitted to gastrointestinal surgery. It occurs in approximately in 3.4% to 15% of cases. In Colombia the overall incidence of anastomotic leak is not known. Material and methods: A prospective cohort study that included patients undergoing anastamosis and who were followed up for up to 30 days. A descriptive analysis of the information was performed. The variables were analyzed with the chi-square test and the Kaplan-Meller graphs were used to determine the time to the event. Data analyses was performed on STATA 13. Results: 195 patients were admitted. 47.1% were male, and the median age of the study group was 60 years (ICR: 48-70). The incidence of anastomotic failure was 10.8% and the incidence rate was 10.2 per 1000 person-years; 29.7% of the patients presented postoperative complications and a mortality rate of 9.7%. The median hospital stay was 8 days (ICR: 5 - 16). Conclusion: The incidence of anastomotic leak observed appears in accordance with reports published in the world literature. The history of abdominal surgery as well as emergency surgery were the most frequent factors among the patients who developed anastomosis leak

Assessment of frailty and its influence factors in maintenance hemodialysis patients / 中华肾脏病杂志

Objective To investigate the frailty in maintenance hemodialysis (MHD) patients and its influence factors. Methods A total of 127 adults undergoing hemodialysis from January 2015 and January 2016 in our center were recruited. Their clinical data and blood biochemical data were collected. Frailty was assessed using Fried's Frailty Phenotype. Quantification of coronary artery calcification (CACs) was determined by multi-slice spiral computed tomography (MSCT). According to the frailty scores, patients were divided into non-frailty, pro-frailty and frailty group. Their in clinical and biochemical index as well as CACs were compared. The correlations of frailty scores with above index were assessed by Spearman's correlation. Multiple logistic regression analysis was applied to evaluate the effect factors of frailty on MHD patients. Results Among 127 selected patients, 46(36.22%) patients without frailty, 45(35.43%) patients with pro-frailty, and 36(28.35%) patients with frailty. The age, diabetes, haemoglobin, albumin, pre-albumin, C-reactive protein, fibroblast growth factor 23 (FGF23), CACs and left ventricular end-diastolic dimension (LVEDD) of the 3 groups had statistical differences (all P<0.05). The degrees of calcification among 3 groups were also different statistically (F=31.769, P<0.001). In patients with MHD, frailty was positively correlated with age (r=0.545, P<0.001), diabetes (r=0.236, P=0.008), C-reactive protein (r=0.245, P=0.006), FGF23 (r=0.189, P=0.034) and CACs (r=0.396, P<0.001), while negatively correlated with haemoglobin (r=-0.257, P=0.004), albumin (r=-0.380, P<0.001), pre-albumin (r=-0.313, P<0.001). Age (OR=1.076), C-reactive protein (OR=1.176), albumin (OR=0.796) and artery calcification (OR=2.465) were independent influence factors for frailty in MHD patients (all P<0.05). Conclusions The prevalence of frailty is high among MHD patients. Frailty is associated with age, C-reactive protein, albumin and artery calcification in MHD patients.

Effect of Personalized Nutritional Counseling on the Nutritional Status of Hemodialysis Patients

This study set out to evaluate the impact of personalized nutritional counseling (PNC) on the nutritional status of hemodialysis (HD) patients. This was an intervention study for 10 months at 2 hospitals. Anthropometric, biochemical, dietary, and body composition parameters were measured at baseline and after 3 and 6 months of PNC. A total of 42 patients (23 men and 19 women) were included. Intake of dietary protein, serum albumin, and cholesterol levels had increased significantly from baseline to month 6 (p < 0.05). Among the bioelectrical impedance analysis (BIA) parameters, both the body cell mass (BCM) and the fat free mass (FFM) had significantly reduced at month 3 compared to baseline (p < 0.05). However, there was no difference between baseline and month 6. We assessed the nutritional status of the subjects using the malnutrition inflammation score (MIS), and divided them into an adequately nourished (AN) and a malnourished (MN) group at baseline. In the subgroup analysis, serum levels of albumin and cholesterol had increased significantly, particularly from baseline to month 6 in the MN group (p < 0.05). This study suggests that consecutive PNC contributed to the improvement of the protein intake, serum levels of albumin, cholesterol and to the delay of muscle wasting, which could also have a positive impact on the nutritional status, particularly in malnourished patients receiving HD treatment.