Relação do risco nutricional e perfil glicêmico no desfecho de pacientes críticos / Relationship of nutritional risk and glycemic profile in the outcome of critically ill patients

Em pacientes críticos o risco nutricional e a hiperglicemia associam-se ao aumento da incidência de desfechos desfavoráveis. Objetivo: Avaliar a relação do risco nutricional pelo Nutrition Risk in Critically III, versão modificada (mNUTRIC) e perfil glicêmico nos desfechos de alta, óbito e tempo de internação de pacientes críticos e verificar o impacto das ferramentas Acute Physiology and Chronic Health Disease Classification System II (APACHE II) e do Sepsis-Related Organ Failure Assessment (SOFA) nesses desfechos. Método: Estudo longitudinal prospectivo desenvolvido em Unidade de Terapia Intensiva (UTI). Foram incluídos adultos, com tempo ≥ 48 horas de internação e com registro mínimo de duas aferições glicêmicas. Excluíram-se pacientes em cuidados paliativos, readmitidos nas UTI e gestantes. O teste Exato de Fisher e Shapiro Wilk foram utilizados para avaliar as variáveis categóricas e contínuas, respectivamente. Posteriormente, utilizou-se o teste de Mann-Whitney ou t-Student não pareado. Realizou-se análise de regressão logística e linear. O nível de significância adotado foi de 5%. Resultados: Ao avaliar 35 pacientes, 45,7% apresentaram alto risco nutricional. Foi observado associação do risco nutricional com os desfechos de alta e óbito; o SOFA associou-se ao óbito e tempo de internação. O incremento de 1 ponto no escore do SOFA aumentou a chance de óbito em 83% e tempo maior de internação em 0,49 dias. O perfil glicêmico e APACHE II não se associou aos desfechos. Conclusão: o escore SOFA foi o instrumento que apresentou associações significativas com o desfecho do óbito e maior tempo de internação de pacientes críticos

In critically ill patients, nutritional risk and hyperglycemia are associated with an increased incidence of unfavorable outcomes. Objective: To evaluate the relationship of nutritional risk by the Nutrition Risk in Critically III, modified version (mNUTRIC) and glycemic profile in the outcomes of discharge, death and length of stay in critically ill patients and to verify the impact of the Acute Physiology and Chronic Health Disease Classification System II (APACHE II) and the Sepsis-Related Organ Failure Assessment (SOFA) tools on these outcomes. Method: Prospective longitudinal study developed in an Intensive Care Unit (ICU). Adults were included, with ≥ 48 hours of hospitalization and with a minimum record of two blood glucose measurements. Patients in palliative care, readmitted to ICU and pregnant women were excluded. Fisher's Exact test and Shapiro Wilk test were used to evaluate categorical and continuous variables, respectively. Subsequently, the Mann-Whitney or unpaired t-Student test was used. Logistic and linear regression analysis was performed. The significance level adopted was 5%. Results: When evaluating 35 patients, 45.7% were at high nutritional risk. An association was observed between nutritional risk and discharge and death outcomes; SOFA was associated with death and length of hospital stay. The increment of 1 point in the SOFA score increased the chance of death by 83% and a longer hospital stay by 0.49 days. Glycemic profile and APACHE II were not associated with outcomes. Conclusion: the SOFA score was the instrument that showed significant associations with the outcome of death and longer hospital stay in critically ill patients

Incidencia de desnutrición y factores sociodemográficos asociados, en pacientes de del hospital universitario de Karbala / Incidence of malnutrition and sociodemographic factors associated, in patients from the Karbala Teaching Hospital

Antecedentes: La desnutrición es un importante problema de salud en el grupo de edad de pediatría que contribuye a aumentar la mortalidad y morbilidad de los pacientes ingresados. Pacientes y método: Estudio descriptivo, aleatorizado, transversal de 2965 casos entre 6 y 60 meses de los cuales 500 casos tenían desnutrición desde el 15 de noviembre de 2019 al 31 de enero de 2020, datos hospitalarios para evaluar la incidencia de desnutrición aguda severa y desnutrición aguda moderada y leve. Desnutrición y su relación con algunos factores sociodemográficos (trabajo paterno, peso al nacer, tipo de alimentación, edad, sexo). Resultados: la incidencia de desnutrición aguda severa es 1%, la incidencia de desnutrición aguda moderada es 10% y desnutrición leve 27% de la muestra de pacientes tomada 469 pacientes existe una fuerte relación de todos los grados de desnutrición con la edad paterna y bajo nacimiento peso con alguna relación con el tipo de alimentación. Conclusiones: si bien la incidencia de desnutrición aguda severa ha disminuido en los últimos años en el hospital universitario de Karbala, existe un marcado aumento en la incidencia de desnutrición aguda moderada y desnutrición leve con su impacto en la salud pediátrica general en cuanto a morbilidad y mortalidad se deben tomar esfuerzos para manejar la desnutrición aguda moderada y desnutrición leve ofreciendo asesoramiento y apoyo nutricional especialmente en personas que no son Empleadores gubernamentales.

Background: Malnutrition is a major health problem in pediatrics age group contribute to increase mortality and morbidity of admitted patients. Patients and method: A descriptive randomized cross sectional study of 2965 cases between 6 -60 months from which 500 cases had malnutrition from15th of November 2019 to 31st of January 2020 hospital-based data to evaluate incidence of sever acute malnutrition and moderate acute malnutrition and mild malnutrition and its relation to some sociodemographic factors (paternal job, birth weight, type of feeding, age, sex). Results: the incidence of severe acute Malnutrition is 1%, the incidence of moderate acute malnutrition is 10% and mild malnutrition 27% from the sample of patients taken 469 patients there is a strong relationship of all degree of malnutrition to paternal age and low birth weight with some relation to type of feeding. Conclusions: while the incidence of severe acute malnutrition has been decreased last years In Karbala teaching hospital, there is marked increase in incidence of moderate acute malnutrition and mild malnutrition with their impact on general pediatric health regarding morbidity and mortality efforts should be taken to manage the moderate acute malnutrition and mild malnutrition by offering nutritional advice and support especially in people who are not governmental Employer.

Programas de Protección Nutricional de la Agenda Venezuela / Nutritional protection programs of the Venezuela Agenda

Venezuela ha pasado a ser un país asimétrico, con grandes desigualdades y la inseguridad alimentaria familiar constituye quizás el problema nutricional más importante. En 1996, se comenzó a implementar la "Agenda Venezuela", la cual tiene un componente de protección social, que incluye 14 programas, para compensar a los grupos de población más desfavorecidos por las medidas económicas. Objetivo. Describir y analizar las fortalezas y debilidades de los programas de la Agenda, más vinculados con la situación nutricional. Materiales y métodos. Se basó en el análisis de informes presentados por los organismos ejecutores, de una encuesta de opinión realizada en Caracas, además de entrevistas a coordinadores de los programas. Se examinaron los programas: alimentos estratégicos, subsidio familiar, alimentación escolar, merienda y comedores escolares, hogares y multihogares de cuidado diario. Resultados. Las debilidades más comunes son: deficiente evaluación y apoyo educativo, escasa cobertura, solapamiento de beneficiarios, problemas de tipo logístico y presupuestario. A pesar de la fuerte inversión de recursos, el déficit nutricional en menores de seis años presenta una tendencia ascendente, lo cual reitera que los problemas nutricionales son multicausales y requieren de políticas sociales integrada, estables en el tiempo y focalizadas en los grupos más vulnerables. Conclusiones. Esta situación obliga a replantearse los programas en función a la pertinencia, factibilidad, costo-eficiencia e impacto y ha reiterado, la necesidad de un proceso de descentralización para otorgar más responsabilidad y poder de decisión a los gobiernos estatales, municipales y a la comunidad organizada y lograr un mayor impacto en la población objetivo y su contexto(AU)

Venezuela has become an asymmetric country, with great inequalities and family food insecurity is perhaps the most important nutritional problem. In 1996, the "Venezuela Agenda" began to be implemented, which has a social protection component, which includes 14 programs, to compensate the most disadvantaged population groups for economic measures. Objective. Describe and analyze the strengths and weaknesses of the Agenda programs, more linked to the nutritional situation. Materials and methods. It was based on the analysis of reports submitted by the executing agencies, an opinion poll conducted in Caracas, as well as interviews with program coordinators. The programs were examined: strategic food, family subsidy, school feeding, snack and school canteens, daily care homes and multi-homes. Results. The most common weaknesses are poor evaluation and educational support, poor coverage, overlapping beneficiaries, logistical and budgetary problems. Despite the strong investment of resources, the nutritional deficit in children under six years of age shows an upward trend, which reiterates that nutritional problems have multiple causes and require integrated social policies, stable over time and focused on the most vulnerable groups. Conclusions. This situation forces us to reconsider the programs based on their relevance, feasibility, cost-efficiency and impact and has reiterated the need for a decentralization process to grant more responsibility and decision-making power to state and municipal governments and to the organized community and achieve a greater impact on the target population and its context(AU)

Complementariedade do escore NUTRIC modificado com ou sem proteína C-reativa e avaliação subjetiva global na predição de mortalidade em pacientes críticos / Complementarity of modified NUTRIC score with or without C-reactive protein and subjective global assessment in predicting mortality in critically ill patients

RESUMO Objetivo: Avaliar a concordância entre o escore NUTRIC modificado e o escore NUTRIC com proteína C-reativa na identificação de pacientes em risco nutricional e na predição da mortalidade entre pacientes críticos. Avaliou-se também o risco de óbito com agrupamento dos pacientes segundo o risco nutricional e a desnutrição detectada pela avaliação subjetiva global. Métodos: Estudo de coorte em pacientes admitidos em uma unidade de terapia intensiva. O risco nutricional foi avaliado por meio do escore NUTRIC modificado e uma versão do escore NUTRIC com proteína C-reativa. Aplicou-se avaliação subjetiva global para diagnóstico de desnutrição. Calculou-se a estatística de Kappa e construiu-se uma curva ROC considerando o NUTRIC modificado como referência. A validade preditiva foi avaliada considerando a mortalidade em 28 dias (na unidade de terapia intensiva e após a alta) como desfecho. Resultados: Estudaram-se 130 pacientes (63,05 ± 16,46 anos, 53,8% do sexo masculino). Segundo o NUTRIC com proteína C-reativa, 34,4% foram classificados como escore alto, enquanto 28,5% dos pacientes tiveram esta classificação com utilização do NUTRIC modificado. Segundo a avaliação subjetiva global, 48,1% dos pacientes estavam desnutridos. Observou-se concordância excelente entre o NUTRIC modificado e o NUTRIC com proteína C-reativa (Kappa = 0,88; p < 0,001). A área sob a curva ROC foi igual a 0,942 (0,881 - 1,000) para o NUTRIC com proteína C-reativa. O risco de óbito em 28 dias estava aumentado nos pacientes com escores elevados pelo NUTRIC modificado (HR = 1,827; IC95% 1,029 - 3,244; p = 0,040) e pelo NUTRIC com proteína C-reativa (HR = 2,685; IC95% 1,423 - 5,064; p = 0,002). Observou-se elevado risco de óbito nos pacientes com alto risco nutricional e desnutrição, independentemente da versão do NUTRIC aplicada. Conclusão: A concordância entre o escore NUTRIC modificado e o NUTRIC com proteína C-reativa foi excelente. Além disto, a combinação da avaliação com um escore NUTRIC mais avaliação subjetiva global pode aumentar a precisão para predição de mortalidade em pacientes críticos.

ABSTRACT Objective: To evaluate the concordance between the modified NUTRIC and NUTRIC with C-reactive protein instruments in identifying nutritional risk patients and predicting mortality in critically ill patients. The risk of death in patient groups was also investigated according to nutritional risk and malnutrition detected by subjective global assessment. Methods: A cohort study of patients admitted to an intensive care unit. Nutritional risk was assessed by modified NUTRIC and a version of NUTRIC with C-reactive protein. Subjective global assessment was applied to diagnose malnutrition. Kappa statistics were calculated, and an ROC curve was constructed considering modified NUTRIC as a reference. The predictive validity was assessed considering mortality in 28 days (whether in the intensive care unit or after discharge) as the outcome. Results: A total of 130 patients were studied (63.05 ± 16.46 years, 53.8% males). According to NUTRIC with C-reactive protein, 34.4% were classified as having a high score, while 28.5% of patients had this classification with modified NUTRIC. According to SGA 48.1% of patients were malnourished. There was excellent agreement between modified NUTRIC and NUTRIC with C-reactive protein (Kappa = 0.88, p < 0.001). The area under the ROC curve was equal to 0.942 (0.881 - 1.000) for NUTRIC with C-reactive protein. The risk of death within 28 days was increased in patients with high modified NUTRIC (HR = 1.827; 95%CI 1.029 - 3.244; p = 0.040) and NUTRIC with C-reactive protein (HR = 2.685; 95%CI 1.423 - 5.064; p = 0.002) scores. A high risk of death was observed in patients with high nutritional risk and malnutrition, independent of the version of the NUTRIC score applied. Conclusion: An excellent agreement between modified NUTRIC and NUTRIC with C-reactive protein was observed. In addition, combining NUTRIC and subjective global assessment may increase the accuracy of predicting mortality in critically ill patients.

Intervención nutricional precoz en ancianos con neumonía adquirida en la comunidad / Precocious nutritional intervention in elder people with community-acquired pneumonia

RESUMEN Introducción: la nutrición tiene importancia capital en la evolución de los pacientes ingresados. La prevalencia de malnutrición oscila entre 30% y 60% de los enfermos hospitalizados. Objetivo: evaluar impacto en la mortalidad y complicaciones a corto plazo de una intervención nutricional precoz. Material y método: se realizó un estudio caso control con todos los pacientes que ingresaron en la Unidad de Cuidados intensivos emergentes con el diagnóstico de neumonía adquirida en la comunidad asociada a desnutrición en Hospital Militar Dr. Carlos J. Finlay, de noviembre de 2017 hasta mayo del 2018. Resultados: la media de la edad del estudio fue de 80,73 ± 9,01 años. El 46 % fueron mujeres. La mortalidad global estuvo en el 26 %. El 69 % de los pacientes presento alguna complicación. Existió una mayor sobrevida en el grupo de estudio (7 fallecidos y 29 vivos), que en el grupo de control donde hubo 12 fallecidos y 24 vivos x2 = 0,18. En la tabla 2 se evidencia que existe diferencia entre los grupos según las complicaciones aparecidas. Fue marcada la diferencia entre los grupos en relación a la cantidad de pacientes con diarreas. La incidencia fue mayor tanto en el subgrupo de vivos(8) como en el de fallecidos(3) del grupo control. Por otro lado la hiperglucemia fue mucho mayor en el grupo de estudio(11) y sin embargo, no hubo impacto en la mortalidad x2 = 0,03. En la tabla 3 se evidencia una fuerte evidencia que relaciona al estado nutricional deficiente con una peor evolución. Entre los fallecidos solo 1 tenía un estado nutricional catalogado como desnutrido ligero, sin embargo entre los 22 fallecidos 14 presentaron desnutrición severa. Conclusiones: el estado nutricional al ingreso impacta negativamente en la mortalidad a corto plazo y la estrategia nutricional mixta precoz no reduce ese aspecto sin embargo si reduce el número de complicaciones aunque se asoció a mayor incidencia de hiperglucemia sin impactar en la mortalidad (AU).

SUMMARY Introduction: nutrition has a capital importance in the evolution of in-patients. Malnutrition prevalence ranges from 30 % to 60 % of the admitted patients. Objective: to evaluate the impact on mortality and the short time complications of the precocious nutritional intervention. Material and Method: a case control study was carried out with all patients who entered the Emergency Intensive Care Unit with the diagnosis of community-acquired pneumonia associated to malnutrition in the Military Hospital "Dr, Carlos J. Finlay" from November 2017 to May 2018. Results: the average age was 80.73 ± 9.01 years. 46 % were female patients. Global mortality was 26 %. 69 % of patients had complications. The group of study showed a higher survival (7 deads and 29 survivors) than the control one where there were 12 deads and 24 survivors (2=0.18). Table 2 shows that there are differences between groups according to the complications found. The difference between groups was remarkable in relation to the quantity of patients with diarrhea. The incidence was higher both in the group of survivors(8) and in the group of dead peoples(3) of the control group. On the other hand, hyperglycemia was much higher in the group of study(11) but without striking on mortality (2= 0.03). Table 3 shows strong evidence relating deficient nutritional status to a worth evolution. Among the deceased patients only 1 had a nutritional status classified as slightly malnutrition, but among the 22 deceased, 14 had severe malnutrition. Conclusions: the nutritional status at admission negatively strikes on short term mortality, and mixed precocious nutritional strategy does not reduce that aspect. However it does reduce the number of complications, though it was associated to a higher incidence of hyperglycemia without striking on mortality (AU).

Adductor Pollicis Muscle Thickness as a Marker of Nutritional Status in Heart Failure

Malnutrition is associated with morbidity and mortality in patients with heart failure (HF). Thus, it is essential to apply reliable indicators to assess the nutritional status of these individuals. Objective: To evaluate the thickness of the adductor pollicis muscle (APM) in patients with HF as an indicator of somatic protein status and correlate the obtained values with conventionally used parameters and electrical bioimpedance (EBI) markers. Methods: Cross-sectional study with patients with HF undergoing regular outpatient treatment. APM thickness was measured in the dominant arm, and the values obtained were classified according to gender and age. The anthropometric parameters assessed included the body mass index (BMI) and specific parameters to assess the muscle (arm muscle circumference [AMC] and arm muscle area [AMA]). Values of phase angle (PA), standard PA (SPA), and lean mass were obtained by EBI. Statistical analyses were performed with the software Statistical Package for the Social Sciences, version 19, using unpaired Student's t, Mann-Whitney, or one-way analysis of variance (ANOVA) tests for comparisons between groups, as appropriate. The correlation between variables of interest was performed using Pearson's or Spearman's correlation coefficient, as adequate. The level of significance was set at 5%. Results: About 70% of the 74 patients evaluated were classified as malnourished according to the APM thickness. Values of AMC, AMA, and lean mass correlated positively with APM thickness (p < 0.005). The APM thickness also correlated positively with PA and SPA (r = 0.49, p < 0.001 and r = 0.31, p = 0.008, respectively). Conclusion: Patients with HF presented a high frequency of protein malnutrition when APM thickness was used as an indicator of nutritional status. APM thickness values correlated with conventional measures of somatic protein evaluation and may be related to the prognosis of these patients, since they correlated positively with PA and SPA

Relationship between nutritional status and the clinical outcomes of patients with and without neoplasms according to multiple correspondence analysis / Relação entre estado nutricional e desfechos clínicos pela técnica da análise de correspondência múltipla em pacientes com e sem neoplasias

ABSTRACT BACKGROUND For many years, many studies have reported undesirable outcomes that may occur during the hospital stay of patients diagnosed with malnutrition or even at some nutritional risk. OBJECTIVE To investigate the relationship between nutritional status and clinical outcomes during hospital stay using the multiple correspondence analysis technique. METHODS This cross-sectional study included 600 patients with and without neoplasms. The following data were collected: subjective global assessment, nutritional indicators, nutritional risk screening, anthropometric data (body mass index (BMI), mid-upper arm circumference (MUAC), mid-upper arm muscle circumference (MUAMC), triceps skinfold thickness (TST), recent weight loss (RWL)), and habitual energy intake (HEI/ER <75%). The clinical outcomes of interest were complications, length of hospital stay (LOHS), and death. The data were analyzed by the chi-square or Fisher’s exact test at a significance level of 5%. Multiple correspondence analysis was used for the multivariate data analysis. RESULTS The multiple correspondence analysis map for the patients with neoplasms showed that the following characteristics were associated and represented by death, complications, and a greater likelihood of LOHS ≥7 days: underweight according to BMI; TST, MUAC, and MUAMC ≤15th percentile; malnutrition according to the subjective global assessment; at nutritional risk according to the nutritional risk screening; being male; age ≥60 years; and HEI/ER <75%. The multiple correspondence analysis map for the patients without neoplasms showed that the following characteristics were associated and represented by death: underweight according to BMI; TST ≤15th percentile; malnutrition according to the subjective global assessment; and at nutritional risk according to the nutritional risk screening. Complications and LOHS ≥7 days represented the categories male, no recent weight loss, HEI/ER <75%, MUAC and MUAMC ≤15th percentile, TST between the 15th and 85th percentiles, and age <60 years. CONCLUSION The results of this study confirm an association between unsatisfactory nutritional indicators and undesirable clinical outcomes.

RESUMO CONTEXTO Muitos estudos já vêm relatando há muitos anos, alguns desfechos indesejáveis que podem se manifestar durante o curso da hospitalização em pacientes diagnosticados com desnutrição ou até mesmo com algum risco nutricional. OBJETIVO Explorar pela técnica da análise de correspondência múltipla a relação entre o estado nutricional e os desfechos clínicos apresentados no decorrer da internação em pacientes hospitalizados. MÉTODOS Estudo transversal com 600 pacientes com e sem neoplasias. Foram estudados os indicadores nutricionais de avaliação subjetiva global, screening de risco nutricional, antropometria (IMC, circunferência braquial-CB, circunferência muscular do braço-CMB, prega cutânea triciptal-PCT), perda de peso recente e consumo energético habitual (CEH/NE <75%). Como desfechos clínicos, foram considerados a presença de complicações, tempo de internação e óbito. Os dados foram analisados pelo teste qui-quadrado ou exato de Fisher, com nível de significância de 5%. Para a análise multivariada dos dados, utilizou-se a análise de correspondência múltipla. RESULTADOS O mapa fornecido pela análise de correspondência múltipla no grupo de pacientes com neoplasias, mostrou que as categorias de baixo peso pelo IMC, PCT, CB e CMB ≤ ao percentil 15, desnutrido pela avaliação subjetiva global, com risco nutricional pelo screening de risco nutricional, com perda de peso recente, sexo masculino, idade ≥ a 60 anos e CEH/NE <75% se associaram e foram representadas pelo óbito, com complicações e mais próximos do tempo de internação ≥ a 7 dias. O mapa fornecido pela análise de correspondência múltipla no grupo de pacientes sem neoplasias, mostrou que as categorias de baixo peso pelo IMC, PCT ≤ ao percentil 15, desnutrido pela avaliação subjetiva global e com risco nutricional pelo screening de risco nutricional se associaram e foram representadas pelo óbito. Complicações e tempo de internação ≥ 7 dias representaram as categorias de sexo masculino, sem perda de peso recente, CEH/NE <75%, CB e CMB ≤ ao percentil 15, PCT entre percentil 15 e 85 e idade < 60 anos. CONCLUSÃO Os resultados deste estudo confirmaram uma associação entre indicadores nutricionais insatisfatórios e desfechos clínicos indesejáveis.

Perfil nutricional e fatores associados à desnutrição e ao óbito em pacientes com indicação de terapia nutricional / Nutritional profile and associated factors with malnutrition and death in patients with nutritional support indication

Objetivo: Analisar o perfil nutricional, demográfico e clínico de indivíduos hospitalizados com indicação de terapia nutricional, assim como verificar as variáveis que se relacionam à ocorrência de desnutrição e óbito. Método: Estudo transversal retrospectivo, realizado em um hospital filantrópico de Minas Gerais, com os dados dos pacientes adultos e idosos que receberam terapia nutricional enteral e/ou parenteral entre 2011 e 2014. Resultados: Foram analisados os dados de 688 indivíduos, com idade média de 69 anos (DP=17,5 anos). Dos pacientes avaliados, 55,5% apresentavam algum grau de desnutrição, segundo a Avaliação Subjetiva Global, sendo 22,5% desnutridos graves. A maioria (81,5%) atingiu a meta nutricional e 56,6% foram a óbito. Ter 60 anos ou mais, estar em Unidade de Terapia Intensiva (UTI) e o atendimento pelo Sistema Único de Saúde foram fatores que se associaram à maior frequência de desnutrição e ao óbito. Conclusão: É preocupante a frequência de indivíduos que já iniciam a terapia nutricional com algum grau de desnutrição, ressaltando-se a necessidade da intervenção nutricional precoce. Idosos e pacientes em UTI foram grupos potencialmente mais vulneráveis à desnutrição e ao óbito e, requerem, portanto, atenção especial.(AU)

Objective: To analyze the nutritional status, demographic and clinical profile of hospitalized patients with nutritional support indication, as well as check the variables that relate to the occurrence of malnutrition and death. Methods: A retrospective cross-sectional study in a philanthropic hospital in Minas Gerais, with data from adults and elderly patients who received enteral and/or parenteral nutrition between the years 2011 to 2014. Results: Data of 688 individuals were analyzed, with mean age of 69 years (SD: 17.5 years). Among the patients, 55.5% had some degree of malnutrition according to the Subjective Global Assessment, and 22.5% were severely malnourished. Most of patients (81.5%) reached the nutritional goal and 56.6% died. Be 60 years or older, be in the Intensive Care Unit (ICU) and the attendance by the Unified Health System were factors that were associated with higher frequency of malnutrition and death. Conclusion: It is worrying the high frequency of individuals who already begin to nutritional support with some degree of malnutrition, emphasizing the need for early nutritional intervention. Elderly and patients in ICU were potentially most vulnerable to malnutrition and death, and therefore require special attention.(AU)

Morbimortalidad asociada al estado nutricional y vía de alimentación en niños con parálisis cerebral / Morbimortality associated to nutritional status and feeding path in children with cerebral palsy

Introducción: Los niños y adolescentes con Parálisis Cerebral (PC) tienen elevada prevalencia de desnutrición, asociada a peor pronóstico. Para la adecuada evaluación nutricional existen nuevas curvas de crecimiento (Brooks y Col) que han planteado puntos de corte del índice Peso/Edad asociados a mayor morbimortalidad. Objetivo: Evaluar si pacientes con PC, en dicha categoría de riesgo nutricional (RN), presentan mayor riesgo de hospitalización y muerte. Pacientes y Método: Estudio observacional y prospectivo de una cohorte de pacientes con PC, controlados en un centro ambulatorio de referencia. Se registró: datos demográficos, socioeconómicos, evaluación funcional motora y nutricional basal. En seguimiento durante un año se constataron hospitalizaciones y mortalidad. Investigación aprobada por la comisión de ética. Resultados: Se reclutaron 81 niños con PC, edad 131,6 ± 60,4 meses (25-313), 60% de sexo masculino, 77,5% no se movilizaba por sí mismo. Los 23 pacientes con RN (28,4%), presentaban menor masa muscular y masa grasa (p = 0,000). Durante el año de seguimiento, 29 pacientes requirieron hospitalización (35,8%) y 4 fallecieron (4,9%). El grupo con RN no tuvo mayor morbilidad ni mortalidad que los sin RN. Sin embargo, ambos riesgos fueron mayores en los pacientes gastrostomizados versus los alimentados por vía oral (RR: 2,98 IC 95%: 1.32-6.75 al combinar ambas variables). Conclusiones: En esta cohorte de niños y adolescentes con PC seguidos durante un año, aquellos definidos como de riesgo nutricional según nuevas curvas, tuvieron similar morbimortalidad a los que tenían estado nutricional aceptable. La morbimortalidad fue mayor en los gastrostomizados.

Introduction: Children and adolescents with cerebral palsy (CP) have a high prevalence of malnutrition associated to poor prognosis. For an adequate nutritional assessment, new growth curves (Brooks, 2011) are available, in which precise cut-off points in Weight/Age index correlate to increased morbidity and mortality rate. Objective: To evaluate risk of hospitalization and death in patients with CP, according to nutritional risk (NR). Patients and Method: Observational and prospective cohort study of patients with CP in an outpatient referral center. We registered demographic, socioeconomic data and nutritional assessment. During a one-year follow-up, hospitalizations and mortality were recorded. The correspondent committee extended an ethical approval. Results: 81 CP patients were recruit, age 131.6 ± 60.4 months (25-313), 60 % male, 77.5 % without independent mobility. The 23 NR patients (28.4%) had lower muscle and fat mass (p = 0.000). During the follow-up, 29/81 patients required hospitalization (35.8%) and 4/81 died (4.9%). There was not an increased risk of hospitalization and/or mortality in NR group, but both were significantly higher in gastrostomy-fed children (RR: 2,98 CI 95%: 1.32-6.75 combining both variables). Conclusions: In this study, children and adolescents with severe CP and nutritional risk had similar morbidity and mortality during a one-year follow-up, compared to those with acceptable nutritional status. Both risks were higher in gastrostomy-fed than the orally fed children.

La paradoja de la transición pidemiológica / The paradox of epidemiological transition

En el año dos mil se celebró en la ciudad de Nueva York la Cumbre del Milenio, en donde se aprobó la Declaración del milenio. En esta, tomando como base la problemática existente a nivel global, se establecieron los Objetivos del Milenio. Estos constituyen un plan convenido entre todas las naciones del mundo y las instituciones de desarrollo más importantes a nivel mundial, y en los cuales se proponen: (1) Erradicar la pobreza extrema y el hambre. (2) Lograr la enseñanza primaria universal. (3) Promover la igualdad entre los géneros y la autonomía de la mujer; (4) reducir la mortalidad infantil. (5) Mejorar la salud materna. (6) Combatir el VIH/SIDA, el paludismo y otras enfermedades. (7) Garantizar la sostenibilidad del medio ambiente. (8) Fomentar una asociación mundial para el desarrollo. De estos objetivos, al menos cuatro involucran de manera directa al sector salud y de ellos todos incluyen al perfil epidemiológico clásico de nuestro país. Sin embargo, hacia el 2010, cuando se presenta el Tercer informe de avances en el cumplimiento de los objetivos de desarrollo del milenio, se evidenció que aún se está lejos de cumplir alguno de los objetivos. Además, mientras no es posible resolver los temas prioritarios para el sistema de salud, empieza a ser evidente el aumento de casos de enfermedades como diabetes mellitus, hipertensión arterial, dislipidemias y otras, que tienen como consecuencia complicaciones como infartos de miocardio, falla cardíaca, eventos cerebrovasculares y otras complicaciones que saturan los servicios de salud, dando como resultado objetivos prioritarios no cumplidos y el surgimiento de problemas de salud que eran considerados poco prevalentes en Guatemala.

In the year 2000, it took place in New York City the Millennium Summit, and The Millennium Declaration was approved. Taking into account the global development issues, the Millennium Development Goals were established. These constitute an agreement between the World’s nations and the most important development institutions worldwide. The Goals are: (1) Eradicate Extreme Hunger and Poverty. (2) Achieve Universal Primary Education. (3) Promote Gender Equality and Empower Women. (4) Reduce Child Mortality. (5) Improve Maternal Health. (6) Combat HIV/AIDS, Malaria and other diseases. (7) Ensure Environmental Sustainability. (8) Develop a Global Partnership for Development. Of these goals, at least four are related to health and our country’s epidemiology. By year 2010, when the Third Report on the Millennium Goals in Guatemala was published, it was evident that the accomplishment of the goals was anything but close to achieve. Meanwhile it is not possible to solve the health priorities in the country, other diseases previously considered almost exclusive from the First World have emerged, and diabetes mellitus, hypertension, dyslipidemia and its complications gain terrain. As a result of this phenomenon, now we are facing priority goals not accomplished and a growing pool of chronic diseases that collapse the health care system.

Relación entre estado nutricional y evolución postoperatoria, en cirugía oncológica digestiva / Nutritional status and postoperative complications in patients with digestive cancer

Background: Risk of malnutrition is elevated among oncologic patients, and this increases postoperative morbidity and mortality. Aim: To study the association between nutritional status and postoperative outcomes in a group of patients with gastrointestinal cancers. Patients and Methods: We studied 129 patients with diagnosis of digestive cancer, previous to potentially curative surgery. Nutritional status was evaluated through anthropometric measures, Subjective Global Assessment (SGA), dietary intake recalls and routine biochemical parameters. Functional performance was assessed by the Karnofsky index (KI). Cancer stage was classified according to TNM4. During the postoperative period, complications, length of stay at the critical care ward and duration of hospitalization were registered. Thirty days after discharge, patients were contacted, and the appearance of new complications was listed. Results: According to SGA 14.7% of patients were classified as well nourished (A), 57.3% as moderately undernourished or at risk of malnutrition (B) and 27.9% as severely malnourished (C). The incidence of total complications was 25.5%. Nutritional status was not associated with cancer stage. The frequency of complications among patients classified as A, B and C were 5.5, 25.3 and 37.1% respectively (p = 0.03). Conclusions: We detected a high frequency of malnutrition in this group of patients. Overall the frequency of postoperative complications was low, however malnourished patients exhibited a higher rate of surgical complications.

Nutritional risk and anthropometric evaluation in pediatric liver transplantation

OBJECTIVE: To analyze the nutritional status of pediatric patients after orthotopic liver transplantation and the relationship with short-term clinical outcome. METHOD: Anthropometric evaluations of 60 children and adolescents after orthotopic liver transplantation, during the first 24 hours in a tertiary pediatric intensive care unit. Nutritional status was determined from the Z score for the following indices: weight/age height/age or length/age, weight/height or weight/length, body mass index/age, arm circumference/age and triceps skinfold/age. The severity of liver disease was evaluated using one of the two models which was adequated to the patients' age: 1. Pediatric End-stage Liver Disease, 2. Model for End-Stage Liver Disease. RESULTS: We found 50.0% undernutrition by height/age; 27.3% by weight/age; 11.1% by weight/height or weight/ length; 10.0% by body mass index/age; 61.6% by arm circumference/age and 51.0% by triceps skinfold/age. There was no correlation between nutritional status and Pediatric End-stage Liver Disease or mortality. We found a negative correlation between arm circumference/age and length of hospitalization. CONCLUSION: Children with chronic liver diseases experience a significant degree of undernutrition, which makes nutritional support an important aspect of therapy. Despite the difficulties in assessment, anthropometric evaluation of the upper limbs is useful to evaluate nutritional status of children before or after liver transplantation.

Mortalidad por desnutrición en menores de cinco años, Colombia, 2003-2007 / Death rate by malnutrition in children under the age of five, Colombia

Introducción. Los mayores problemas de mortalidad en menores de cinco años se presentan en países con altos índices de pobreza, lo que demuestra la iniquidad en relación con los países desarrollados. Se han identificado causas generales de mortalidad, como trastornos perinatales, sarampión, VIH/ sida, diarrea e infecciones respiratorias agudas, por lo que se hace énfasis en que la desnutrición ha tenido que ver con la mitad de ellas, aproximadamente, como una causa subyacente. Objetivo. Caracterizar la mortalidad por desnutrición utilizando un método de ajuste para la tasa, dadas las dificultades en su estimación por las limitaciones en la identificación de la desnutrición como causa básica de muerte. Materiales y métodos. Se llevó a cabo un estudio descriptivo que incluyó análisis de códigos CIE- 10 de las estadísticas vitales entre 2003-2007, con estimación de las tasas de mortalidad, aplicación del método de causas múltiples para enfermedades infecciosas y cálculo de las probabilidades de muerte. Resultados. La desnutrición, como antecedente, tiene asociación con las enfermedades infecciosas; la frecuencia de la enfermedad infecciosa como causa básica de muerte fue siete veces mayor cuando coexistió la desnutrición como causa antecedente. Una vez ajustada la tasa de mortalidad, se encontró que aumentó cinco veces el valor inicial. El método de "análisis de causas múltiples" establece su efectividad como metodología en el ajuste de este tipo de mortalidad. Conclusión. La desnutrición puede ser una causa básica o subyacente de muerte en una de cada ocho defunciones, en niños menores de un año, y en una de cada tres, en niños de uno a cuatro años.

Introduction. Much higher mortalities occur in children under five in developing countries with high poverty rates compared with developed countries. Causes of death are related to perinatal conditions, measles, HIV/AIDS, diarrhea, respiratory diseases and others. Throughout the world, malnutrition has been identified as the underlying cause of approximately half of these deaths. Objective. Death rate due to malnutrition was described using an adjusted method that takes into account the difficulties of identifying malnutrition as a direct cause of death. Materials and methods. A descriptive study included analysis of the International Classification of Diseases (ICD-10) vital statistics from 2003-2007. Death rates were estimated, a method of analysis of multiple causes was applied for infectious diseases, along with calculations of death probabilities. Results. Malnutrition was associated with infectious diseases. The frequency of infectious disease as a direct cause of death was almost seven times higher in cases with the antecedent of malnutrition. When adjusted death rate values were used, the initial value increased nearly five times. The probability of death after the adjustment for inadequate classification increased approximately four times. The Analysis of Multiple Causes Method was established as an effective method in analyzing malnutrition and infectious diesease mortality in Colombia. Conclusion. Malnutrition may be a direct underlying cause of death in one of eight deaths in children <1 year old and one of three deaths in 1-4-year-olds.

Mortalidad de adultos mayores por deficiencias nutricionales en los Departamentos de Colombia / Elderly mortality caused by nutritional deficiency in Colombia’s Departments

Objetivo: Comparar la mortalidad de personas de 65 años y más de edad por deficiencias nutricionales en Colombia, según Departamento de residencia habitual en el año 2008. Métodos: Bajo el enfoque empírico-analítico, se realizó un estudio descriptivo transversal, con 989 certificados de defunción del año 2008, cuya causa básica de muerte fuese por deficiencias nutricionales (códigos E40-E64 de la clasificación internacional de enfermedades, décima revisión). Se hizo análisis de las distri-buciones de defunción según algunas variables demográficas, así como el cálculo de las tasas de mortalidad por edad, sexo y lugar de residencia habitual. Se usaron los paquetes computacionales SPSS versión 10 y ArcGis 10.0 (licencia Universidad CES). Resultados: La tasa de mortalidad por deficiencias nutricionales fue de 34,5 defunciones por cien mil habitantes, 16 Departamentos registraron un riesgo mayor que el nacional, siendo mayor en Vaupés, Guaviare, Guainía, Bolívar y Atlántico. Es de anotar que las mujeres aportaron más en las defunciones y también registraron un riesgo mayor (35,4) que los hombres (33,4). Conclusiones: Las defunciones por deficiencias nutricionales fueron más frecuentes en las mujeres, los mayores de 80 años de edad y pertenecer al régimen subsidiado, pero gran parte de los fallecidos no estaba asegurado. El Departamento del país que presentó la mayor mortalidad fue Vaupés con un riesgo de 658,8 para los hombres y 456,6 para las mujeres, superando a todos los demás, por un amplio margen.

Objective: Comparing mortality in adults aged 65 years or older caused by nutritional deficiency in Colombia, according to department of usual residence in 2008. Methods: A cross-sectional study of 989 death certificates from 2008 was conducted adopting an empirical-analytic approach; underlying cause of death was due to nutritional deficiency (International Classification of Diseases:E40-E64, tenth revision). The distribution of death according to demographic variables was analyzed and mortality rates calculated by age, gender and place of residence. SPSS (version 10) and ArcGIS (10.0) software packages were used. Results: The mortality rate was 34.5 nutritional deficiency-related deaths per hundred thousand inhabitants; 16 departments reported a higher risk than the national average, this being higher in Vaupés, Guaviare, Guainía, Bolívar and Atlántico. It should be noted that women accounted for more deaths and a slightly higher risk was also recorded for them (35.4) than for men (33.4). Conclusions: Deaths from nutritional deficiency were more common in females aged over 80 years old and people belonging to the subsidized regime(not many of the deceased were insured). The Colombian department having the highest mortality rate was Vaupés (658.8 risk for men and 456.6 for women), surpassing all others by a wide margin.

Malnutrición en niños colombianos con infección por VIH/SIDA / Malnutrition in Colombian children with HIV/AIDS infection

Introducción: La desnutrición (DNT) es una de las complicaciones más tempranas que se presenta en niños con infección por VIH/SIDA, asociada a su morbimortalidad. Igualmente como consecuencia de la terapia antriretroviral y otros medicamentos utilizados, se han encontrado problemas de resistencia a la insulina y obesidad. Objetivo: Determinar la prevalencia de malnutrición (MNT) en niños con infección por VIH/SIDA por carga viral de la Clínica de VIH/SIDA del Hospital Universitario del Valle de Cali, Colombia (HUV) y su posible asociación con algunos factores de riesgo. Metodología: Estudio descriptivo, observacional de corte transversal, con análisis de casos y controles, a quienes se les tomaron datos como carga viral, %CD4, peso y talla. Se categorizó la carga viral (copias/ml) en: <400, ≥400-<300000, ≥30000-<1 millón y ≥1 millón; y el %CD4 en: <15%, ≥15%-<25% y ≥25%. Se consideró DNT global (déficit P/E≥10%), DNT crónica (déficit T/E≥5%), DNT aguda (déficit P/T≥10%) y sobrepeso (exceso P/T≥10%). Resultados: Fueron incluidos 111 niños entre 0 meses y 15 años de edad, con predominio del género masculino (51,3%), con modo de transmisión vertical en 91,8%. El 58.5% tenían entre ≥400-<300000 copias/ml de carga viral; y el 59% presentaron %CD4 ≥25%. La valoración nutricional evidenció DNT global en 64%, DNT aguda en 58%, DNT crónica en 22% y sobrepeso en 18%. Hubo riesgo de 1.7, 1.5 y 2.0 veces más de presentar DNT global, aguda y crónica, respectivamente, si la carga viral era ≥400 copias/ml. Conclusión: En niños con infección por VIH/SIDA por carga viral de la Clínica Pediátrica de VIH/SIDA del HUV de Cali, Colombia, la prevalencia de MNT fue superior al 18%, con una relación positiva superior a 1.5 veces entre carga viral y los diferentes tipos de DNT.

Introduction: Undernutrition (UNT) is a complication that occurs earlier in children with HIV/AIDS associated morbidity and mortality. Also as a result of anti-retroviral therapies and other drugs used, have encountered problems of insulin resistance and obesity. Objective: To determine the prevalence of malnutrition (MNT) in children diagnosed with HIV/AIDS by viral load in the Pediatric Clinic HIV/AIDS at the Hospital Universitario del Valle in Cali, Colombia (HUV) and its possible association with certain risk factors. Methodology: A descriptive cross-sectional study, with case-control analysis, whose data were taken as viral load, CD4%, weight and height. Were categorized viral load (copies / ml): <400, ≥ 400 - <300000, ≥ 30000 - <1 million and ≥ 1 million, and the %CD4 <15%, ≥ 15% - <25% ≥ 25%. UNT is considered global (low W/A≥10%), chronic (low H/A≥5%), acute (low W/H≥10%) and overweight (excess W/H≥10%). Results: We included 111 children from 0 months to 15 years old with male predominance (51.3%), mode of transmission in 91.8%. 58.5% were aged ≥ 400 - <300,000 copies/ml viral load, and 59% had CD4% ≥25%. Nutritional assessment showed 64% global UNT, 58% acute UNT, 22% chronic UNT and 18% overweight. Risk was 1.7, 1.5 and 2.0 times the present global, acute and chronic UNT, respectively, if the viral load was ≥ 400 copies / ml. Conclusion: In children diagnosed with HIV/AIDS by viral load of Pediatric Clinic HIV/AIDS at the HUV in Cali, Colombia, the prevalence of MNT was higher than 18%, with a positive relationship more than 1.5 times between viral load and the different types of UNT.

El niño que no progresa de peso / Failure to thrive

Entre el 8 y 10% de los niños atendidos en atención primaria, presentan una falta de progreso en el peso. El diagnóstico diferencial incluye ingesta calórica inadecuada, inadecuada absorción y metabolismo aumentado. Se reconoce a un niño que no sube de peso por su historia alimentaria, historia médica, historia social, historia familiar y evaluación del apetito. Entre las diferentes causas de falla para crecer están baja talla constitucional, abuso sexual, maltrato infantil, depresión postparto, enfermedad celíaca y esofagitis eosinofílica, entre otros. Entre los pilares en el manejo del niño que no progresa de peso están enfoque terapéutico, apoyo nutricional, hábitos dietéticos y manejo especializado.

Between 8 and 10% of children seen in primary care, have a lack of progress in weight. The differential diagnosis includes inadequate caloric intake, inadequate absorption and increased metabolism. It is recognized that a child does not gain weight by diet history, medical history, social history, family history and evaluation of appetite. Among the various causes of failure to thrive are constitutional short stature, sexual abuse, child abuse, postpartum depression, celiac disease and eosinophilic esophagitis, among others. Among the mainstays in the management of child weight are not progressing therapeutic approach, nutritional support, dietary habits and specialized management.

Desnutrição em paciente com doença pulmonar obstrutiva crônica / Malnutrition in patients with chronic obstructive pulmonary disease

A doença pulmonar obstrutiva crônica (DPOC) é uma patologia responsável por muitas mortes em todo o mundo e é causada principalmente pelo tabagismo. A DPOC apresenta, como característica associada, um estado nutricional deficiente. O caso relatado é de uma paciente de 63 anos, ex-tabagista, internada em um hospital do interior do Rio Grande do Sul por broncopneumonia e com diagnóstico de DPOC há 3 anos. A paciente permaneceu internada por 15 dias, com uma evolução desfavorável do estado nutricional, mesmo superando a ingestão energética estimada. Pacientes com DPOC apresentam taxa de metabolismo basal aumentada e infecções associadas, o que pode acelerar ainda mais o catabolismo e gerar anorexia. A terapia nutricional é muito importante para a recuperação desses pacientes.

Chronic obstructive pulmonary disease (COPD) is a leading cause of death worldwide and is mainly caused by smoking. COPD has been associated with poor nutritional status. We report the case of a 63-year-old female patient, an ex-smoker, admitted to a hospital in southern Brazil with bronchopneumonia and a 3-year diagnosis of COPD. She stayed in hospital for 15 days, with an unfavorable outcome for nutritional status, despite meeting the estimated energy intake. COPD patients have increased basal metabolic rate and associated infections, which may lead to accelerated catabolism and cause anorexia. In these cases, nutrition therapy is very important for patient recovery.

El estado nutricional, la respuesta inflamatoria sistémica y la mortalidad en el anciano internado / Nutritional status, systemic inflammatory response and mortality in the elderly hospitalized patient

La desnutrición en el anciano involucra un estado inflamatorio. Con el objetivo de evaluar en el paciente internado la relación con la respuesta inflamatoria sistémica y la mortalidad desarrollamos un estudio de cohortes prospectivo en el que evaluamos un score nutricional (SGA), años de instrucción, capacidad funcional, falla orgánica (Marshall), presencia de sepsis, comorbilidades (Charlson), estado cognitivo (MMSE), albúmina, eritrosedimentación y mortalidad. Se incluyeron 52 pacientes, 19 hombres (36.5%) y 33 mujeres (63.5%) con una mediana de edad de 80 (RI 12.5) años. Los pacientes normonutridos fueron 29 (55.8%) y los desnutridos 23 (44.2%).El 53.8% de los pacientes desarrollaron sepsis al ingreso o en la internación. La mortalidad intrahospitalaria en toda la muestra fue 7.7% (n = 4) y al año fue del 31.8% (n = 14). En el análisis comparativo se evidenció mayor edad (80 vs. 78; p = 0.012), menos años de instrucción (7 vs. 8; p = 0.027), un MMST menor (14 vs. 27; p = 0.017), menor capacidad funcional previa (21 vs. 32; p < 0.0001), menor valor de albumina (3 vs. 3.35; p = 0.014) y mayor score de falla orgánica de ingreso (3 vs. 1; p = 0.01) con mayor número de órganos afectados (2 vs. 1; p = 0.003) en los desnutridos con respecto a los normonutridos. También se observó mayor incidencia de sepsis -al ingreso o durante la internación- (73.9% vs. 37.9%; p = 0.01) y niveles de sepsis más graves en desnutridos. La mortalidad al año fue significativamente mayor en los desnutridos (52.2% vs. 9.5%, log rank test = 0.002). En conclusión, los pacientes desnutridos presentaron mayor respuesta inflamatoria sistémica.

In order to evaluate the relationship between systemic inflammatory response and mortality in the older hospitalized patient, we developed a prospective cohort study in which we evaluated a nutritional score (SGA), years of instruction, functional status, organic failure (Marshall), presence of sepsis, comorbidities (Charlson), cognitive state (MMSE), albumin, erythrocyte sedimentation rate and mortality. Fifty two patients were included, 19 men (36.5%) and 33 women (63.5%), mean age was 80 (Interquartile Range 12.5) years. 29 (55.8%) patients were well-nourished and 23 (44.2%) malnourished, 53.8% of patients developed sepsis at admission or during hospitalization. Total nosocomial mortality was 7.7 % (n = 4) and one-year mortality was 31.8% (n = 14). Comparative analyses showed older age (80 vs. 78; p = 0.012), less years of instruction (7 vs. 8; p = 0.027), lower MMST (14 vs. 27; p = 0.017), lower previous functional status (21 vs. 32; p < 0.0001), lower albumin (3 vs. 3.35; p = 0.014) and higher organic failure score at admission (3 vs. 1; p = 0.01) with more number of affected organs (2 vs. 1; p = 0.003) in malnourished patients compared to well nourished ones. Higher incidence of sepsis -at admission or during hospitalization- (73.9% vs. 37.9%; p = 0.01) and more severe stages of sepsis were also observed in malnourished patients. One-year mortality was significantly higher in malnourished (52.2% vs. 9.5%, log rank test = 0.002). In conclusion, malnourished patients presented greater systemic inflammatory response.