GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community.

RATIONALE: This initiative is focused on building a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings. METHODS: In January 2016, the Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. GLIM appointed a core leadership committee and a supporting working group with representatives bringing additional global diversity and expertise. Empirical consensus was reached through a series of face-to-face meetings, telephone conferences, and e-mail communications. RESULTS: A two-step approach for the malnutrition diagnosis was selected, i.e., first screening to identify "at risk" status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition. The malnutrition criteria for consideration were retrieved from existing approaches for screening and assessment. Potential criteria were subjected to a ballot among the GLIM core and supporting working group members. The top five ranked criteria included three phenotypic criteria (weight loss, low body mass index, and reduced muscle mass) and two etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden). To diagnose malnutrition at least one phenotypic criterion and one etiologic criterion should be present. Phenotypic metrics for grading severity as Stage 1 (moderate) and Stage 2 (severe) malnutrition are proposed. It is recommended that the etiologic criteria be used to guide intervention and anticipated outcomes. The recommended approach supports classification of malnutrition into four etiology-related diagnosis categories. CONCLUSION: A consensus scheme for diagnosing malnutrition in adults in clinical settings on a global scale is proposed. Next steps are to secure further collaboration and endorsements from leading nutrition professional societies, to identify overlaps with syndromes like cachexia and sarcopenia, and to promote dissemination, validation studies, and feedback. The diagnostic construct should be re-considered every 3-5 years.

GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community.

RATIONALE: This initiative is focused on building a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings. METHODS: In January 2016, the Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. GLIM appointed a core leadership committee and a supporting working group with representatives bringing additional global diversity and expertise. Empirical consensus was reached through a series of face-to-face meetings, telephone conferences, and e-mail communications. RESULTS: A two-step approach for the malnutrition diagnosis was selected, i.e., first screening to identify "at risk" status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition. The malnutrition criteria for consideration were retrieved from existing approaches for screening and assessment. Potential criteria were subjected to a ballot among the GLIM core and supporting working group members. The top five ranked criteria included three phenotypic criteria (non-volitional weight loss, low body mass index, and reduced muscle mass) and two etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden). To diagnose malnutrition at least one phenotypic criterion and one etiologic criterion should be present. Phenotypic metrics for grading severity as Stage 1 (moderate) and Stage 2 (severe) malnutrition are proposed. It is recommended that the etiologic criteria be used to guide intervention and anticipated outcomes. The recommended approach supports classification of malnutrition into four etiology-related diagnosis categories. CONCLUSION: A consensus scheme for diagnosing malnutrition in adults in clinical settings on a global scale is proposed. Next steps are to secure further collaboration and endorsements from leading nutrition professional societies, to identify overlaps with syndromes like cachexia and sarcopenia, and to promote dissemination, validation studies, and feedback. The diagnostic construct should be re-considered every 3-5 years.

Cannibalism in non-native brown trout Salmo trutta and rainbow trout Oncorhynchus mykiss stream-dwelling populations.

Introduced and allopatric populations of brown trout Salmo trutta and rainbow trout Oncorhynchus mykiss were sampled in Slovenia for stable isotope analysis to assess dietary niche shifts through ontogeny and estimate the propensity for cannibalism. Both S. trutta and O. mykiss are cannibals, with higher average relative contribution of conspecific assimilated energy for S. trutta (27·9%) compared with O. mykiss (7·7%). The smallest cannibal was 166 mm in the S. trutta population and 247 mm in the O. mykiss population.

Long-Term Outcomes of Intestinal and Multivisceral Transplantation at a Single Center in Argentina.

BACKGROUND: Intestinal failure (IF) patients received parenteral nutrition (PN) as the only available therapy until intestinal transplantation (ITx) evolved as an accepted treatment. The aim of this article is to report the long-term outcomes of a series of ITx performed in pediatric and adult patients at a single center 9 years after its creation. PATIENTS AND METHODS: This is a retrospective analysis of the ITx performed between May 2006 and January 2015. Diagnoses, pre-ITx mean time on PN, indications for ITx, time on the waiting list for types of ITx, mean total ischemia time, and warm ischemia time, time until PN discontinuation, incidence of acute and chronic rejection, and 5-year actuarial patient survival are reported. RESULTS: A total of 42 patients received ITx; 80% had short gut syndrome (SG); the mean time on PN was 1620 days. The main indication for ITx was lack of central venous access followed by intestinal failure-associated liver disease (IFALD) and catheter-related infectious complications. The mean time on the waiting list was 188 days (standard deviation, ±183 days). ITx were performed in 26 children and 14 adults. In all, 32 procedures were isolated ITx (IITX); 10 were multiorgan Tx (MOT; 3 combined, 7 multivisceral Tx (MVTx), 1 modified MVTx and 2 with kidney); 2 (4.7 %) were retransplantations: 1 IITx, 1 MVTx, and 5 including the right colon. Thirteen patients (31%) received abdominal rectus fascia. All procedures were performed by the same surgical team. Total ischemia time was 7:53 ± 2:04 hours, and warm ischemia time was 40.2 ± 10.5 minutes. The mean length of implanted intestine was 325 ± 63 cm. Bishop-Koop ileostomy was performed in 67% of cases. In all, 16 of 42 Tx required early reoperations. The overall mean follow-up time was 41 ± 35.6 months. The mean time to PN discontinuation after Tx was 68 days (P = .001). The total number of acute cellular rejection (ACR) episodes until the last follow-up was 83; the total number of grafts lost due to ACR was 4; and the total graft lost due to chronic rejection was 3. At the time of writing, the overall 5-year patient survival is 55% (65% for IITx vs 22% for MOT; P = .0001); 60% for pediatric recipients vs 47% for adults (P = NS); 64% when the indication for ITx was SG vs 25% for non-SG (P = .002). CONCLUSIONS: At this center, candidates with SG, in the absence of IFALD requiring IITx, showed the best long-term outcomes, independent of recipient age. A multidisciplinary approach is mandatory for the care of intestinal failure patients, to sustain a rehabilitation and transplantation program over time.

Case Report: Spleen-preserving Multivisceral Transplant for Peutz-Jeghers Syndrome.

CASE REPORT: A 24-year-old man diagnosed with Peutz-Jeghers syndrome as a child underwent multiple surgeries owing to intussusception. Pretransplant workup showed >150 polyps along the gastrointestinal (GI) tract, some of them with high-grade dysplasia. Despite having intestinal sufficiency, a modified multivisceral transplantation was offered. PROCEDURE: An 18-year-old donor was procured using University of Wisconsin solution. The recipient's surgery started with a midline incision. Mobilization of the right colon and the root of the mesentery was done to isolate the superior mesenteric artery. The same maneuver was done with the left and sigmoid colon. The common bile duct was then isolated and transected at the cystic duct level. The abdominal portion of the esophagus and the proximal stomach were isolated and divided at the gastroesophageal junction. After that, the pancreas was mobilized, preserving the spleen with the splenic vessels. The distal GI tract was transacted at the level of the proximal rectum. For engraftment, an arterial conduit was placed in the infrarenal aorta and anastomosed to the graft's aortic patch. End-to-side portal reconstruction was made at the level of the portal vein, allowing performing a duct-to-duct biliary reconstruction over a 5-Fr T-tube. A hand-sewn gastrogastric anastomosis and piloroplasty were performed; the distal anastomosis was done with circular staplers. A gastrojejunostomy and a loop ileostomy were the final steps of the procedure. RESULTS: The patient stayed in intensive care for 2 days and enteral feeds were started on day 7. Currently, 23 months after transplant he is alive with an excellent quality of life.

Temporal changes in allele frequencies in a small marble trout Salmo marmoratus population threatened by extreme flood events.

The effect of extreme floods on the genetic composition of marble trout Salmo marmoratus living in Lipovscek, a tributary of the Soca River in Slovenia, which has been affected by multiple destructive flood events for centuries was investigated. By monitoring genetic variability during the period 2004-2011, apparent signatures of genetic erosion including a decline in observed and expected heterozygosities and allelic richness were observed. Contemporary effective population size was estimated between 11 and 55 individuals, which is congruent with census data. The data suggest asymmetric gene flow between the two sections of the river. The existence of substantial downstream migration (15-19%) was confirmed by paternity analysis. A small (1-3%) upstream migration was also suggested, which was confirmed by tagging data. Overall, low genetic diversity has not prevented the survival of the Lipovscek population, which might be a common feature of salmonid freshwater populations.

A simplified method to estimate body growth parameters of the European eel Anguilla anguilla.

A simple approach is proposed to fit a body growth model for the European eel Anguilla anguilla to data-poor case studies. The model is a modified von Bertalanffy curve allowing for delayed sex determination and sexual dimorphism. The proposed procedure provides preliminary estimates of model parameters on the basis of average age and body length of silver eels.

Eco-evolutionary dynamics induced by massive mortality events.

An eco-genetic model tuned on a population of marble trout Salmo marmoratus subject to periodic flood events was used to explore how the evolution of growth rates interacting with density-dependent processes can modify size at age and population structure and in turn influence the resilience of populations. Fish with greater growth potential were assumed to have higher mortality rates. The results of simulations were compared between two scenarios, one in which populations may evolve growth rates and the other one in which the distribution of growth rates within a population is kept fixed. Evolving populations had a greater proportion of age 1 year individuals in the population, greater median length at age 3 years (the typical age at sexual maturity for S. marmoratus) and lower population sizes. The slightly smaller population sizes did not affect realized extinction risk. Resilience, defined as the number of years necessary to rebound from flood-induced population collapse, was on average from 2 to 3 years in both scenarios, with no significant difference between them. Moderate heritability of growth, relaxation of density-dependent processes at low densities and rapid recovery to a safe population size combine to limit the capacity to evolve faster recovery after flood-induced population collapses via changing growth rates.

Empirical standard mass equation for Salmo marmoratus.

Total length (L(T)) (range 24-1000 mm; mean ±S.E. = 170.21 ± 0.36 mm) and mass (W) (range 0.10-9590 g; mean ±S.E. = 76.03 ± 0.87 g) of 36,460 specimens of marble trout Salmo marmoratus were used to compute a standard mass (W(s)) equation for this species by means of the empirical percentile (EmP) method. The EmP W(s) equation calculated was: log(10) W(s) = -5.208 + 3.202 log(10) L(T) - 0.046 (log(10) L(T))(2) (L(T) range 90-570 mm) and it is valid throughout the species' area of distribution across Europe.

An evaluation of indices of gross pathology associated with the nematode Anguillicoloides crassus in eels.

This study compares two alternative indices for quantifying the gross pathology of the swimbladder of eels, Anguilla anguilla (L.), infected with the nematode Anguillicoloides crassus. Two observers recorded twice the scores obtained by the two indices on the same set of 71 wild caught eels (from elver to silver eels, French Mediterranean lagoons). The Length Ratio Index (LRI), performed better than the Swimbladder Degenerative Index (SDI), in three of four predefined criteria of decision. First, the LRI better correlated with an estimate of the swimbladder volume reduction, a functional consequence of the infection (representativeness). Also, the LRI was less prone to subjectivity (inter-observer variability) and more precise (intra-observer variability), although less easy to generate (time needed for measurement/assessment). Using a sub-sample of 32 unaffected eels (showing minor if any swimbladder damage and no living worms at autopsy), we ascertained a linear relationship between the swimbladder length and the total body length, a prerequisite of isometric growth, to definitively accept the new ratio index as a valid alternative to the SDI. Also, because the LRI can be recorded on live specimens with radio-imagery (non-invasive method), we recommend its use, and provide a graph of correspondence between the SDI scores, the LRI scores and the estimated proportion of gas loss in the swimbladder.

Morphological and genetic seasonal dynamics of European eel Anguilla anguilla recruitment in southern France.

The fine scale morphological and genetic dynamics of successive waves of Anguilla anguilla glass eel recruitment was studied over a 2 year period at a southern European Mediterranean location (Camargue, France) with continuous recruitment. Using morphometric [total length (L(T)), mass (M), condition (K) and pigmentation stage] as well as genetic (allozyme) markers, the aim was to test for the existence of temporally separated spawning groups and explore the relation between genetic variability and morphological heterogeneity of recruits. The results showed that L(T), M and K varied over time, being highest from the end of summer to winter (peaking in December) and lowest in spring (lowest in April). The pigmentation stages within monthly samples were highly diverse with a heterogeneous seasonal pattern. Allozyme data showed high genetic variability values within samples, but low genetic differentiation among samples (F(ST) = 0.003, P < 0.05). Pairwise comparisons between samples indicated a positive correlation between genetic differentiation and difference in recruitment time (days), with a marked increase in genetic differentiation around 250 days between monthly recruitment samples. Furthermore, genetic diversity increased with the number of pigmentation stages per sample and was negatively correlated with the North Atlantic Oscillation (NAO) index during the putative year of trans-oceanic migration. No correlation, however, was found between the level of multilocus heterozygosity (MLH) and growth variables. A situation of genetic patchiness with fluctuating parental contribution can thus best explain the patterns observed, although the existence of two separate spawning periods cannot be excluded. More discriminatory and sensitive genetic markers, such as (neutral and adaptive) microsatellites, could probably provide additional insights into the most probable hypothesis explaining the population structure and recruitment heterogeneity of A. anguilla.

Evaluación de ingesta en pacientes con hepatopatías crónicas / Evaluation of ingestion in patients with chronic liver diseases

La malnutrición calórico-protéica (MCP) es frecuente entre los pacientes con hepatopatías crónicas (HC) estableciéndose hasta en un 80 por ciento. El problema es multifactorial, siendo la disminución de la ingesta una de las causas más relevantes. Objetivo: evaluar la ingesta calórico-protéica en pacientes con HC. Se evaluaron prospectivamente 60 pacientes (26 mujeres, 43,3 por ciento) con una edad media de 54,1 años, con los siguientes diagnósticos: cirrosis biliar primaria 11 (18,3 por ciento), cirrosis alcohólica 26 (46,3 por ciento), hepatopatías autoinmunes 12 (20 por ciento), cirrosis criptogenética 6 (10 por ciento), Budd-Chiari 1 (1,7 por ciento), Hemocromatosis 1 (1,7 por ciento), cirrosis viral 3 (5 por ciento). Se utilizó el recordatorio de 3 días para la recolección de datos de ingesta, la evaluación global subjetiva EGS) para evaluación nutricional y la clasificación de Child-Pugh para evaluar severidad de la hepatopatía...

Evaluación de ingesta en pacientes con hepatopatías crónicas / Evaluation of ingestion in patients with chronic liver diseases

La malnutrición calórico-protéica (MCP) es frecuente entre los pacientes con hepatopatías crónicas (HC) estableciéndose hasta en un 80 por ciento. El problema es multifactorial, siendo la disminución de la ingesta una de las causas más relevantes. Objetivo: evaluar la ingesta calórico-protéica en pacientes con HC. Se evaluaron prospectivamente 60 pacientes (26 mujeres, 43,3 por ciento) con una edad media de 54,1 años, con los siguientes diagnósticos: cirrosis biliar primaria 11 (18,3 por ciento), cirrosis alcohólica 26 (46,3 por ciento), hepatopatías autoinmunes 12 (20 por ciento), cirrosis criptogenética 6 (10 por ciento), Budd-Chiari 1 (1,7 por ciento), Hemocromatosis 1 (1,7 por ciento), cirrosis viral 3 (5 por ciento). Se utilizó el recordatorio de 3 días para la recolección de datos de ingesta, la evaluación global subjetiva EGS) para evaluación nutricional y la clasificación de Child-Pugh para evaluar severidad de la hepatopatía...(AU)

Anguillicolosis: dynamics of the infection over two decades.

The dynamics of the infection of the European eel Anguilla anguilla L. by the Asian nematode Anguillicola crassus Kuwahara, Niimi and Itagaki, 1974 (i.e. anguillicolosis) was monitored over 2 decades in an oligohaline canal in southern France (Camargue, Mediterranean coast). Since the first mention of the parasite in this canal in 1985, which was also the first record in France, prevalence of pre-adult and adult forms has risen from 32 to 73%. However, during the last 7 yr (1997 to 2003), prevalence seems to have stabilized around values of 60 to 70% and parasite load, though inter-annual variation is substantial, shows no sign of increase (intensity for the last 5 yr: min. = 3.70, max. = 9.66, mean = 6.01). Our results thus confirm the dynamic pattern observed elsewhere in Europe, i.e. a rapid spread following the introduction of the parasite in a water system and then stabilization around ceiling levels. We review possible mechanisms that may explain such a leveling off in the infection spread. We particularly document the possibility that repetitive infections may render the infected organ, i.e. the swimbladder, unsuitable for further A. crassus establishment. In support of this hypothesis, we showed that the infection rate is lower among eels with severely damaged swimbladders.

Extreme genetic differentiation among the remnant populations of marble trout (Salmo marmoratus) in Slovenia.

Populations of the marble trout (Salmo marmoratus) have declined critically due to introgression by brown trout (Salmo trutta) strains. In order to define strategies for long-term conservation, we examined the genetic structure of the 8 known pure populations using 15 microsatellite loci. The analyses reveal extraordinarily strong genetic differentiation among populations separated by < 15 km, and extremely low levels of intrapopulation genetic variability. As natural recolonization seems highly unlikely, appropriate management and conservation strategies should comprise the reintroduction of pure populations from mixed stocks (translocation) to avoid further loss of genetic diversity.

Spatial and temporal variation in Anguillicola crassus counts: results of a 4 year survey of eels in Mediterranean lagoons.

We present the results of a survey of anguillicolosis in the Rh6ne River delta. From January 1997 to December 2000, a total of 13,319 eels (Anguilla anguilla from elver to silver phase) were examined, in which we found 22,227 swimbladder nematodes (Anguillicola crassus adults and pre-adults). A generalised linear model (GLM) framework was used to explore the relative contribution of various factors to the occurrence, intensity and abundance of the parasite. We reveal a major influence of the month of sampling, and we document the existence of a seasonal pattern with regular peaks in early summer and late winter. In contrast, the year of sampling is of secondary importance, and no particular trend in the development of the infection can be detected. More than a decade after the first record of A. crassus in the Rhjne River delta, anguillicolosis has thus attained a constant infection rate of nearly 50%, with a mean number of 3 or 4 macroscopic lumen worms per infected eel. The eel length strongly influences the intensity and the abundance of the nematode, but has little if any effect on the probability of being infected. There exists a linear relationship between eel size and the number of parasites, but not between eel size and prevalence. We observe a decrease in the proportion of infected individuals among elver eels. We discuss this result in relation to the possible mortality of heavily infected individuals and/or a change in the eels' alimentary diet.

The health state of the eel swimbladder as a measure of parasite pressure by Anguillicola crassus.

We have developed an index based on macroscopic criteria to easily assess the health state of the eel swimbladder as a result of infection by the nematode Anguillicola crassus. In the sampling area (brackish lagoons of the French Mediterranean coast), 92% of the host sample (1,251 eels covering all size classes) showed pathological signs of infection. The general trend was for increasing damage as eel size increased, thus suggesting accumulation of pathological effects. We also revealed a non-linear relationship between the swimbladder index and the abundance of living worms. In particular, we showed that severely damaged swimbladders harboured very few living nematodes. We argue that the swimbladder degenerative index more closely reflects the parasite pressure than does classic parasite count. We found seasonal variation in the swimbladder index, with maximum damage occurring in July and thereafter a trend for healthy individuals. We discuss the possibility that the seasonal decrease in the swimbladder index could reflect the death of the more severely affected individuals during the warmest months.