Effects of malnutrition on length of stay in patients hospitalized in an acute psychiatric ward.

INTRODUCTION: Psychiatric patients are considered at risk for malnutrition due to pharmacological treatments, lifestyle habits and the mental illness by itself. Even though metabolic risk factors have been related to worse outcomes in certain conditions, the evidence regarding the nutritional status and its impact on the length of stay in psychiatric inpatients is scarce. This study aims to characterize the nutritional status in acute psychiatric patients, to correlate it with the length of stay, and to find specific potential indicators of malnutrition. METHODS: Adult patients admitted to the Hospital Clínic of Barcelona acute psychiatric ward throughout a 1-year period were included in this cross-sectional study. Sociodemographic and clinical variables were registered, including length of stay and the nutritional status measured with the CONUT score. RESULTS: Malnutrition was observed in 42.5% of patients. Plasmatic transferrin saturation, protein and iron levels were inversely correlated with length of stay, having low iron levels an association with longer hospitalizations. The length of stay was not influenced by diagnosis or treatment. Negative correlations with the nutritional status were found in: BMI, cholesterol, triglycerides, albumin, total proteins, prealbumin, iron, lymphocytes and zinc levels, and transferrin saturation. The multivariate analysis showed a significant association for cholesterol and zinc levels, lymphocyte count, and BMI. CONCLUSIONS: Our results suggest that nutritional status might influence the course of psychiatric admissions. Cholesterol and zinc levels, lymphocyte count, and BMI might be factors strongly associated with malnutrition. This consideration might allow the identification of profiles in which lifestyle interventions could be implemented.

Effects of ezetimibe on cholesterol metabolism in HIV-infected patients with protease inhibitor-associated dyslipidemia: a single-arm intervention trial.

BACKGROUND: The effects of ezetimibe on cholesterol metabolism in HIV-infected patients receiving boosted protease inhibitors have not been thoroughly assessed. The aim of this study was to assess cholesterol homeostasis in patients with PI associated dyslipidemia and its relationship with the response to treatment with the cholesterol-absorption inhibitor ezetimibe. METHODS: Fifteen patients with ritonavir-boosted PI-containig therapy and LDL-cholesterol > 3.36 mmol/L (>130 mg/dL) were assessed at baseline and after an 8-week course of ezetimibe 10 mg/d. Serum non-cholesterol sterols were measured at each visit as markers of cholesterol synthesis and absorption. Total-, LDL-, and HDL-cholesterol triglycerides, apolipoproteins A1 and B, high sensitivity C-reactive protein, CD4 cells and HIV-1 RNA were also measured. RESULTS: Ezetimibe treatment was well tolerated in all patients and resulted in significant reductions in total cholesterol (-11.4%, p = .002), LDL-cholesterol (-20.4%, p = .003), non-HDL-cholesterol (-13.4%, p = .002) and apolipoprotein B (-9.1%, p = .021). Treatment with ezetimibe was associated with decreased cholesterol absorption markers (campesterol-to-cholesterol ratio -43.0%, p = .001; sitosterol-to-cholesterol ratio -41.9%, p = .001) and increased synthesis markers (lathosterol-to-cholesterol ratio 53.2%, p = .005). Baseline absorption or synthesis markers were unrelated to the response to treatment. CD4 cell count and plasma HIV-1 RNA remained unchanged. CONCLUSIONS: The level of cholesterol absorption or synthesis does not appear to be a major determinant of the responsiveness to ezetimibe in patients on ritonavir-boosted PI-containing therapy. TRIAL REGISTRATION: EudraCT: 2006-006156-36.

Use of diet, nutritional supplements and exercise in HIV-infected patients receiving combination antiretroviral therapies: a systematic review.

BACKGROUND: The use of combination antiretroviral therapy (cART) has improved the prognosis of HIV infection, but it has also been linked to a spectrum of body composition changes and metabolic alterations known as the lipodystrophy syndrome. Nutritional status could influence body composition changes. METHODS: We performed a systematic search of published peer-reviewed data on the effects of diet, nutrition support and exercise on body composition and metabolic complications in patients receiving cART. RESULTS: Few controlled studies, most of them with small sample size, were found. Oral nutritional support increases protein and energy intake, and results in body weight and fat mass gains. Resistance exercise, with or without an aerobic component, increases lean mass and can improve insulin resistance. Low-fat diets or exercise can result in loss of fat mass, and they should be used with caution in subjects with lipoatrophy. CONCLUSIONS: Nutritional support and exercise result in small but significant body composition changes and can be used as complementary interventions. There is a need for further research on nutritional interventions in HIV-infected patients receiving cART.

Phytosterolemia in parenteral nutrition patients: implications for liver disease development.

OBJECTIVE: Phytosterols present in parenteral nutrition (PN) lipid emulsions have been linked to phytosterolemia and cholestatic liver disease, although no direct relation has been established. We investigated the relation among plasma phytosterol (PY) infused, total plasma PY levels, and possible links to PN-associated liver disease. METHODS: Twenty-seven adult patients on home PN were enrolled in the study. PYs were measured in plasma and lipid emulsions by gas chromatography. Liver function tests and blood counts were assessed to identify hepatic impairment, and biopsies were performed in eight patients. RESULTS: Mean total plasma PY level was higher in patients than in controls (55.4 +/- 6.2 versus 14.8 +/- 2.3 microg/mL). Simple linear regression models showed a correlation among total plasma PY, liver function tests, and platelet counts, which was stronger for total bilirubin (r(2) = 0.53, P = 0.0001) and aspartate aminotransferase (r(2) = 0.50, P = 0.0001) and weaker for platelet counts (r(2) = 0.158, P = 0.04); between infused lipid and liver function tests, the correlation was significant for total bilirubin (r(2) = 0.19, P = 0.038) and aspartate aminotransferase (r(2) = 0.164, P = 0.049). In multiple linear regression analysis, a decreased oral diet (b = -52.3, P = 0.001) and infused PY (b = 2.54, P = 0.093) were risk factors for high plasma PY levels (r(2) = 0.54). Biopsies showed moderate to severe liver impairment in five patients. CONCLUSION: Liver damage may be linked to high plasma PY levels and strengthened by lack of an oral diet in patients on home PN.

Increased cholesterol absorption rather than synthesis is involved in boosted protease inhibitor-associated hypercholesterolaemia.

OBJECTIVE: The aim of this study was to compare the differential effects of first-line efavirenz (EFV)-based vs. boosted lopinavir-based antiretroviral regimens on cholesterol metabolism. DESIGN: Multicentre, open-label, randomized clinical trial. METHODS: Forty-nine naive HIV-infected patients were randomized (1 : 1) to receive either ritonavir-boosted lopinavir (LPV/r) or EFV both in combination with tenofovir and emtricitabine (ClinicalTrials.gov: NCT00759070). Lipid profile and serum phytosterols and cholesterol precursors were determined at baseline and after 16 weeks. RESULTS: After 16 weeks of intervention, total and non-HDL cholesterol as well as triglyceride levels significantly increased in the LPV/r-group (+1.0 ±â€Š0.8; +0.8 ±â€Š0.7 and +0.8 ±â€Š1.5 mmol/l, respectively), but not in the EFV-group (+0.4 ±â€Š0.7; +0.4 ±â€Š0.6 and 0.2 ±â€Š0.5 mmol/l, respectively). Markers of cholesterol absorption (campesterol-to-cholesterol and sitosterol-to-cholesterol ratios) significantly increased in the LPV/r-group, but not in the EFV-group, whereas there were no changes in either group of the lathosterol-to-cholesterol ratio, a marker of cholesterol synthesis. CONCLUSION: Treatment with an LPV/r-based therapy increased total cholesterol relative to EFV-based therapy. Our data suggest that absorption rather than synthesis is the mechanism involved in LPV/r-associated increased total cholesterol.

Fertility in adult women with classic galactosemia and primary ovarian insufficiency.

OBJECTIVE: To study pregnancy chance in adult women with classic galactosemia and primary ovarian insufficiency. Despite dietary treatment, >90% of women with classic galactosemia develop primary ovarian insufficiency, resulting in impaired fertility. For many years, chance of spontaneous conception has not been considered, leading to counseling for infertility. But an increasing number of reports on pregnancies in this group questions whether current counseling approaches are correct. DESIGN: Multicenter retrospective observational study. SETTING: Metabolic centers. PATIENT(S): Adult women (aged >18 y) with confirmed classic galactosemia and primary ovarian insufficiency were included. INTERVENTION(S): Participants and medical records were consulted to obtain study data in a standardized manner with the use of a questionnaire. MAIN OUTCOME MEASURE(S): Conception opportunities, time to pregnancy, pregnancy outcome, hormone replacement therapy use, fertility counseling, and the participants' vision of fertility were evaluated. Potential predictive factors for increased pregnancy chance were explored. RESULT(S): Eighty-five women with classic galactosemia and primary ovarian insufficiency participated. Twenty-one women actively attempted to conceive or did not take adequate contraceptive precautions. Of these 21 women, nine became pregnant spontaneously (42.9%). This was higher than reported in primary ovarian insufficiency due to other causes (5%-10%). After a period of 12 months, a cumulative proportion of 27.8% of couples had conceived, which increased to 48.4% after 24 months and 61.3% after 27 months. Predictive factors could not be identified. A considerable miscarriage rate of 30% was observed (6 of 20 pregnancies). Although a substantial proportion of women expressed a child-wish (n = 28/53; 52.8%), the vast majority of participants (n = 43/57; 75.4%) considered conceiving to be highly unlikely, owing to negative counseling in the past. CONCLUSION(S): The pregnancy rate in women with classic galactosemia and primary ovarian insufficiency was higher than for women with primary ovarian insufficiency of any cause. This shifting paradigm carries significant implications for fertility counseling and potential application of fertility preservation techniques.

Effects of free leucine supplementation and resistance training on muscle strength and functional status in older adults: a randomized controlled trial.

OBJECTIVE: To assess the effect of free leucine supplementation combined with resistance training versus resistance training only on muscle strength and functional status in older adults. METHODS: This was a randomized, double-blind, placebo-controlled, parallel study with two intervention groups. Thirty older adults were randomly assigned to receive either 10 g leucine/day (leucine group [LG], n=15) or a placebo (control group [CG], n=15), plus resistance training over a 12-week period. Maximal overcoming isometric leg strength, functional status, nutritional status, body composition, health-related quality of life, depression, and dietary intake were assessed at 4 and 12 weeks. Missing data at 12 weeks were handled using mixed models for repeated measurements for data imputation. RESULTS: Twenty-four subjects completed the 4-week assessment and eleven completed the 12-week intervention. Clinically significant gains were found in isometric leg strength at both assessment time points. Analysis of the effect size also showed how participants in LG outperformed those in CG for chair stands and the timed up and go test. No significant changes were observed for the rest of the outcomes. CONCLUSION: Our combined analysis showed moderate changes in isometric leg muscle strength and certain components of functional status. The magnitude of changes found on these outcomes should be qualified as a positive effect of the concomitant intervention.

Usefulness of dietary enrichment on energy and protein intake in elderly patients at risk of malnutrition discharged to home.

INTRODUCTION: Malnutrition is a cause for concern among many admitted elderly patients, being common at hospital admission and discharge. OBJECTIVES: The objective of this study was to assess if diet enrichment with small servings of energy and protein dense foods, improves energy and nutrient intake in elderly patients at risk of malnutrition discharged to home. METHODS: This was a retrospective case series study in elderly patients at risk of malnutrition treated with diet enrichment. There was a data review of dietary and health records of elderly patients discharged to home. Forty-one patients, mean age of 83 ± 5 years, met the inclusion criteria; 13 patients had been lost after 4 weeks of treatment and a total of 24 patients after 12 weeks. Records contained food intake data assessed at baseline, and after 4 and 12 weeks of treatment. Mini Nutritional Assessment, anthropometric measurements, routine biochemical parameters and the Barthel Index were assessed at baseline and after 12 weeks. RESULTS: Compared to baseline, patients significantly improved their energy and protein intake after 4 weeks of treatment, fulfilling the mean nutritional requirements. The improvement in energy and protein intake was still manifest at week 12. After 12 weeks of dietary enrichment, a significant weight gain was observed (4.1%, p = 0.011), as well. No significant changes were detected in functional status. CONCLUSIONS: Using small servings of energy and protein dense foods to enrich meals seems a feasible nutritional treatment to increase energy and protein intake and meet nutritional goals among elderly patients discharged to home.

Introducción: La desnutrición es causa de preocupación en muchos pacientes ingresados, siendo frecuente al ingreso y alta hospitalaria. Objetivos: El objetivo de este estudio fue valorar si el enriquecimiento de la dieta con pequeñas raciones de alimentos densos en energía y nutrientes mejora la ingesta energética y de nutrientes en pacientes ancianos con riesgo de desnutrición dados de alta al domicilio. Métodos: Estudio retrospectivo de una serie de casos en paciente ancianos con riesgo de desnutrición tratados con enriquecimiento de la dieta. Se revisaron los datos de la historia clínica y dietética de pacientes ancianos dados de alta a domicilio. Cuarenta-y-un pacientes, con una edad media de 83 ± 5 años, cumplieron los criterios de inclusión; 13 pacientes se perdieron después de 4 semanas de tratamiento y un total de 24 después de 12 semanas. El historial contenía datos de la ingesta de alimentos valorada a nivel basal, y después de 4 y 12 semanas de tratamiento. El Mini Nutritional Assessment, las medidas antropométricas, los parámetros bioquímicos rutinarios y el Índice de Barthel fueron valorados a nivel basal y después de 12 semanas. Resultados: En comparación al inicio, los pacientes mejoraron significativamente su ingesta energética y proteica después de 4 semanas de tratamiento, cumpliendo con los requerimientos nutricionales medios. La mejora en la ingesta de energía y proteínas todavía era manifiesta en la semana 12. Después de 12 semanas de enriquecimiento de la dieta, también se observó un incremento significativo en el peso (4.1%, p = 0.011). No se detectaron cambios significativos en el estado funcional. Conclusiones: El uso de pequeñas raciones de alimentos con elevada densidad energética y proteica para enriquecer las comidas parece ser un tratamiento nutricional factible para incrementar la ingesta energética y proteica y cumplir con los objetivos nutricionales en paciente ancianos dados de alta al domicilio.

Preoperative nutritional status and post-operative infection in total knee replacements: a prospective study of 213 patients.

PURPOSE: To assess the potential relationship between preoperative nutritional status, including anthropometric parameters, and infection following total knee replacement surgery. METHODS: A total of 213 patients undergoing total knee replacement between December 2007 and May 2008 were prospectively studied. Patients with rheumatoid arthritis were excluded. For each patient we pre-operatively checked biochemical and anthropometric parameters of nutrition information about co-morbidities such as diabetes and high blood pressure, ASA score, age, and gender. Information about early infections, both superficial and deep, was collected. A descriptive statistical analysis and univariate/multivariate logistic regression model for risk factors were performed. RESULTS: Eleven patients (5.16%) had an infection, 5 deep and 6 superficial. Neither co-morbidities nor preoperatively biochemical parameters were associated with infection. However, in the univariate logistic regression model there was an inversely proportional relationship between triceps skinfold (TSF) and infection. After adjusting for age, ASA score and gender (multivariate logistic regression), TSF remained significantly associated with infection. CONCLUSION: There was a statistically significant association between TSF and post-operative infection risk after TKR. LEVEL OF EVIDENCE: Level I (Prospective prognostic study).

Potential usefulness of an EPA-enriched nutritional supplement on chemotherapy tolerability in cancer patients without overt malnutrition.

OBJECTIVES: To assess the effect of an intervention with an Eicosapentaenoic Acid-enriched oral nutritional supplement on chemotherapy tolerability in patients with advanced colorectal cancer. METHODS: Thirteen patients diagnosed with stage IV colorectal cancer were included. Patients in the experimental group received 2 packs of supplement per day during 12 weeks plus dietary counseling. The control group only received dietary counseling. Patients were assessed for nutritional status, dietary intake, health related quality of life (HRQOL) and chemotherapy compliance. RESULTS: Only patients in the supplemented group significantly increased their weight after the intervention. They also had better scores in important domains of HRQOL, compared to controls. Although not statistically significant, the supplemented group did not experience interruptions in their chemotherapy treatment compared to the control group, with more interruptions due to toxicity. CONCLUSIONS: The present study, although limited by sample size, points out towards a positive effect of the intervention on chemotherapy tolerability.