Serum Interleukin 6, Controlling Nutritional Status (CONUT) Score and Phase Angle in Patients with Crohn's Disease.

Crohn's disease (CD) is a chronic inflammatory disorder that may occur in any segment of the gastrointestinal tract. Asymptomatic or untreated inflammation along with malnutrition can often coexist in patients with CD, impairing clinical outcomes, therefore the aim of this study was to assess the relationship between inflammation, malnutrition risk and nutritional status in CD patients. Consecutive adult CD outpatients aged 18-65 years were recruited. Disease activity was clinically defined by the Crohn's Disease Activity Index (CDAI), whilst anthropometry and phase angle (PhA) were measured. The Controlling Nutritional Status (CONUT) score was retrospectively calculated for screening malnutrition risk and blood samples were taken. A total of 140 CD patients with a mean age of 38.8 ± 13.9 years and an average weight of 64.9 ± 12.0 kg were included. Serum interleukin (IL)-6 concentration was increased in active-CD patients, unrelated to medical treatment, which was associated with CDAI and PhA. Based on the CONUT score, the prevalence of patients with moderate/severe malnutrition risk (score ≥ 5) was 10%, showing lower age, body mass index and fat mass, but higher IL-6 and IL-1ß levels than subjects classified as not at risk (score 0-1). Finally, increased IL-6 levels and reduced PhA values were identified as independent predictors of moderate/severe malnutrition risk (p < 0.05). In conclusion, IL-6 increased in active-CD patients, which was inversely correlated with PhA. Although the CONUT score might be helpful for identifying CD patients at moderate/severe risk of malnutrition, larger studies are needed to verify these results in different settings.

Inflammation and malnutrition in inflammatory bowel disease.

Inflammatory bowel disease (IBD), which includes Crohn's disease and ulcerative colitis, has become increasingly prevalent worldwide in the past decade. The nutritional status of patients with IBD is often impaired, with malnutrition presenting as imbalanced energy or nutrient intake, including protein-energy malnutrition, disease-related malnutrition, sarcopenia, and micronutrient deficiency. Additionally, malnutrition can manifest as overweight, obesity, and sarcopenic obesity. Malnutrition can lead to disturbances in gut microbiome composition that might alter homoeostasis and cause a dysbiotic state, potentially triggering inflammatory responses. Despite the clear link between IBD and malnutrition, little is known about the pathophysiological mechanisms beyond protein-energy malnutrition and micronutrient deficiencies that could promote inflammation through malnutrition, and vice versa. This Review focuses on potential mechanisms that trigger a vicious cycle between malnutrition and inflammation, and their clinical and therapeutic implications.

Post-discharge consequences of protein-energy malnutrition, sarcopenia, and frailty in older adults admitted to rehabilitation: A systematic review.

BACKGROUND & AIMS: Malnutrition, sarcopenia, and frailty are three prevalent wasting conditions among older rehabilitation patients that lead to multiple health-related negative outcomes. This systematic review and meta-analysis aimed to determine the post-discharge consequences of malnutrition, sarcopenia, and frailty in older adults admitted to inpatient rehabilitation. METHODS: MEDLINE, Embase, Web of Science, and CINAHL databases were searched on 20 April, 2021 for longitudinal studies in older adults (≥65 years) admitted for inpatient rehabilitation. This systematic review included and synthesised studies that 1) measured malnutrition, sarcopenia, and/or frailty using a validated assessment tool or guideline; and 2) reported the association with post-discharge mortality, physical function, quality of life, or discharge location. The Academy of Nutrition & Dietetics Quality Criteria Checklist and GRADE criteria were used to assess risk of bias and evidence certainty. Where possible, data were pooled using Revman. RESULTS: Twenty-six observational studies (n = 9709 participants in total) with similarly aged populations were included. Eight, seven, and eleven studies assessed malnutrition, sarcopenia, and frailty, respectively. Follow-up periods ranged from immediate to 7 years post-rehabilitation. Malnutrition was associated with discharge to a higher level of care (GRADE: very low), and worse quality of life (GRADE: very low) and physical function (GRADE: very low). Sarcopenia was associated with worse physical function (GRADE: very low) and lower rate of home discharge (OR: 0.14; 95%CI: 0.09-0.20; I2:30%; GRADE: low). Frailty was associated with increased mortality (GRADE: very low), hospital readmission (GRADE: very low), and decreased home discharge (GRADE: very low). CONCLUSION: Wasting conditions in older adults during rehabilitation admission may be associated with poorer quality of life, lower rates of home discharge, and higher rates of health service use, physical dysfunction, and mortality following discharge. Further research is needed to investigate the comparative and combined impacts, as well as the overlap of malnutrition, sarcopenia, and frailty during and after rehabilitation to guide priority screening and intervention.

Portal Hypertension in Malnutrition and Sarcopenia in Decompensated Cirrhosis-Pathogenesis, Implications and Therapeutic Opportunities.

Malnutrition and sarcopenia are highly prevalent in patients with decompensated cirrhosis and are associated with poorer clinical outcomes. Their pathophysiology is complex and multifactorial, with protein-calorie malnutrition, systemic inflammation, reduced glycogen stores and hormonal imbalances all well reported. The direct contribution of portal hypertension to these driving factors is however not widely documented in the literature. This review details the specific mechanisms by which portal hypertension directly contributes to the development of malnutrition and sarcopenia in cirrhosis. We summarise the existing literature describing treatment strategies that specifically aim to reduce portal pressures and their impact on nutritional and muscle outcomes, which is particularly relevant to those with end-stage disease awaiting liver transplantation.

Interactive effects of vitamin D and serum uric acid concentration on protein-energy wasting in maintenance hemodialysis patients.

This study aimed to explore the influence of the interaction between vitamin D level and blood uric acid level on protein-energy wasting (PEW) in patients with Maintenance hemodialysis (MHD), in order to provide a solution for disease prevention. For this aim, a total of 150 patients with maintenance hemodialysis aged 30-79 years in a hospital were included in the study. The logistic regression model was used to analyze the relationship between vitamin D level, blood uric acid level and PEW, and the additive interaction was evaluated by calculating the relative excess risk ratio (RERI) attributive ratio (AP) and synergy index (S) of the interaction. Finally, the ROC curve was drawn to evaluate the diagnostic value of vitamin D level and blood uric acid level for PEW. In this study, the detection rate of PEW was 68%, low vitamin D level was 57.33%, and high blood uric acid level was 64.67%. Compared with non-low vitamin D levels, the PEW risk was OR=16.794, 95%CI: 4.973-60.356; Compared with those without high uric acid levels, the PEW risk was OR=7.599, 95%CI: 2.460-23.468. However, there was no multiplicative interaction between the two on PEW risk (OR=0.345, 95%CI: 0.060-1.983, P=0.233). In the additive interaction analysis, the PEW risk OR=43.992,95%CI: 12.795-151.253, higher than those with only high uric acid levels or only low vitamin D levels, the combination of the two had a summative interaction with PEW risk, with a RERI of 20.599 (95%CI: -26.158-67.356) API was 0.468 (-0.159-1.095) and S was 1.920 (0.569-6.483). In conclusion, both vitamin D deficiency and high uric acid levels were associated with an increased risk of PEW in MHD patients, and low vitamin D and high uric acid levels had a summative interaction with protein-energy expenditure risk.

Fluid Overload and Tissue Sodium Accumulation as Main Drivers of Protein Energy Malnutrition in Dialysis Patients.

Protein energy malnutrition is recognized as a leading cause of morbidity and mortality in dialysis patients. Protein-energy-wasting process is observed in about 45% of the dialysis population using common biomarkers worldwide. Although several factors are implicated in protein energy wasting, inflammation and oxidative stress mechanisms play a central role in this pathogenic process. In this in-depth review, we analyzed the implication of sodium and water accumulation, as well as the role of fluid overload and fluid management, as major contributors to protein-energy-wasting process. Fluid overload and fluid depletion mimic a tide up and down phenomenon that contributes to inducing hypercatabolism and stimulates oxidation phosphorylation mechanisms at the cellular level in particular muscles. This endogenous metabolic water production may contribute to hyponatremia. In addition, salt tissue accumulation likely contributes to hypercatabolic state through locally inflammatory and immune-mediated mechanisms but also contributes to the perturbation of hormone receptors (i.e., insulin or growth hormone resistance). It is time to act more precisely on sodium and fluid imbalance to mitigate both nutritional and cardiovascular risks. Personalized management of sodium and fluid, using available tools including sodium management tool, has the potential to more adequately restore sodium and water homeostasis and to improve nutritional status and outcomes of dialysis patients.

Quality of Life in Patients with Renal Failure Undergoing Hemodialysis.

A good quality of life is one of the many indicators that determine the success of hemodialysis (HD) therapy. Factors that significantly affect the quality of life of patients with renal failure who undergo HD include sociodemographic condition, mental state (depression), severity of kidney disease, accompanying disorders, HD duration, non-adherence towards prescribed medication and nutritional problems. Among said factors, the metabolic and nutritional disorder commonly known as protein energy wasting (PEW), plays an important role in the clinical course of renal failure patients. The aim of nutrition management in patients with renal failure is to slow down the progression of kidney disease, improve quality of life, and reduce cardiovascular morbidity and mortality.

Risk of Chronic Disease after an Episode of Marasmus, Kwashiorkor or Mixed-Type Severe Acute Malnutrition in the Democratic Republic of Congo: The Lwiro Follow-Up Study.

Background: Long-term impact of different forms of severe acute malnutrition (SAM) in childhood on the emergence of noncommunicable diseases (NCDs) is poorly known. Aim: To explore the association between subtypes of SAM during childhood, NCDs, and cardiovascular risk factors (CVRFs) in young adults 11 to 30 years after post-SAM nutritional rehabilitation. Methods: In this follow-up study, we investigated 524 adults (mean age 22 years) treated for SAM during childhood in eastern Democratic Republic of the Congo (DRC) between 1988 and 2007. Among them, 142 had a history of marasmus, 175 of kwashiorkor, and 207 had mixed-form SAM. These participants were compared to 407 aged- and sex-matched control adults living in the same community without a history of SAM. Our outcomes of interest were cardiometabolic risk markers for NCDs. Logistic and linear regressions models were sued to estimate the association between subtype of SAM in childhood and risk of NCDs. Results: Compared to unexposed, former mixed-type SAM participants had a higher adjusted ORs of metabolic syndrome [2.68 (1.18; 8.07)], central obesity [1.89 (1.11; 3.21)] and low HDL-C (High-density lipoprotein cholesterol) [1.52 (1.08; 2.62)]. However, there was no difference between groups in terms of diabetes, high blood pressure, elevated LDL-C (low-density lipoprotein cholesterol) and hyper TG (hypertriglyceridemia) and overweightness. Former mixed-type SAM participants had higher mean fasting glucose [3.38 mg/dL (0.92; 7.7)], reduced muscle strength [−3.47 kg (−5.82; −1.11)] and smaller hip circumference [−2.27 cm (−4.24; −0.31)] compared to non-exposed. Regardless of subtypes, SAM-exposed participants had higher HbA1c than unexposed (p < 0.001). Those with a history of kwashiorkor had cardiometabolic and nutritional parameters almost superimposable to those of unexposed. Conclusion: The association between childhood SAM, prevalence of NCDs and their CVRFs in adulthood varies according to SAM subtypes, those with mixed form being most at risk. Multicenter studies on larger cohorts of older participants are needed to elucidate the impact of SAM subtypes on NCDs risk.

Revisional Surgery of One Anastomosis Gastric Bypass for Severe Protein-Energy Malnutrition.

BACKGROUND: One anastomosis gastric bypass (OAGB) is safe and effective. Its strong malabsorptive component might cause severe protein-energy malnutrition (PEM), necessitating revisional surgery. We aimed to evaluate the safety and outcomes of OAGB revision for severe PEM. METHODS: This was a single-center retrospective analysis of OAGB patients undergoing revision for severe PEM (2015-2021). Perioperative data and outcomes were retrieved. RESULTS: Ten patients underwent revision for severe PEM. Our center's incidence is 0.63% (9/1425 OAGB). All patients were symptomatic. Median (interquartile range) EWL and lowest albumin were 103.7% (range 57.6, 114) and 24 g/dL (range 19, 27), respectively, and 8/10 patients had significant micronutrient deficiencies. Before revision, nutritional optimization was undertaken. Median OAGB to revision interval was 18.4 months (range 15.7, 27.8). Median BPL length was 200 cm (range 177, 227). Reversal (n = 5), BPL shortening (n = 3), and conversion to Roux-en-Y gastric bypass (RYGB) (n = 2) were performed. One patient had anastomotic leak after BPL shortening. No death occurred. Median BMI and albumin increased from 22.4 kg/m2 (range 20.6, 30.3) and 35.5 g/dL (range 29.2, 41), respectively, at revision to 27.5 (range 22.2, 32.4) kg/m2 and 39.5 g/dL (range 37.2, 41.7), respectively, at follow-up (median 25.4 months, range 3.1, 45). Complete resolution occurs after conversion to RYGB or reversal to normal anatomy, but not after BPL shortening. CONCLUSIONS: Revisional surgery of OAGB for severe PEM is feasible and safe after nutritional optimization. Our results suggest that the type of revision may be an important factor for PEM resolution. Comparative studies are needed to define the role of each revisional option.

Anemia, overhydration, and lower muscle strength in hemodialysis patients with protein-energy wasting.

INTRODUCTION: The protein-energy wasting (PEW) syndrome is a common complication in hemodialysis (HD) patients associated to morbidity and mortality. Our objective was to assess the prevalence of PEW and its association with erythropoietin resistance index (ERI) score, body composition by impedance, health-related quality of life, and muscle strength. METHODS: In this cross-sectional, observational, multicenter study, we included data from 191 HD patients from three HD clinics located in Mexico City, Mexico. Clinical and biochemistry variables, body composition, handgrip strength, and the KDQOL-SF36 questionnaire were collected for each patient. FINDINGS: Prevalence of PEW was 22% (n = 41/191), with a higher frequency in those with diabetes mellitus (59% vs. 49%, p = 0.04). Subjects with PEW had lower hemoglobin levels (9.5 + 1.6 g/dl vs. 10.3 + 1.7 g/dl; p = 0.005) and higher ERI scores (19.2 ± 11.2 vs. 15.6 ± 8.2; p = 0.04) compared with the non-PEW group. In analysis of body composition, PEW was associated to higher overhydration status (42.2 vs. 24.9 OH/kg; p = 0.009), higher extracellular water (263 ± 40 vs. 246 ± 32 ml/kg; p = 0.019), lower lean tissue index (12.2 ± 3.2 vs. 14.1 ± 3.7 ml/m2 ; p = 0.021), and lower fat tissue index (9.6 ± 5.7 vs. 12.3 ± 6.2 ml/m2 ; p = 0.043). Handgrip strength was lower in PEW patients (22.5 vs. 28.1 kg; p = 0.002). Finally, no significant differences were observed between groups in quality-of-life assessment. DISCUSSION: In this study, PEW was associated to poor responsiveness to erythropoiesis-stimulating agents, lower muscle strength, and higher overhydration status due to the increase in extracellular water which replaced the loss of tissue. Nevertheless, quality-of-life assessment was not different in patients with PEW compared with those without this complication.

Mechanisms of Kwashiorkor-Associated Immune Suppression: Insights From Human, Mouse, and Pig Studies.

Malnutrition refers to inadequate energy and/or nutrient intake. Malnutrition exhibits a bidirectional relationship with infections whereby malnutrition increases risk of infections that further aggravates malnutrition. Severe malnutrition (SM) is the main cause of secondary immune deficiency and mortality among children in developing countries. SM can manifest as marasmus (non-edematous), observed most often (68.6% of all malnutrition cases), kwashiorkor (edematous), detected in 23.8% of cases, and marasmic kwashiorkor, identified in ~7.6% of SM cases. Marasmus and kwashiorkor occur due to calorie-energy and protein-calorie deficiency (PCD), respectively. Kwashiorkor and marasmic kwashiorkor present with reduced protein levels, protein catabolism rates, and altered levels of micronutrients leading to uncontrolled oxidative stress, exhaustion of anaerobic commensals, and proliferation of pathobionts. Due to these alterations, kwashiorkor children present with profoundly impaired immune function, compromised intestinal barrier, and secondary micronutrient deficiencies. Kwashiorkor-induced alterations contribute to growth stunting and reduced efficacy of oral vaccines. SM is treated with antibiotics and ready-to-use therapeutic foods with variable efficacy. Kwashiorkor has been extensively investigated in gnotobiotic (Gn) mice and piglet models to understand its multiple immediate and long-term effects on children health. Due to numerous physiological and immunological similarities between pigs and humans, pig represents a highly relevant model to study kwashiorkor pathophysiology and immunology. Here we summarize the impact of kwashiorkor on children's health, immunity, and gut functions and review the relevant findings from human and animal studies. We also discuss the reciprocal interactions between PCD and rotavirus-a highly prevalent enteric childhood pathogen due to which pathogenesis and immunity are affected by childhood SM.

Protein Energy Wasting in a Cohort of Maintenance Hemodialysis Patients in Dhaka, Bangladesh.

Malnutrition is associated with high rates of mortality among patients with end stage kidney disease (ESKD). There is a paucity of data from Bangladesh, where around 35,000−40,000 people reach ESKD annually. We assessed protein-energy wasting (PEW) amongst 133 patients at a single hemodialysis setting in Dhaka. Patients were 49% male, age 50 ± 13 years, 62% were on twice-weekly hemodialysis. Anthropometric, biochemical, and laboratory evaluations revealed: BMI 24.1 ± 5.2 kg/m2, mid-arm muscle circumference (MAMC) 21.6 ± 3.6 cm, and serum albumin 3.7 ± 0.6 g/dL. Based on published criteria, 18% patients had PEW and for these patients, BMI (19.8 ± 2.4 vs. 25.2 ± 5.2 kg/m2), MAMC (19.4 ± 2.4 vs. 22.2 ± 3.8 cm), serum albumin (3.5 ± 0.7 vs. 3.8 ± 0.5 g/dL), and total cholesterol (135 ± 34 vs. 159 ± 40 mg/dL), were significantly lower as compared to non-PEW patients, while hand grip strength was similar (19.5 ± 7.6 vs. 19.7 ± 7.3 kg). Inflammatory C-reactive protein levels tended to be higher in the PEW group (20.0 ± 34.8 vs. 10.0 ± 13.9 p = 0.065). Lipoprotein analyses revealed PEW patients had significantly lower low density lipoprotein cholesterol (71 ± 29 vs. 88 ± 31 mg/dL, p < 0.05) and plasma triglyceride (132 ± 51 vs. 189 ± 103 mg/dL, p < 0.05), while high density lipoprotein cholesterol was similar. Nutritional assessments using a single 24 h recall were possible from 115 of the patients, but only 66 of these were acceptable reporters. Amongst these, while no major differences were noted between PEW and non-PEW patients, the majority of patients did not meet dietary recommendations for energy, protein, fiber, and several micronutrients (in some cases intakes were 60−90% below recommendations). Malnutrition Inflammation Scores were significantly higher in PEW patients (7.6 ± 3.1 vs. 5.3 ± 2.7 p < 0.004). No discernible differences were apparent in measured parameters between patients on twice- vs. thrice-weekly dialysis. Data from a larger cohort are needed prior to establishing patient-management guidelines for PEW in this population.

The role of albumin and the extracellular matrix on the pathophysiology of oedema formation in severe malnutrition.

BACKGROUND: While fluid flows in a steady state from plasma, through interstitium, and into the lymph compartment, altered fluid distribution and oedema can result from abnormal Starling's forces, increased endothelial permeability or impaired lymphatic drainage. The mechanism of oedema formation, especially the primary role of hypoalbuminaemia, remains controversial. Here, we explored the roles of albumin and albumin-independent mechanisms in oedema formation among children with severe malnutrition (SM). METHODS: We performed secondary analysis of data obtained from two independent clinical trials in Malawi and Kenya (NCT02246296 and NCT00934492). We then used an unconventional strategy of comparing children with kwashiorkor and marasmus by matching (discovery cohort, n = 144) and normalising (validation cohort, n = 98, 2 time points) for serum albumin. Untargeted proteomics was used in the discovery cohort to determine plausible albumin-independent mechanisms associated with oedema, which was validated using enzyme-linked immunosorbent assay and multiplex assays in the validation cohort. FINDINGS: We demonstrated that low serum albumin is necessary but not sufficient to develop oedema in SM. We further found that markers of extracellular matrix (ECM) degradation rather than markers of EG degradation distinguished oedematous and non-oedematous children with SM. INTERPRETATION: Our results show that oedema formation has both albumin-dependent and independent mechanisms. ECM integrity appears to have a greater role in oedema formation than EG shedding in SM. FUNDING: Research Foundation Flanders (FWO), Thrasher Foundation (15122 and 9403), VLIR-UOS-Ghent University Global Minds Fund, Bill & Melinda Gates Foundation (OPP1131320), MRC/DfID/Wellcome Trust Global Health Trials Scheme (MR/M007367/1), Canadian Institutes of Health Research (156307), Wellcome Trust (WT083579MA).

Thymic Dysfunction and Atrophy in COVID-19 Disease Complicated by Inflammation, Malnutrition and Cachexia.

Background: The current COVID-19 pandemic has put millions of people, especially children at risk of protein-energy malnutrition (PEM) by pushing them into poverty and disrupting the global food supply chain. The thymus is severely affected by nutritional deficiencies and is known as a barometer of malnutrition. Aim: The present commentary provides a novel perspective on the role of malnutrition-induced thymic dysfunction, involution and atrophy on the risk and severity of disease in children during the COVID-19 pandemic. Methods: A review of pertinent indexed literature including studies examining the effects of malnutrition on the thymus and immune dysfunction in COVID-19. Results: Protein-energy malnutrition and micronutrient deficiencies of zinc, iron and vitamin A are known to promote thymic dysfunction and thymocyte loss in children. Malnutrition- and infection-induced thymic atrophy and immune dysfunction may increase the risk of first, progression of COVID-19 disease to more severe forms including development of multisystem inflammatory syndrome in children (MIS-C); second, slow the recovery from COVID-19 disease; and third, increase the risk of other infections. Furthermore, malnourished children may be at increased risk of contracting SARS-CoV-2 infection due to socioeconomic conditions that promote viral transmission amongst contacts and create barriers to vaccination. Conclusion: National governments and international organizations including WHO, World Food Program, and UNICEF should institute measures to ensure provision of food and micronutrients for children at risk in order to limit the health impact of the ongoing COVID-19 pandemic.

The effect of wasting and stunting during severe acute malnutrition in infancy on insulin sensitivity and insulin clearance in adult life.

Adults who had non-edematous severe acute malnutrition (SAM) during infancy (i.e., marasmus) have worse glucose tolerance and beta-cell function than survivors of edematous SAM (i.e., kwashiorkor). We hypothesized that wasting and/or stunting in SAM is associated with lower glucose disposal rate (M) and insulin clearance (MCR) in adulthood.We recruited 40 nondiabetic adult SAM survivors (20 marasmus survivors (MS) and 20 kwashiorkor survivors (KS)) and 13 matched community controls. We performed 150-minute hyperinsulinaemic, euglycaemic clamps to estimate M and MCR. We also measured serum adiponectin, anthropometry, and body composition. Data on wasting (weight-for-height) and stunting (height-for-age) were abstracted from the hospital records.Children with marasmus had lower weight-for-height z-scores (WHZ) (-3.8 ± 0.9 vs. -2.2 ± 1.4; P < 0.001) and lower height-for-age z-scores (HAZ) (-4.6 ± 1.1 vs. -3.4 ± 1.5; P = 0.0092) than those with kwashiorkor. As adults, mean age (SD) of participants was 27.2 (8.1) years; BMI was 23.6 (5.0) kg/m2. SAM survivors and controls had similar body composition. MS and KS and controls had similar M (9.1 ± 3.2; 8.7 ± 4.6; 6.9 ± 2.5 mg.kg-1.min-1 respectively; P = 0.3) and MCR. WHZ and HAZ were not associated with M, MCR or adiponectin even after adjusting for body composition.Wasting and stunting during infancy are not associated with insulin sensitivity and insulin clearance in lean, young, adult survivors of SAM. These data are consistent with the finding that glucose intolerance in malnutrition survivors is mostly due to beta-cell dysfunction.

[Update 2021: Coronavirus pandemic - challenges for geriatrics]. / Update 2021: Corona-Pandemie ­ Herausforderungen für die Geriatrie.

Nobody supposed that after one year of the pandemia, the SARS-CoV-2 Virus and its emerging mutants dominates the press, our lives and the health system as a whole. As for Geriatric Medicine, many things have also changed: The majority of COVID-19 patients are no more the (oldest) old and mortality is less observed in multimorbid persons, as most of them have been vaccinated. (Oldest) old persons are still especially vulnerable to die due to a COVD-19 infection. In longterm care, a significant higher mortality was seen in the former waves, but now, some longterm care facilities have more places that they can fill. This is a situation that many European countries would never have anticipated.Ressource allocationin stormy times is now more openly discussed, especially who should be admitted to intensive care units. This has led to more detailed and new guidelines which may help even when the pandemia is over. Here, some thoughts regarding the care of older adults in times of the pandemia are discussed.

Leptin Deficiency, Caused by Malnutrition, Makes You Susceptible to SARS-CoV-2 Infection but Could Offer Protection from Severe COVID-19.

In much of the developing world, severe malnutrition is the most prevalent cause of immunodeficiency and affects up to 50% of the population in some impoverished communities. As yet, we do not know how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) will behave in populations with immunodeficiency caused by malnourishment. Interestingly, researchers are now speculating that, in some instances, a defective cellular immune system could paradoxically be a protective factor against severe disease in certain patients contracting SARS-CoV and SARS-CoV-2. This could be linked to the absence of T-cell activation. Based on available information presented here, it is plausible that the hyperimmune response, and subsequent cytokine storm often associated with severe coronavirus disease 2019 (COVID-19), could be "counteracted" by the defective immune response seen in individuals with malnutrition-induced leptin deficiency. In this paper, we proposed a theory that although those with malnutrition-linked leptin deficiency are at risk of SARS-CoV-2 infection, they are at lower risk of developing severe COVID-19.

Immunomodulatory diet in pediatric age.

In the last few decades, the importance of a functioning immune system and health status has become more evident. Multiple factors are able to influence the development of chronic diseases and diet is one of the most important environmental factors. Evidence demonstrates that dietary patterns high in fat and low in fiber are associated with the development of non-communicable diseases. Moreover, optimal nutritional status can modulate immune maturation and response to inflammation. During inflammatory conditions, nutritional deficiencies may occur, establishing a vicious circle, consequently a balanced nutritional status is essential to prevent and counteract infections. Dietary diversity can prevent allergic diseases and nutrients such as DHA, arginine, vitamins and trace elements have an impact on physical barriers (such as gut mucosal barrier and skin), on the immune system response and on microbiome modulation. Protein deficiencies can compromise innate and adaptive immune functions; arginine availability can affect the immune response in injured states and other disease processes; EPA and DHA can modulate both innate and adaptive immunity; prebiotics have a beneficial effect on the functioning of the immune system. Zinc, copper, selenium and iron are involved in the correct development and function of the immune system. Vitamins D, E, A, B and C have a role on immune system through different mechanisms of action. Since a complex interplay exists between diet, microbiome and epigenetic factors which determine nutrient-induced changes on the immune function, the effect of each single nutrient may be difficult to study. Well-designed intervention studies, investigating the effects of whole dietary pattern, should be performed to clarify impact of foods on the immune function and disease risk.

In-patient outcomes of patients with diabetic ketoacidosis and concurrent protein energy malnutrition: A national database study from 2016 to 2017.

Introduction:Patients often present to the hospital with a well-known complication of diabetes mellitus, namely diabetic ketoacidosis (DKA). In this study, we assess the clinical outcomes of DKA hospitalizations with and without protein-energy malnutrition (PEM).Methods:This was a population-based, retrospective observational study using data gathered from the Nationwide Inpatient Sample (NIS) for 2016 and 2017. Hospitalizations of adults >/ = 18 years old with a principal diagnosis of DKA were obtained using ICD-10 codes and divided into groups based on a secondary diagnosis of PEM. The primary outcome was in-hospital mortality. Secondary outcomes included length of stay (LOS), total hospital charges (THC), and system-based complications.Results:Patients with PEM had a statistically significant difference in the adjusted odds for in-hospital mortality compared to patients without PEM (aOR 1.73, 95% CI: 1.20-2.49, p = 0.004). Patients with DKA and PEM had an increased risk of developing sepsis (aOR 2.99, 95% CI: 2.49-3.58, p < 0.001), septic shock (aOR 3.37, 95% CI: 2.31-4.91, p < 0.001), acute kidney failure (aOR 1.27, 95% CI: 1.17-1.37, p < 0.001), acute respiratory failure (aOR 2.23, 95% CI: 1.83-2.73, p < 0.001), deep vein thrombosis (aOR 1.91, 95% CI: 1.43-2.54, p < 0.001), and pulmonary embolism (aOR 2.36, 95% CI: 1.42-3.94, p = 0.001). Patients with DKA and PEM also had an increased mean THC (aOR 19,200, 95% CI 16,000-22,400, p < 0.001) in US dollars and increased LOS (aOR 2.26, 95% CI 1.96-2.57, p < 0.001) in days when compared to patients without PEM.Conclusion:Patients hospitalized for DKA with a secondary diagnosis of PEM within the same admission had a statistically significantly higher in-hospital mortality.