Undernutrition and 60-day mortality in critically ill children with respiratory failure: a prospective cohort study.

BACKGROUND: To determine whether undernutrition affects 60-day mortality in pediatric acute respiratory failure. METHODS: Subjects with acute respiratory failure aged between two months and 13 years were included in the study. The Z-scores were calculated on admission and children were categorized into two groups of undernutrition and normal nutrition. The nutritional intake of the children was measured daily. The outcome was 60-day mortality. RESULTS: A total of 126 patients met the inclusion criteria; 41% were undernourished based on the Z-score of BMI and weight for height, 50% based on the Z-score of height and length for age and 45% based on the Z-score of weight for age. Overall, the 60-day mortality rate was 27.8%. The Cox regression analysis adjusted with PIM2, age and gender, showed that undernutrition has a significant relationship with 60-day mortality based on the weight for age Z-score (HR = 2.33; CI: 1.175-4.638). In addition, undernutrition has a significant relationship with 60-day mortality based on the BMI for age (HR = 3.04; CI:1.070-8.639) and weight for height (HR = 2.62; CI: 1.605-6.658) Z-scores. The mean calorie and protein intake of 72% of the children was less than 80% of their calorie needs. The time to start feeding in 63% of the children was more than 48 h. There was no relationship between the time of starting nutrition and nutritional intake during PICU admission and mortality. CONCLUSION: Undernutrition is prevalent in mechanically ventilated children in the PICU and may be associated with 60-day mortality.

Preoperative Serum Level of Vitamin D is a Possible Protective Factor for Peritumoral Brain Edema of Meningioma: A Cross Sectional Study.

Meningioma is associated with the development of vasogenic edema defined as disrupted blood brain barrier. Vitamin D3 through its own nuclear receptor can regulate the expression of many effective agents on the integrity of the blood brain barrier. This study aimed to investigate the association between preoperative serum levels of 25(OH)D and peritumoral brain edema in patients with meningioma. One hundred and twelve patients with meningioma completed the study. Serum 25(OH)D levels assessment and magnetic resonance imaging (MRI) were done for all patients at the beginning of the study. The percentage of edema index (EI) was used to estimate the extent of peritumoral brain edema through preoperative MRI. The median serum level of 25(OH)D in the patients with the percentage of EI < 100% was significantly higher than those with > 100% (65.58 vs. 37.33, P < 0.001). The median percentage of EI was 24.9. Preoperative serum levels of 25(OH)D had an inverse and significant correlation with the percentage of EI as by increasing each 1 ng/mL of serum 25(OH)D, EI was decreased approximately 4% (95% CI; -5.984 to -1.952, P < 0.001). Vitamin D may be a protective factor for peritumoral brain edema of meningioma.

Vitamin D and Postoperative Delirium After Coronary Artery Bypass Grafting: A Prospective Cohort Study.

OBJECTIVE: Postoperative delirium is the most common neuropsychiatric complication after cardiac surgery. Vitamin D contributes to numerous brain processes, regulation of neurotrophic factors, neuroprotection, neuroplasticity, and brain development, which could play a role in delirium pathophysiology. The authors evaluated the association of admission serum levels of 25-hydroxyvitamin D [25(OH)D] with the occurrence of delirium after coronary artery bypass surgery. DESIGN: A prospective cohort study. SETTING: University hospital. PARTICIPANTS: Coronary artery bypass surgery patients. MEASUREMENTS AND MAIN RESULTS: Serum levels of 25(OH)D were measured for 398 patients upon admission. Delirium was measured using the confusion assessment method for the intensive care unit. RESULTS: Postoperative delirium was detected in 17% (n = 68) of the patients. 25(OH)D deficiency (less than 20 ng/dL) was found in 41.2% (n = 164) of the patients. The median serum level of 25(OH)D was 21 ng/dL (12.8-32.85) in delirium and 24.2 ng/dL (14.4-42.5) in nondelirium patients (p = 0.04). Multivariate regression analysis adjusted by other risk factors indicated that admission severe hypovitaminosis D was associated with the occurrence of delirium (odds ratio = 3.18; 95% confidence interval: 1.29-7.78; p = 0.01). CONCLUSIONS: Preoperative severe vitamin D deficiency was associated with the occurrence of delirium after coronary artery bypass grafting surgery.

Improved physical disability and nutritional status by bovine colostrum supplementation in adults with traumatic peri-trochanteric femoral fracture: A randomized, controlled, clinical trial.

OBJECTIVES: Patients with femur fracture after surgery are at risk of malnutrition, weight loss, disability, and mobility complications. In the present study the role of colostrum supplementation on physical disability, and some nutritional variables after surgery has been investigated. RESEARCH METHODS & PROCEDURES: Patients were randomly assigned to two groups. The intervention group received 45 g colostrum and the control group received 15 g whey protein daily for 21 days (each containing 12 g of protein). The trend comparison during 30 days of variables including weight, appetite, serum albumin level, hemoglobin and lymphocytes between the two groups was modeled with the generalized estimation equation. Moreover, the trend comparison during 90 days of Oswestry Disability Index (ODI) between the two groups was calculated. RESULTS: The basic characteristics were the same between the two groups (colostrum, n = 46; control, n = 48). Protein intake was the same in both groups during the study period. There was a significant difference in weight gain (ß = 0.32, 95 % CI: 0.09-0.54; P = 0.005) within 30 days after operation between the colostrum and control groups in favor of the increase in the colostrum group. Compared to the control group, patients in the colostrum group had a 0.31 score more appetite (P < 0.001), 0.17 g/dL higher serum albumin level (P = 0.001), 0.5 mg/dL higher hemoglobin level and 440 more blood lymphocytes (P < 0.001) during the 30 days of intervention. Regarding physical function disability, patients in the colostrum group had about 4 ODI scores lower than the control group during the study period. CONCLUSION: Colostrum supplement can increase appetite, hemoglobin, serum albumin level and the number of blood lymphocytes more than the control group. It can also accelerate weight gain and physical performance after surgery.

Nutritional status and clinical outcomes of brain tumor surgery in pediatric intensive care unit: A prospective cohort study.

BACKGROUND: To determine whether nutritional status affects mortality and length of stay in the pediatric intensive care unit (PICU) after brain tumor surgery. METHODS: Subjects aged 2 months to 13 years with brain tumor surgery were included in the study. Z-scores of BMI for age, weight for age, and weight for length were calculated at admission. Undernutrition was defined as Z-score < -2. Nutritional intake was measured daily by a clinical nutritionist. Outcomes to be measured included duration of hospitalization and mortality. Regression analyses was used to investigate the relationship between nutritional variables and outcomes. RESULTS: A total of 63 patients met the inclusion criteria. Undernutrition at admission was found in 33% of subjects based on Z-scores of BMI and weight for length. The mortality rate was 17.5%. Calorie and protein intake was <50% of the target in 50.7% and 42.8 % of children, respectively. Undernutrition by weight for age Z-score, BMI for age and weight for length Z-scores, and low protein intake increased mortality risk by 5, 5.9 and 4.7 times, respectively. The risk of shorter PICU-free days was independently 80% and 90% lower in those receiving <50% of protein and calorie requirements. CONCLUSION: Undernutrition at admission is prevalent in children undergoing brain tumor surgery and is associated with a higher risk of mortality. Caloric and protein intake during hospitalization is generally low, leading to longer PICU stay.

Malnutrition elevates delirium and ICU stay among critically ill older adult COVID-19 patients.

Background and aim: Malnutrition among intensive care unit (ICU) patients is associated with a higher risk of mortality and prolonged hospitalization. However, the influence of malnutrition on severe outcomes of ICU patients with coronavirus disease 2019 (COVID-19) is unclear. By evaluating the effect of malnutrition on the outcomes of COVID-19 in the ICU in older adult patients, this study will contribute to new knowledge of assessing the nutritional status and recovery of these patients. Methods: In the current single center prospective study, 310 critically ill COVID-19 patients with an age range of ≥65 years were recruited. Data on demographic characteristics, laboratory parameters, comorbidities, medications, and types of mechanical ventilation were collected in the first 24 h of ICU admission. Malnutrition was defined based on the two-step approach of the Global Leadership Initiative on Malnutrition (GLIM) scale at baseline. During the 45 days after the baseline, we collected data on delirium incidence, mortality, invasive mechanical ventilation (IMV) requirement, length of ICU and hospital admission, and re-hospitalization. Results: In this study, the prevalence of malnutrition was 63.4% among critically ill COVID-19 patients. During the 45-day follow-up, 190 (61.3%) COVID-19 deaths were recorded among the baseline 310 patients. After controlling for potential confounders, malnutrition was associated with an increased risk of delirium so malnourished COVID-19 patients had a significantly 35% higher risk of delirium than those without malnutrition (HR: 1.35, 95% CI: 1.01-1.83). Such a significant association was not for COVID-19 mortality and IMV requirement. In addition, malnutrition was associated with a significantly 84% greater odds of prolonged ICU admission (OR: 1.84, 95% CI: 1.09-3.10). No significant association was seen between malnutrition and re-hospitalization and also prolonged hospital admission. Conclusion: Malnutrition was associated with an increased risk of delirium and prolonged ICU admission among critically ill older adult COVID-19 patients. Prevention, diagnosis, and treatment of malnutrition could be a key component in improving outcomes in these patients.

Bosentan for high-risk outpatients with COVID-19 infection: a randomized, double blind, placebo-controlled trial.

Background: The endothelium is supposedly activated and damaged in COVID-19 because of endothelin-1 over-secretion. This study evaluates the effect of bosentan as an endothelin receptor blocker on the progression of disease in high-risk outpatients with COVID-19 infection. Methods: From 15 December 2021 to 15 May 2022, high-risk outpatients were randomly assigned to receive bosentan, 62.5 mg or placebo twice daily from enrollment for 30 days. Both groups received standard medical treatment too. On day 30 of the trial, the patients underwent complete doppler ultrasound of the lower extremities to detect asymptomatic thromboembolic events. The primary outcome in this study was hospitalization or death from any cause within the first 15 days. Secondary outcomes included thromboembolic events, hospital-free days and death from any cause within 30 days after randomization (IRCT.ir, IRCT20211203053263N1). Findings: Basal characteristics of the two groups were similar. Primary outcomes occurred in 3 (2.3%) of the 129 patients in the bosentan group versus 15 (11.5%) of the 130 patients in the placebo group [risk difference: -9.2% (95% CI: -15.3 to -3.1), P = 0.006]. Median hospital-free days was significantly higher in the bosentan group (P = 0.004). A total of three deaths occurred and all were in the control group. Bosentan was associated with a nonsignificant reduction in mortality compared with placebo (P = 0.24). Thromboembolic events occurred in one (1%) of 97 patients in the bosentan group versus nine (8.7%) of 104 patients in the placebo group within 30 days after randomization [risk difference: -8.3% (95% CI: -14.4 to -2.2), P = 0.008]. Interpretation: Early administration of bosentan may prevent disease progression and thromboembolic events in high-risk outpatients with COVID-19. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Associations of body mass index with severe outcomes of COVID-19 among critically ill elderly patients: A prospective study.

Background and Aim: Few studies assessed the associations of overweight and obesity with severe outcomes of coronavirus disease 2019 (COVID-19) among elderly patients. This study was conducted to assess overweight and obesity in relation to risk of mortality, delirium, invasive mechanical ventilation (IMV) requirement during treatment, re-hospitalization, prolonged hospitalization, and ICU admission among elderly patients with COVID-19. Methods: This was a single-center prospective study that was done on 310 elderly patients with COVID-19 hospitalized in the intensive care unit (ICU). We collected data on demographic characteristics, laboratory parameters, nutritional status, blood pressure, comorbidities, medications, and types of mechanical ventilation at baseline. Patients were followed up during ICU admission and until 45 days after the first visit, and data on delirium incidence, mortality, need for a form of mechanical ventilation, discharge day from ICU and hospital, and re-hospitalization were recorded for each patient. Results: During the follow-up period, we recorded 190 deaths, 217 cases of delirium, and 35 patients who required IMV during treatment. After controlling for potential confounders, a significant association was found between obesity and delirium such that obese patients with COVID-19 had a 62% higher risk of delirium compared with normal-weight patients (HR: 1.62, 95% CI: 1.02-2.57). This association was not observed for overweight. In terms of other outcomes including ICU/45-day mortality, IMV therapy during treatment, re-hospitalization, prolonged hospitalization, and ICU admission, we found no significant association with overweight and obesity either before or after controlling for potential confounders. Conclusion: We found that obesity may be a risk factor for delirium among critically ill elderly patients with COVID-19.

Effect of intravenous ascorbic acid administration on hemorrhage and wound complications in total abdominal hysterectomy: A prospective randomized clinical trial.

OBJECTIVE: Previous studies mentioned the beneficial effects of vitamin C on the hemorrhage and wound healing. We evaluated the effects of vitamin C on the hemorrhage, hemoglobin concentration, and wound complications in total abdominal hysterectomy. MATERIALS AND METHODS: In this randomized, double-blind, placebo-controlled trial, 80 patients with total abdominal hysterectomy were randomly divided into the study and control groups to receive either intravenous 2 g of vitamin C in normal saline or solely normal saline therapy. The first 1-g dose of ascorbic acid was administrated the night before surgery, and the second 1 g was administrated during surgery. RESULTS: The mean age of the participants was 37.8 ± 4.8 years with a mean preoperative plasma vitamin C concentration of 5.07 ± 2.1 mg/dL, close to the subclinical deficiency. The basal characteristics of both groups were the same. The hemorrhage volume was slightly higher in the control group (345.2 ± 31.8 ml vs. 388.1 ± 28.3 ml, P < 0.001). CONCLUSION: Intravenous vitamin C administration had a positive effect on reducing hemorrhage during total abdominal hysterectomy. TRIAL REGISTRATION: Clinicaltrials.gov.identifier: NCT03965637.

Obesity and posterior spine fusion surgery: A prospective observational study.

OBJECTIVE: Obesity is an important issue in spine surgeries due to its negative effects on the quality of surgery, more complications, and adverse consequences. This study compared the outcomes of obese and non-obese patients undergoing instrumented posterior fusion surgery in the lumbar spine. METHODS: In this prospective observational study conducted in a university hospital, we compared the rate of vertebral fusion, surgical site infection (SSI), pain, and disability in 160 patients undergoing instrumented posterior fusion surgery in the lumbar spine between obese and non-obese patients. RESULTS: A total of 160 patients, 80 in each group, were included. Obesity was associated with a significantly higher prevalence of diabetes, hypertension, coronary artery disease (CAD), and chronic obstructive pulmonary disease (COPD) (P < 0.05). Poor outcomes, including non-fusion, SSI, pain, and disability were significantly higher in the obese group versus the non-obese group (P < 0.05). The multiple regression analysis indicated that obesity is an independent predictor of non-fusion, more pain, disability, and SSI. CONCLUSION: These findings suggest that the association of obesity with postoperative complications may help in the evaluation and selection of patients before surgery and preoperative weight management is important.

Ascorbic Acid to Prevent Postpolypectomy Bleeding in the Colon: A Randomized Controlled Trial.

INTRODUCTION: It has been reported that vitamin C replacement can quickly reverse nonspecific bleeding in surgical patients with normal coagulation parameters. We evaluated the effect of intravenous ascorbic acid administration for prevention of postpolypectomy bleeding in large polyps of the colon. MATERIALS AND METHODS: Patients with large polyps with heads larger than 10 mm, stalk diameter larger than 5 mm, and a length larger than 10 mm were included in this randomized controlled clinical trial. In the study group, the first 500 mg intravenous dose of vitamin C diluted in normal saline was administered 2 h before colonoscopic resection of polyps and the second and third similar doses were administered on days 2 and 3 of polypectomy, respectively. The control group received normal saline in a similar fashion. The resection of polyps was performed in snare and cut-blend mode. Early and late postoperative bleeding were compared between the two groups. RESULTS: A total of 153 polyps were resected by endoscopic polypectomy. Early bleeding was observed in 7.2% of the patients, which was significantly lower in the vitamin C group (2.6% vs 11.8%, P = 0.03). Late bleeding was observed in 6.5% of the patients with a trend lower in the vitamin C group (2.6% vs 10.5%, P = 0.057). The proportion of postprocedural bleeding was significantly higher in the vitamin C group (5% vs 20%, P = 0.007). Hazard ratios of early and postprocedural bleeding were 78% and 76% lower in the vitamin C group compared to the control group (P < 0.05). CONCLUSION: Intravenous ascorbic acid infusion could reduce postpolypectomy bleeding.

Refeeding Syndrome and Its Related Factors in Critically Ill Coronavirus Disease 2019 Patients: A Prospective Cohort Study.

Background and Aim: Malnutrition and its complications is usually neglected in critically ill COVID-19 patients. We conducted the present study to investigate the prevalence of refeeding syndrome and its related factors in this group of patients. Methods: In this prospective cohort study, 327 patients were assessed for being at risk and developing refeeding syndrome. The criteria was ASPEN consensus recommendations for refeeding syndrome released in 2020. Malnutrition was assessed based on global leadership initiative on malnutrition (GLIM) criteria. The relation between actual protein, calorie intake, and refeeding syndrome was also evaluated via cox regression model. The data concerning calorie and protein intake were gathered for 5 days after initiating feeding. The daily protein and calorie intake were divided by kilogram body weight in order to calculate the actual protein (g/kg/day) and energy (kcal/kg/day) intake. Results: Among the subjects, 268 (82%) were at risk of refeeding syndrome and 116 (36%) got involved in this syndrome. Malnutrition, according to the GLIM criteria, was found in 193 (59%) of the subjects. In the at-risk population, the risk of refeeding syndrome was reduced by 90% with the rise in protein intake (CI; 0.021-0.436, P = 0.002), increased by 1.04 times with the increase in age (CI; 1.032-1.067, P < 0.001), and by 1.19 times with the rise in the days from illness onset to admission (CI; 1.081-1.312, P < 0.001) in adjusted cox model analysis. Conclusion: The incidence of refeeding syndrome is relatively high, which threatens the majority of critically ill COVID-19 patients. Increased protein intake was found to reduce the occurrence of refeeding syndrome.

Implementation of a Case Presentation Program for Clinical Nutrition Students.

Background and Aims: To implement a training method increase clinical nutritionists' knowledge and make doctors more familiar with this specialty. Methods: The study was conducted in an internship course of all third semester clinical nutrition students. At first, conventional training was presented for students, and then, in the same duration, case presentation training program was implemented. The presentations were filmed and uploaded to the Internet, and the link was placed on the hospital's website. At the end of the 2 phases, the students were asked to answer the survey questionnaire. Additionally, consultation report sheets were evaluated and scored by 2 physicians. Number of consultation requests was also recorded in 2 study phases. Results: The mean satisfaction score was statistically higher in the case presentation training program than in the conventional program. All the students recommended similar case report program courses for the students in the future. Although the mean consultation report score was not statistically different between the two training programs, case presentation program resulted in significantly better scores in 4 items of nutrition focused physical examinations, assessment of malnutrition, assessment of related laboratory tests, and food-drug interactions. Number of consultation requests was significantly increased during the case presentation program training compared to the conventional training from 194 to 272 (P < 0.001). Conclusion: From the students' perspective, the case-based learning report was preferred to the conventional method. From the physicians' viewpoint, the answer to the counseling sheets was more complete and helpful.

Vitamin D deficiency is Associated with Increased Risk of Delirium and Mortality among Critically Ill, Elderly Covid-19 Patients.

BACKGROUND AND AIM: Data on the associations of vitamin D levels with severe outcomes of coronavirus disease 2019 (COVID-19) among critically ill elderly patients are not conclusive and also no information is available about some outcomes such as delirium. Therefore, the current study was done to assess these associations in critically ill elderly COVID-19 patients. METHODS: In total, 310 critically ill COVID-19 patients, aged ≥ 65 years, were included in the current single center prospective study. All patients were hospitalized in the intensive care unit (ICU). We collected data on demographic characteristics, laboratory parameters, blood pressure, comorbidities, medications, and types of mechanical ventilation at baseline (the first day of ICU admission). Patients were categorized based on serum 25(OH)D3 levels at the baseline [normal levels (>30 ng/mL), insufficiency (20-30 ng/mL), deficiency (<20 ng/mL)]. Data on delirium incidence, mortality, invasive mechanical ventilation (IMV) requirement during treatment, length of ICU and hospital admission, and re-hospitalization were recorded until 45 days after the baseline. RESULTS: Vitamin D deficiency and insufficiency were prevalent among 12 % and 37 % of study participants, respectively. In terms of baseline differences, patients with vitamin D deficiency were more likely to be older, have organ failure, take propofol, need IMV, and were less likely to need face mask compared to patients with normal levels of vitamin D. A significant positive association was found between vitamin D deficiency and risk of delirium. After controlling for potential confounders, patients with vitamin D deficiency had a 54 % higher risk of delirium compared to those with vitamin D sufficiency (HR: 1.54, 95 % CI: 1.02-2.33). Such a positive association was also seen for 45-day COVID-19 mortality (HR: 3.95, 95 % CI: 1.80-8.67). Also, each 10 ng/mL increase in vitamin D levels was associated with a 45 % and 26 % lower risk of 45-day mortality (HR: 0.55, 95 % CI: 0.40-0.74) and ICU mortality due to COVID-19 (HR: 0.74, 95 % CI: 0.60-0.92), respectively. In terms of other COVID-19 outcomes including IMV requirement during treatment, prolonged hospitalization, and re-hospitalization, we found no significant association in relation to serum 25(OH)D3 levels either in crude or fully adjusted models. CONCLUSION: Vitamin D deficiency was associated with an increased risk of delirium and mortality among critically ill elderly COVID-19 patients.

High-fat low-carbohydrate enteral feeding enriched with olive oil and acute respiratory failure: A double-blind, randomized, controlled trial.

BACKGROUND AND AIM: The study evaluated the impact of two types of high fat diet on the outcomes of acute pulmonary failure. METHODS: A total of 93 Ventilated acute pulmonary failure patients with enteral feeding were assigned randomly to the control group with carbohydrate-based formula (protein: 20%, fat: 30%, carbohydrate: 50%) and two study groups with fat-based formula, including group A (protein: 20%, In equal proportions of olive and sunflower oil 45%, charbohydrate:35%) and group B (protein: 20%, sunflower oil:45%, charbohydrate:35%). The diets were prescribed for 14 days. RESULTS: In each group, 16 patients completed the study. The PaCO2 decreased significantly in the study group A compared with the control group at weaning. The risk of separation from mechanical ventilation during study period was eight times higher in the study group A than the control group. On day 10 of intervention, serum hs-CRP decreased significantly in the control group and the study group A compared to the baseline. Serum concentration of total antioxidant capacity was increased significantly in the study group A on day 10 of the intervention, but in the other two groups it was reduced. Gastrointestinal complications, including diarrhea and high gastric residual volume, were not different between the groups. CONCLUSION: With a fat-based diet high in olive oil, more patients were weaned during the study period. This diet reduced the PaCo2 at weaning, reduced the serum level of hs-CRP, and increased the serum level of total antioxidant capacity concentration. Fat-based diet high in sunflower oil did not have any beneficial effects on outcomes.

Single high-dose vitamin D3 injection and clinical outcomes in brain tumor resection: A randomized, controlled clinical trial.

BACKGROUND & AIMS: Vitamin D is known as a neuroprotective hormone with anti-inflammatory and immune-modulatory properties. We evaluated the effect of vitamin D3 injection on vitamin D status and clinical outcomes in patients with low serum levels of 25-hydroxyvitamin D [25(OH)D] undergoing craniotomy for brain tumor resection. METHODS: Patients with benign brain tumors and serum 25(OH)D levels ≤20 ng/mL were randomized to two groups with an equal number of subjects. The study group (n = 30) received intramuscular injection of 300,000 IU vitamin D3 prior to surgery. The control group (n = 30) was left without intervention, and both groups underwent routine therapies. RESULTS: On day 5 after craniotomy, the serum 25(OH)D levels increased significantly in the study group (P= <0.001). The length of ICU and hospital stay was significantly lower in the study group compared to the control group (P = 0.01 and P = 0.008, respectively). It was true when the age, tumor size, tumor type, Karnofsky Performance Scale (KPS) score, and calcium and albumin levels at baseline entered the logistic regression model (OR = 0.17 (95%CI = 0.04-0.72, P = 0.01), and OR = 0.19 (95%CI = 0.04-0.82, P = 0.02), respectively). With and without the application of logistic regression analysis, there was no significant difference in perioperative complications. CONCLUSIONS: Intramuscular injection of 300,000 IU of vitamin D3 in patients with low serum levels of 25(OH)D undergoing craniotomy, could rise safely the serum 25(OH)D level. This intervention, significantly reduced the length of ICU stay and hospitalization. REGISTERED UNDER: Clinicaltrials.gov.identifier no: NCT03248544. Date: 8/14/2017.

Protein and Energy Intake Assessment and Their Association With In-Hospital Mortality in Critically Ill COVID-19 Patients: A Prospective Cohort Study.

Background and Aim: It is partially known that nutritional intake could alleviate proteolysis and course of disease severity in patients with COVID-19; however, not enough data are available in this regard. The present study aimed to assess protein and energy intake and their association with in-hospital mortality in critically ill COVID-19 patients. Methods: A total of 126 patients with COVID-19, who were critically ill, ≥5 days and a subset of 111 patients in ICU ≥10 days completed the present prospective observational cohort study. Results: Protein and energy intakes on Day 5 of ICU admission in survivors were 46 and 58% of target values, respectively. These values in non-survivors were 42 and 50% of target values, respectively (p < 0.05). In the sample ≥10 days, protein and energy intakes in survivors reached 64 and 87% of target values, respectively, without statistically significant differences with non-survivors. In the sample ≥5 days, Cox proportional hazard regression was adjusted for GLIM, APACHE II, comorbidity, and age; the results indicated that the patients with protein and energy intake lower than 0.59 g/kg/day and 14 kcal/kg/day, had ~2-fold mortality hazard (protein: HR, 2.38; 95% CI, 1.40-4.03; P = 0.001 and energy: HR, 2.23; 95% CI, 1.27-3.92; P = 0.005). Conclusion: Actual protein and energy intakes in critically ill patients with COVID-19 are in suboptimal levels compared with goal recommendations in these patients. Moreover, higher amounts of protein and energy intakes in the early acute phase were significantly associated with better survival and lower risk of in-hospital mortality.

The validity of the global leadership initiative on malnutrition criteria for diagnosing malnutrition in critically ill patients with COVID-19: A prospective cohort study.

BACKGROUND AND AIM: We conducted the present study to investigate the nutritional status of critically ill COVID-19 patients and validate the GLIM criteria with respect to the SGA. METHODS: In this prospective cohort study, 109 ICU patients were assessed for malnutrition based on GLIM and SGA criteria. The relation between nutrition assessment tools and duration of hospitalization and mortality were also evaluated. The sensitivity and specificity of GLIM criteria concerning the detection of malnutrition was assessed based on the area under the curve. RESULTS: Malnutrition, according to the SGA and GLIM criteria, was found in 68 (62.4%) and 66 (61.5%) of our subjects. There was an optimal agreement between the GLIM criteria and the SGA criteria regarding malnutrition diagnosis (K = 0.85, P < 0.001). The area under curve for the GLIM was stratified based on the SGA results and was 0.927 (95% CI: 0.868-0.985) with a sensitivity and specificity of 92% and 93%, respectively. CONCLUSION: Malnutrition is frequently observed in critically ill COVID-19 patients. GLIM criteria is a valid tool and has a strong association with mortality and longer duration of ICU stay.

Association of intestinal permeability with admission vitamin D deficiency in patients who are critically ill.

Emerging data have led to the hypothesis that vitamin D plays a role in promoting epithelial barrier dysfunction. Therefore, intestinal permeability becomes a significant determiner in the future of patients hospitalized in intensive care unit (ICU). The relationship between vitamin D and intestinal permeability remains unclear in patients who are critically ill. The aim of the study is to document the relationship between the admission vitamin D deficiency and markers of intestinal permeability in the critical care setting. This was a single-center, observational, prospective study in the general ICU of a university-affiliated hospital. A sample of 144 ICU-hospitalized adult patients was recruited between January and May 2018. The admission serum 25-hydroxyvitamin D levels were measured and categorized as <20 and ≥20 ng/dL, respectively. Moreover, the admission plasma endotoxin and zonulin concentrations as markers of intestinal permeability were determined in stringent conditions. The association between markers of intestinal permeability and 25-hydroxyvitamin D levels was assessed adjusting for potential confounders through an estimation of a binary logistic regression model. Our results showed that median plasma endotoxin and zonulin decreased with increasing serum levels of vitamin D categories (p=0.001) in the overall study population. Multivariate binary logistic regression analyses showed a significant association between the plasma endotoxin (OR 0.12, 95% CI 0.03 to 0.52) and zonulin (OR 0.91, 95% CI 0.87 to 0.99) levels with serum levels of vitamin D categories in the overall population. Our finding suggests a relationship between vitamin D deficiency and early alterations in intestinal permeability. Thus, evaluating vitamin D levels in patients who are critically ill may be warranted.

Association between preoperative nutritional status and postoperative delirium in individuals with coronary artery bypass graft surgery: A prospective cohort study.

OBJECTIVES: The prevalence of delirium and undernutrition are both relatively high subsequent to coronary artery bypass graft (CABG) surgery. The aim of this study was to evaluate the association between preoperative malnutrition and the occurrence of delirium after CABG surgery. METHODS: In this prospective cohort study, body mass index, mid-upper arm circumference, triceps skinfold, and adductor pollicis muscle thickness of 398 adult patients before CABG surgery were measured by a single trained dietitian. Also, Nutritional Risk Screening 2002 (NRS-2002) and subjective global assessment (SGA) were obtained from patients. Delirium was defined by the confusion assessment method for the intensive care unit. SPSS software was used for performing the statistical analyses. Logistic regression analysis was applied to examine the effect of various factors on the development of delirium. RESULTS: Postoperative delirium was detected in 17% of patients (n = 68). Multivariate regression analysis adjusted by other risk factors indicated that risk for delirium was 1.56-fold higher in patients with NRS-2002 >3 (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.20-3.24; P = 0.001). Severe undernutrition at admission as assessed by SGA was independently associated with the occurrence of delirium (OR, 2.58; 95% CI, 1.02-3.48; P = 0.005). Risk for delirium was 1.26-fold higher in patients with adductor pollicis muscle thickness <15 mm (OR, 1.26; 95% CI, 1.02-3.14; P = 0.02). CONCLUSIONS: Since the prevalence of delirium is relatively high in CABG surgery and undernutrition is related to postoperative delirium, considering nutrition status with NRS-2002, SGA, or adductor pollicis muscle thickness before surgery could decrease the risk for postoperative delirium.