LETTERS
510
Consejo Superior CientIficas Juan de La Cierva,
TO
THE
5.
de Investigaciones 3, Madrid,
6.
Spain
H.
AND
LINNEWEH.
Y.,
K.
TRAUTNER
AND
J.
C.
R. S. In:
SHALLENBERGER,
Academic
SoMooYI.
Wochschr. EHEART,
Wochschr. 100: 897, 1970. J. C., AND K. TRAUTNER. Schweiz. 104: 177, 1974. J. F., AND B. S.-J. MASON. Am.
8.
Med.
50: 130, 1967. J.-J. OAOC
Nutritional Relationship
status
9. 10.
53: 6, 1970.
and body
between
results
1974,
C.,
72: 275, Esp.
141:
C., 209,
VIDAL-VALVERDE, VALvERDE-LOPEZ.
composition
in
Nutrition,
McNutt.
New
edYork:
p. 67. AND
E. ROJAS-HIDALGO.
An
1976.
VIDAL-VALVERDE,
Clin.
Dietet.
Press,
Sugars
and K. W.
VIDAL-VALVERDE, Quim.
Med.
46: 9,
Wochschr.
1968.
in critically
AND
E.
ROJAS-HIDALGO.
Rev.
1976.
C., E. ROJAS-HIDALGO, Clin. Esp. In press.
AND
S.
Rev.
ill patients.
and mortality.
Sir:
Assessment of protein-calorie malnutrition in surgical patients from plasma proteins and anthropometric measurements has been well documented by Young and Graham (1). In addition, Harvey et al. (2) found that nutritional assessment by delayed hypersensitivity skin test (DH) and secretory protein levels is a valuable routine to identify high risk hospitalized patients and pointed out the association: malnutrition-anergy-sepsis-increased mortality. We wish to report our findings between initial nutritional assessment and body composition, and subsequent mortality, in our Intensive Respiratory Care Unit. Plasma proteins, triglyceridemia (TG), serum iron (Fe), total lymphocyte count (TLC) and DH (testing three antigens: candidin, tuberculin, varidase) were systematically determined in 154 critically ill patients after admission. When studied, 129/154 patients had ventilatory support (intubated or tracheotomised). Overall subsequent mortality was 36% (55/154). Plasma protein levels were highly significantly increased in patients that were subsequently discharged versus those that died: albumin = 33 ± 6 g/liter versus 28 ± 6 g/ liter (P < 10_6); transferrin = 2.12 ± 0.65 liter versus 1.54 ± 0.55 g/liter (P < 10); thyroxin-binding prealbumin = 14.32 ± 7.79 g/liter versus 7.28 ± 5.36 g/liter (P < l0-). Mortality was associated with increased TG: 1.66 ± 1.12 g/liter versus 1.07 ± 0.38 g/liter
< l0), decreased Fe: 51 ±40 g/l00 ml versus 74 ± 45 tg/100 ml (P < 10-2) and decreased TLC: 884 ± 1025 versus 1270 ± 870 (P < 0.02). Initial anergy correlated with subsequent mortality: 35/62 died when DH was negative versus 13/7 1 when it was positive (P < 10). In addition body composition was determined in 98 male subjects of this population using skinfolds, creatininemia, and evaluation of hydric compartments by dilution of isotopic tracers. Body weight, fat weight, lean body mass, total body water, and visceral mass were not different between subsequent survivors and nonsurvivors. On the contrary, muscle cell mass was decreased (-17%, P < l0) and extracellular water was increased (+ 14%, P < l0) in patients who subsequently died. These results are different from those observed in chronic undernutrition by Barac-Nieto et al. (3), where body weight, fat weight, fat free weight, and total body water are decreased with muscle cell mass. Sepsis correlated with anergy, decreased plasma protein levels decreased muscle cell mass, and mortality (P < 10). These results are in agreement with the existence of hepatic dysfunction for protein synthesis (1) and increased gluconeogenesis and lipogenesis in severely injured and septic patients (4), and suggest that these patients cannot well utilize fat as caloric source.
(P
L
Thomas, D. Robert,
M.D. M.D.
Downloaded from https://academic.oup.com/ajcn/article-abstract/32/3/510/4692008 by McMaster University Library user on 04 February 2019
D.
2. SoMooYI,
Dear
S.,
R.-J.
A.
AND
53:6, 1970.
ited by H. L. Sipple
Schweiz.
Assoc.
FERNANDEZ-FLORES
A., AOAC
GOETHE,
468, 7.
1. DAKO,
4. Frraso,
D.
KLINE, JOHNSON.
References
3.
EDITOR
LETfERS
M. Gerard,
TO
THE
1. YOUNG, G. A., AND L. H. Gniw.i. Assessment of protein-calorie malnutrition in surgical patients from
Dear
mortality
in United
1301,
States
1977.
and vitamin
C
Sir:
In the May 1978 issue the editorial (1) summarized the reasons for a realistic optimism about the possibility of coronary heart disease being influenced through changes in the diet Over the past 12 years, a striking decline in coronary mortality rate has been noted in the United States, particularly in the lower age groups (Fig. 1). Simultaneously, DEATH 2 600
30:
RATE!
105
there has been a shift in American dietary habits, involving a decreased consumption of cholesterol and saturated fats and an increased consumption of polyunsaturated fats. Walker (2) assumes these nutritional changes, alongside a lower consumption of tobacco products, a better control of hypertension, coronary care units, exercise programs, and
POPULATION
(lb.
-
io6 20
-
AICORSATE PRODUCTION
2400
15
2 200
10
CORONARY \MORTALITY
2 000
1 800
‘5
-0
-
1958
FIG. production
Census
1962
1966
1970
1. Age adjusted (35 to 74 years) death rate from ischemic of ascorbic acid during the past 20 years in United States. of Manufacturers, United States Department of Commerce.)
1974
YEARS
heart disease per 100,000 population (Sources: Vital Statistics of United
and States
Downloaded from https://academic.oup.com/ajcn/article-abstract/32/3/510/4692008 by McMaster University Library user on 04 February 2019
References
of coronary
511
plasma proteins and anthropometric measurements. Am. J. Clin. Nutr. 31: 429, 1978. 2. HARVEY, K. B., J. A. Ruooinito, C. S. REGAN, B. R. BISTRIAN AND G. L. BLACKBURN. Hospital morbidity-mortality risk factors using nutritional assessment. Am. J. Clin. Nutr. 31: 703, 1978 (abstr.). 3. B.nc-NwTo, M., G. B. Spuan, H. LOTERO, AND M. G. MAKSUD. Body composition in chronic undernutrition. Am. J. Clin. Nutr. 31: 23, 1978. 4. LONG C. L. Energy balance and carbohydrate metabolism in infection and sepsis. Am. J. Clin. Nutr.
M.D.
Service d’Assistance Respiratoire et Reanimation M#{233}dicale Pr. A. Bertoye, Hopital de la Croix Rousse, 69317 Lyon, Cedex 1 France
Decline
EDITOR
510
Consejo Superior CientIficas Juan de La Cierva,
TO
THE
5.
de Investigaciones 3, Madrid,
6.
Spain
H.
AND
LINNEWEH.
Y.,
K.
TRAUTNER
AND
J.
C.
R. S. In:
SHALLENBERGER,
Academic
SoMooYI.
Wochschr. EHEART,
Wochschr. 100: 897, 1970. J. C., AND K. TRAUTNER. Schweiz. 104: 177, 1974. J. F., AND B. S.-J. MASON. Am.
8.
Med.
50: 130, 1967. J.-J. OAOC
Nutritional Relationship
status
9. 10.
53: 6, 1970.
and body
between
results
1974,
C.,
72: 275, Esp.
141:
C., 209,
VIDAL-VALVERDE, VALvERDE-LOPEZ.
composition
in
Nutrition,
McNutt.
New
edYork:
p. 67. AND
E. ROJAS-HIDALGO.
An
1976.
VIDAL-VALVERDE,
Clin.
Dietet.
Press,
Sugars
and K. W.
VIDAL-VALVERDE, Quim.
Med.
46: 9,
Wochschr.
1968.
in critically
AND
E.
ROJAS-HIDALGO.
Rev.
1976.
C., E. ROJAS-HIDALGO, Clin. Esp. In press.
AND
S.
Rev.
ill patients.
and mortality.
Sir:
Assessment of protein-calorie malnutrition in surgical patients from plasma proteins and anthropometric measurements has been well documented by Young and Graham (1). In addition, Harvey et al. (2) found that nutritional assessment by delayed hypersensitivity skin test (DH) and secretory protein levels is a valuable routine to identify high risk hospitalized patients and pointed out the association: malnutrition-anergy-sepsis-increased mortality. We wish to report our findings between initial nutritional assessment and body composition, and subsequent mortality, in our Intensive Respiratory Care Unit. Plasma proteins, triglyceridemia (TG), serum iron (Fe), total lymphocyte count (TLC) and DH (testing three antigens: candidin, tuberculin, varidase) were systematically determined in 154 critically ill patients after admission. When studied, 129/154 patients had ventilatory support (intubated or tracheotomised). Overall subsequent mortality was 36% (55/154). Plasma protein levels were highly significantly increased in patients that were subsequently discharged versus those that died: albumin = 33 ± 6 g/liter versus 28 ± 6 g/ liter (P < 10_6); transferrin = 2.12 ± 0.65 liter versus 1.54 ± 0.55 g/liter (P < 10); thyroxin-binding prealbumin = 14.32 ± 7.79 g/liter versus 7.28 ± 5.36 g/liter (P < l0-). Mortality was associated with increased TG: 1.66 ± 1.12 g/liter versus 1.07 ± 0.38 g/liter
< l0), decreased Fe: 51 ±40 g/l00 ml versus 74 ± 45 tg/100 ml (P < 10-2) and decreased TLC: 884 ± 1025 versus 1270 ± 870 (P < 0.02). Initial anergy correlated with subsequent mortality: 35/62 died when DH was negative versus 13/7 1 when it was positive (P < 10). In addition body composition was determined in 98 male subjects of this population using skinfolds, creatininemia, and evaluation of hydric compartments by dilution of isotopic tracers. Body weight, fat weight, lean body mass, total body water, and visceral mass were not different between subsequent survivors and nonsurvivors. On the contrary, muscle cell mass was decreased (-17%, P < l0) and extracellular water was increased (+ 14%, P < l0) in patients who subsequently died. These results are different from those observed in chronic undernutrition by Barac-Nieto et al. (3), where body weight, fat weight, fat free weight, and total body water are decreased with muscle cell mass. Sepsis correlated with anergy, decreased plasma protein levels decreased muscle cell mass, and mortality (P < 10). These results are in agreement with the existence of hepatic dysfunction for protein synthesis (1) and increased gluconeogenesis and lipogenesis in severely injured and septic patients (4), and suggest that these patients cannot well utilize fat as caloric source.
(P
L
Thomas, D. Robert,
M.D. M.D.
Downloaded from https://academic.oup.com/ajcn/article-abstract/32/3/510/4692008 by McMaster University Library user on 04 February 2019
D.
2. SoMooYI,
Dear
S.,
R.-J.
A.
AND
53:6, 1970.
ited by H. L. Sipple
Schweiz.
Assoc.
FERNANDEZ-FLORES
A., AOAC
GOETHE,
468, 7.
1. DAKO,
4. Frraso,
D.
KLINE, JOHNSON.
References
3.
EDITOR
LETfERS
M. Gerard,
TO
THE
1. YOUNG, G. A., AND L. H. Gniw.i. Assessment of protein-calorie malnutrition in surgical patients from
Dear
mortality
in United
1301,
States
1977.
and vitamin
C
Sir:
In the May 1978 issue the editorial (1) summarized the reasons for a realistic optimism about the possibility of coronary heart disease being influenced through changes in the diet Over the past 12 years, a striking decline in coronary mortality rate has been noted in the United States, particularly in the lower age groups (Fig. 1). Simultaneously, DEATH 2 600
30:
RATE!
105
there has been a shift in American dietary habits, involving a decreased consumption of cholesterol and saturated fats and an increased consumption of polyunsaturated fats. Walker (2) assumes these nutritional changes, alongside a lower consumption of tobacco products, a better control of hypertension, coronary care units, exercise programs, and
POPULATION
(lb.
-
io6 20
-
AICORSATE PRODUCTION
2400
15
2 200
10
CORONARY \MORTALITY
2 000
1 800
‘5
-0
-
1958
FIG. production
Census
1962
1966
1970
1. Age adjusted (35 to 74 years) death rate from ischemic of ascorbic acid during the past 20 years in United States. of Manufacturers, United States Department of Commerce.)
1974
YEARS
heart disease per 100,000 population (Sources: Vital Statistics of United
and States
Downloaded from https://academic.oup.com/ajcn/article-abstract/32/3/510/4692008 by McMaster University Library user on 04 February 2019
References
of coronary
511
plasma proteins and anthropometric measurements. Am. J. Clin. Nutr. 31: 429, 1978. 2. HARVEY, K. B., J. A. Ruooinito, C. S. REGAN, B. R. BISTRIAN AND G. L. BLACKBURN. Hospital morbidity-mortality risk factors using nutritional assessment. Am. J. Clin. Nutr. 31: 703, 1978 (abstr.). 3. B.nc-NwTo, M., G. B. Spuan, H. LOTERO, AND M. G. MAKSUD. Body composition in chronic undernutrition. Am. J. Clin. Nutr. 31: 23, 1978. 4. LONG C. L. Energy balance and carbohydrate metabolism in infection and sepsis. Am. J. Clin. Nutr.
M.D.
Service d’Assistance Respiratoire et Reanimation M#{233}dicale Pr. A. Bertoye, Hopital de la Croix Rousse, 69317 Lyon, Cedex 1 France
Decline
EDITOR
