Daniel Ferreira da Cunha

Hyponatremia in Acute-Phase Response Syndrome Patients in General Surgical Wards

Background: In surgical patients, hypoalbuminemia may occur as a component of acute-phase response (APR) syndrome, which we hypothesized could decrease serum sodium levels. Aim: To compare the frequency of hyponatremia in adult surgical inpatients with or without APR syndrome. Methods: All the simultaneous plasma sodium and albumin results (n = 168), obtained from adults in surgical wards and corresponding to a 6-month period, were searched in the hospital mainframe. Other relevant laboratory and clinical data were also registered. APR was ascertained by the presence of major physical trauma, surgery or infection, plus hypoalbuminemia (serum albumin <3.5 g/dl) and neutrophil left shift (≥7% of band count) associated with peripheral leukopenia (white blood cells <4,000/mm3) or leukocytosis (WBC >9,000/mm3). Hyponatremia was defined by serum sodium concentration <135 mEq/l. Results: APR-positive patients (n = 113) had lower blood hemoglobin (10.92 ± 2.18 vs. 13.53 ± 2.30 g/dl), and serum albumin levels (median, range: 2.8, 1.9–3.4 vs. 3.7, 3.5–4.2 g/dl) than APR-negative (n = 55) ones, the same occurring in relation to antibiotics (54.8 vs. 10.9%) and intravenous 5% dextrose in water (55.7 vs. 20.0%) or isotonic saline (46.0 vs. 9.1%) infusion. The hyponatremia frequency was higher among APR-positive patients (31.0 vs. 10.9%). Conclusion: The higher percentage of hyponatremia among APR-positive patients could be attributed to decreased serum albumin levels associated with APR.Background: In surgical patients, hypoalbuminemia may occur as a component of acute-phase response (APR) syndrome, which we hypothesized could decrease serum sodium levels.

Iron status, malnutrition and acute phase response in HIV-positive patients

Nutritional status and some iron metabolism parameters of acute phase response (APR) positive and APR-negative AIDS patients were studied. Twenty-nine AIDS patients were submitted to 24h food intake recall, anthropometry, and albumin, C-reactive protein (CRP), hemoglobin, ferritin, and total iron binding capacity (TIBC) measurements. Infection plus serum CRP > 7 mg/dl were criteria for APR presence. Protein-energy malnutrition (PEM) was ascertained by body mass index (BMI) lower than 18.5 kg/m2 and height-creatinine index (HCI < 70%). PEM (77.8 vs 40%) and pulmonary tuberculosis (44. 4 vs 9.5%) were more frequent in APR-positive patients, which also had lower serum albumin (3.7 +/- 0.9 vs 4.3 +/- 0.9 g/dl), TIBC (165. 8 +/- 110.7 vs 265.9 +/- 74.6 mg/dl) and blood hemoglobin (10.5 +/- 1. 8 vs 12.6 +/- 2.3g/dl). Iron intake was similar between groups; however, serum ferritin levels (median, range) were higher among APR-positive (568, 45.3-1814 vs 246, 18.4-1577 ng/ml) patients. HIV-positive adults with systemic response to invading pathogens showed worse nutritional status than those APR-negative. In APR-positive AIDS patients, anemia appears to be unrelated to recent iron intake.

Hypophosphatemia in Acute-Phase Response Syndrome Patients

BACKGROUND Hypophosphatemia is common in acutely ill patients and possibly may occur in the acute-phase response syndrome (APR), secondary to hyperglycemia and shifts of extracellular phosphorus into cells. AIM To compare the frequency of hypophosphatemia in patients with or without APR. METHODS All plasma phosphorus results (n = 822) corresponding to a 6-month period were searched using an university hospital mainframe. Relevant laboratory and clinical details were also registered. All cases of alcohol withdrawal, diabetic ketoacidosis, parenteral nutrition, and chronic respiratory alkalosis and patients receiving antacids or intravenous dextrose (5%) in water at a rate higher than 50 g glucose/day were excluded. APR was defined on the basis of severe trauma or infection and at least two of the following: fever, leukopenia (WBC <5,000/mm3), or leukocytosis (WBC >9,000/mm3). Hypophosphatemia was defined as a serum phosphorus concentration <2.0 mg/dl. RESULTS A total of 227 patients were studied. Thirty-five (15.4%) patients fulfilled the criteria for APR. Hypophosphatemia was observed in 11.4% of the APR-positive patients, in contrast to 0.5% in the APR-negative group. Hyperglycemia was more common in APR-positive patients (60.0 vs. 36. 8%). CONCLUSION Our results suggest that hypophosphatemia may be attributed to increased serum glucose levels secondary to tissue injury and infection in APR-positive patients.Background: Hypophosphatemia is common in acutely ill patients and possibly may occur in the acute-phase response syndrome (APR), secondary to hyperglycemia and shifts of extracellular phosphorus into cells. Aim: To compare the frequency of hypophosphatemia in patients with or without APR. Methods: All plasma phosphorus results (n = 822) corresponding to a 6month period were searched using an university hospital mainframe. Relevant laboratory and clinical details were also registered. All cases of alcohol withdrawal, diabetic ketoacidosis, parenteral nutrition, and chronic respiratory alkalosis and patients receiving antacids or intravenous dextrose (5%) in water at a rate higher than 50 g glucose/day were excluded. APR was defined on the basis of severe trauma or infection and at least two of the following: fever, leukopenia (WBC ! 5,000/mm3), or leukocytosis (WBC 19,000/mm3). Hypophosphatemia was defined as a serum phosphorus concentration !2.0 mg/dl. Results: A total of 227 patients were studied. Thirty-five (15.4%) patients fulfilled the criteria for APR. Hypophosphatemia was observed in 11.4% of the APR-positive patients, in contrast to 0.5% in the APR-negative group. Hyperglycemia was more common in APR-positive patients (60.0 vs. 36.8%). Conclusion: Our results suggest that hypophosphatemia may be attributed to increased serum glucose levels secondary to tissue injury and infection in APR-positive patients. OOOOOOOOOOOOOOOOOOOOOO Received: June 23, 1997 Accepted: November 12, 1997 Daniel Ferreira da Cunha, MD Nutrition Division, Department of Internal Medicine Medical School of Uberaba, Getúlio Guaritá s/n 38025-180 Uberaba, MG (Brazil) Tel. +55 (034) 318 5335, Fax +55 (034) 312 1487, E-Mail dfcnutro@mednet.com.br ABC Fax + 41 61 306 12 34 E-Mail karger@karger.ch www.karger.com

Estudo morfométrico do miocárdio em adultos com subnutrição protéico-energética

PURPOSE: To compare cardiac muscle cells width and cardiomyocyte lipofuscin pigment presence between malnourished and non-malnourished necropsied adults. METHODS: Out of 315 necropsy protocols of adults randomly chosen, those with edema, ascitis, systemic arterial hypertension, chronic liver disease, and heart disease were excluded. Malnutrition was defined by body mass index (BMI) <17kg/m2. Cardiomyocytes morphometry study and lipofuscin pigment counts were performed. RESULTS: Malnourished (n=8) and controls (n=4), respectively, showed statistical differences in relation to BMI (14.86±1.13 vs 22.02±0.9kg/m2), heart weight/body weight ratio (0.68±0.09 vs 0.54±0.07%), cardiomyocytes width (10.91±0.77 vs 12.90±1.82µm) and lipofuscin pigment presence (39.1 vs 54.4%). CONCLUSION: When compared with controls, necropsied malnourished adults showed decreased myocardial fibers diameters and lower lipofuscin pigment presence. These findings might reflect altered metabolism, and would be associated with harmful clinical effects in terminally ill patients.

Frequency of metabolic syndrome and the food intake patterns in adults living in a rural area of Brazil.

INTRODUCTION Metabolic syndrome (MetS), a risk factor for atherosclerosis and coronary heart disease, is related to an inadequate food intake pattern. Its incidence is increasing among Brazilian adults, including those living in rural areas. Our aim was not only to describe the frequency of MetS in adults with or without MetS but also to compare their food intake pattern as assessed by the healthy eating index (HEI) and serum albumin and C reactive protein (CRP) levels. METHODS Men and women (n = 246) living in a small village in Brazil were included. MetS was characterized according to the adult treatment panel (ATP III) criteria. Groups were compared by chi-square, student t or Mann-Whitney tests. RESULTS MetS was diagnosed in 15.4% of the cases. The MetS group showed higher CRP (1.8±1.2 vs. 1.0±0.9 mg/dl) and lower albumin (4.3±0.3 vs. 4.4±0.3 g/dl) serum levels compared to the control group. Additionally, the MetS group showed lower scores (median[range]) in the HEI compared to the control group (53.5[31.2-78.1] vs 58[29.7-89.5], respectively). The MetS group also had decreased scores for total fat and daily variety of food intake. CONCLUSIONS The results suggest that adults with MetS displayed chronic mild inflammation and a poorer food intake pattern than the control group.

PROLONGED QTC INTERVALS ON THE ELECTROCARDIOGRAMS OF HOSPITALIZED MALNOURISHED ADULTS

We investigated whether hospitalized malnourished adults would have longer QTc intervals on their electrocardiograms (ECGs) than non-malnourished adults. Seventy-five consecutive adults hospitalized in the Internal Medicine wards of our teaching hospital were prospectively studied. Main diagnoses, anthropometry, including body mass index (kg/m(2)), ECGs, and simultaneous serum levels of sodium, potassium, magnesium, phosphorus, and calcium were recorded. All QT intervals on ECGs were measured in a semiautomatic image analysis system; and QTc intervals were determined with the Bazett formula. Protein-energy malnutrition (PEM) was diagnosed with body mass index below 18.5 kg/m(2). There was no statistical difference between malnourished (n = 30) and non-malnourished (n = 45) with regard to age (40.7 +/- 18.9 y versus 41.4 +/- 16.2 y), male predominance (66.7% versus 80%), or associated diagnoses. Compared with non-malnourished, malnourished patients had higher percentages of positive C-reactive protein (66.7 versus 23.8%), lower serum levels of albumin (2.51 +/- 0.89 g/dL versus 3.41 +/- 0.74 g/dL) and potassium (3.64 +/- 0.65 mEq/L versus 4.12 +/- 0.65 mEq/L), and increased QTc lengths on ECGs (0.423 +/- 0.033 ms versus 0.396 +/- 0.031 ms). Malnourished adults hospitalized in general clinical wards are more likely to have longer QTc intervals on their ECGs, a phenomenon possibly linked to malnutrition and associated electrolyte disturbances.

Avaliação dos níveis séricos das vitaminas A, E, C e B2, de carotenóides e zinco, em idosos hospitalizados

Serum levels of carotenoids, zinc and vitamins A, E, C and B2 were measured in al (n = 202) the elderly patients hospitalized in different wards of the hospital studied from February 1986 to October 1988. The study was conducted on 130 men and 72 women with a mean age of 67.8 years (range: 60 to 88 years). The percentage of nutritional deficiency was 59.5% for zinc, 56.5% for vitamin C, 34.5% for vitamin B2, 25.9% for vitamin E, 13.2% for vitamin A, and 6.8% for carotenoids. Elderly patients with leucoses, megaesophagus, chronic obstructive pulmonary disease, and congestive heart failure represent a group with a high prevalence of deficiency both of zinc and of the vitamins under study. These results show the importance of detecting deficiencies of these micronutrients and provide a basis for a more rational approach to the treatment of elderly patients.Serum levels of carotenoids, zinc and vitamins A, E, C and B2 were measured in al (n = 202) the elderly patients hospitalized in different wards of the hospital studied from February 1986 to October 1988. The study was conducted on 130 men and 72 women with a mean age of 67.8 years (range: 60 to 88 years). The percentage of nutritional deficiency was 59.5% for zinc, 56.5% for vitamin C, 34.5% for vitamin B2, 25.9% for vitamin E, 13.2% for vitamin A, and 6.8% for carotenoids. Elderly patients with leucoses, megaesophagus, chronic obstructive pulmonary disease, and congestive heart failure represent a group with a high prevalence of deficiency both of zinc and of the vitamins under study. These results show the importance of detecting deficiencies of these micronutrients and provide a basis for a more rational approach to the treatment of elderly patients.Foram verificados os niveis sericos de zinco, carotenoides e vitaminas A, E, C, B2 em todos os idosos (n = 202) internados nas diversas enfermarias do hospital estudado, no periodo de fevereiro de 1986 a outubro de 1988. Foram estudados 130 homens e 72 mulheres que apresentaram media de idade de 67,8 anos, com variacao entre 60 a 88. A percentagem de niveis sericos deficitarios foi de 59,5 para o zinco, 56,5% para a vitamina C, 34,5% para a vitamina B2, 26% para a vitamina E, 13,2% para a vitamina A e 6,8% para os carotenoides. Os idosos portadores de leucoses, magaesofogo, doenca pulmonar obstrutiva cronica e insuficiencia cardiaca congestiva constituiram-se no grupo de pacientes com grande prevalencia de estado deficitario de zinco e das vitaminas estudadas, resultados que mostram a importância de se investigar as deficiencias desses micronutrientes e dao subsidios para a abordagem terapeutica mais racional do paciente idoso internado.

Implantação de um sistema de telecardiologia em Minas Gerais: projeto Minas Telecardio

FUNDAMENTO: Embora as doencas cardiovasculares sejam a maior causa de morbimortalidade em todo Brasil, o acesso das populacoes de cidades pequenas a eletrocardiografia e a avaliacao cardiologica e limitado. O uso da telecardiologia para facilitar o acesso da populacao de municipios remotos a eletrocardiografia e a segunda opiniao em cardiologia e promissora, entretanto nao foi formalmente testada. OBJETIVO: Avaliar a viabilidade de se implantar o sistema publico de telecardiologia de baixo custo em pequenas cidades brasileiras. METODOS: Foram selecionadas 82 cidades do Estado de Minas Gerais, com populacao 70% de cobertura pelo Programa Saude da Familia (PSF), com interesse do gestor e acesso pela internet. Em cada municipio foi instalado um aparelho de eletrocardiografo (ECG) digital, com subsequente treinamento da equipe. A implantacao foi coordenada pelo HC/UFMG, em conjunto com outros quatro hospitais universitarios mineiros (UFU, UFTM, UFJF e UNIMONTES). Os ECGs foram realizados nos municipios e enviados pela internet para analise imediata em plantao de telecardiologia. Realizaram-se discussoes de casos medicos on-line e off-line e cursos de atualizacao via web. RESULTADOS: No periodo de implantacao, foram treinados 253 profissionais de saude. De julho de 2006 a novembro de 2008, o projeto atendeu 42.664 pacientes, realizando 62.865 ECGs. Foram efetuados 2.148 atendimentos de urgencia e 420 teleconsultorias. A avaliacao intermediaria apontou boa aceitacao da tecnologia implantada e uma diminuicao de 70% de encaminhamentos de pacientes para outros centros de referencia. CONCLUSAO: E factivel a utilizacao de recursos habituais de informatica para facilitar o acesso de populacoes de cidades pequenas a eletrocardiografia e avaliacao cardiologica especializada.BACKGROUND Although cardiovascular diseases are the main cause of morbimortality in Brazil, the access of small-town populations to electrocardiography and cardiology assessment is limited. The use of telecardiology to assist the access of distant towns to electrocardiography and a second opinion in cardiology is promising; however, it has not been formally assessed. OBJECTIVE To assess the feasibility of implementing a low-cost public telecardiology system in small Brazilian towns. METHODS A total of 82 towns in the state of Minas Gerais, with a population < 10,500 inhabitants, presenting > 70% coverage by the Family Health Program (Programa Saude da Familia-PSF), local government compliance and internet access, were selected. Each town was supplied with digital electrocardiography (ECG) device and a team was trained. The implementation was coordinated by HC/UFMG, together with four university hospitals in the state of Minas Gerais (UFU, UFTM, UFJF and UNIMONTES). The ECG assessments were carried out in the towns and sent through the Internet for prompt analysis by an on-duty telecardiology team. Online and offline discussions on the medical cases were carried out through the Internet, as well as refreshment courses. RESULTS During the implementation period, a total of 253 health professionals were trained. From July 2006 to November 2008, the project assisted 42,664 patients, with a total of 62,865 ECG assessments being performed. A total of 2,148 emergency cases were treated, as well as 420 teleconsultations. The intermediate evaluation showed good acceptance of the implemented technology and a 70% decrease in patient referrals to other reference centers. CONCLUSION The use of the customary resources in informatics to assist the access of small-town populations to electrocardiography and specialized cardiology assessment is feasible.

Nutritional assessment of vitamin E in malnourished patients with AIDS

Malnourished patients with acquired immunodeficiency syndrome (AIDS) may have low serum levels and reduced intake of alpha-tocopherol, mainly in the presence of acute-phase response. The aims of this study were to compare intake and serum levels of alpha-tocopherol between malnourished (MN) and non-malnourished (NMN) AIDS patients and to correlate alpha-tocopherol intake and serum levels. Undernutrition was defined as having a body mass index lower than 18. 5 kg/m(2) or a height-creatinine index lower than 70%. A semiquantitative food frequency questionnaire assessed alpha-tocopherol intake. High-performance liquid chromatography determined vitamin serum levels. The patients were divided into MN (n = 14) and NMN (n = 15) groups. There were no statistical differences in relation to clinical findings between MN and NMN, respectively, including moniliasis (7/14 versus 4/15), neurocryptoccocosis and neurotoxoplasmosis (6/14 versus 6/15), pulmonary tuberculosis (4/14 versus 2/15), and fever (1/14 versus 3/15). MN and NMN groups had similar peripheral blood CD(4) levels (111.4+/-87.1 versus 124.4+/-90.9 cells/mm(3)), and both groups had similar and adequate alpha-tocopherol intake (MN = 50.0+/-11.0 versus NMN = 47.2+/-16.5 mg) and serum levels (MN = 17.8+/-7.2 versus NMN = 19.8+/-6.3 micromol/L). Vitamin E intake and serum levels did not show a significant correlation (r = -0.22, P 0.05). Protein-energy nutrition status and acute-phase response were not factors determining vitamin status among AIDS patients.

Pressure sores among malnourished necropsied adults - preliminary data

UNLABELLED Pressure sores are common among bedridden, elderly, or malnourished patients, and may occur in terminal ill patients because of impaired mobility, fecal or urinary incontinence, and decreased healing capacity. The aim of this study was to compare frequency of pressure sores between malnourished and non-malnourished necropsied adults. METHOD All (n = 201) adults (age >/= 18 years) autopsied between 1986 and 1996 at the Teaching Hospital of Triangulo Mineiro Medical School (Uberaba) were eligible for the study. Gender, race, weight, height and main diagnoses were recorded. Ninety-six cases were excluded because of probable body water retention (congestive heart failure, hepatic insufficiency, nephrotic syndrome) or pressure sores secondary to peripheral vascular ischemia. Body mass index (BMI) was used to define malnourished (BMI < 18.5 kg/m2) and non-malnourished (BMI > 18.5kg/m2) groups. RESULTS Except for weight (42.5kg; range: 28-57 vs. 60; 36-134.5kg) and BMI (16.9; range: 12.4-18.5 vs. 22.7; range: 18.5-54.6kg/m2), respectively, there were no statistical differences among 43 malnourished and 62 non-malnourished cases in relation to age (54.9 +/- 20.4 vs. 52.9 +/- 17.9 years), percentage of white persons (74.4 vs. 64.5%), male gender (76.7 vs. 69.3%) and main diagnoses. Five malnourished (11. 6%) and 7 (11.5%) non-malnourished cases had pressure sores (p=0.89). CONCLUSION Pressure sores were equally common findings in necropsied persons with protein-energy malnutrition, as assessed by body mass index.