Kjell Hellström

Outcome of protein-energy malnutrition in elderly medical patients

PURPOSE To assess the impact of protein-energy malnutrition (PEM) on mortality and the long-term variations in the nutritional status of subjects admitted as emergency cases in a 9-month prospective follow-up study. PATIENTS AND METHODS The study comprised 205 patients without cancer aged 75 years (+/- 1). Malnourished subjects were identified as having at least three nutritional variables (which included weight index, triceps skinfold thickness, arm muscle circumference, serum albumin, and delayed cutaneous hypersensitivity reaction) below the reference range. RESULTS The mortality was 44% in the 41 malnourished patients and 18% in the 164 nonmalnourished subjects (P < 0.001). Among malnourished patients with congestive heart failure the mortality was 80%. Multivariate analysis revealed congestive heart failure, multiple organ disease, and PEM to be predictors of death. When the interaction between these disorders and PEM was considered, the prognostic relevance of PEM remained among the patients with cardiac congestion. Of the surviving subjects, 125 were reexamined after 9 months. At admission, more than half of the patients had displayed elevated levels of serum acid glycoprotein as evidence of an ongoing inflammation and subnormal recordings for serum albumin and delayed cutaneous hypersensitivity. At the reexamination, these variables had normalized in the well-nourished patients and in the 9 patients who had recovered from PEM, but remained unchanged in the 10 patients with persistent PEM. The latter patients were severely malnourished, commonly infected, and often hospitalized. CONCLUSIONS Protein-energy malnutrition in noncancer medical patients is associated with an excess mortality in those with congestive heart failure. Improvement of PEM is accompanied by a decline in inflammatory activity.

Nutritional status and performance capacity in internal medical patients

The nutritional status (3 anthropometric records, serum albumin and delayed cutaneous hypersensitivity (DCH)), recent weight loss, dynamometric capacity and mood were assessed in 205 recently admitted non-cancer internal medical patients. 20% of the subjects were classified as malnourished (3 of the 5 nutritional variables below the reference range). The occurrence of malnutrition was higher (1/3) in multiple organ dysfunction or chronic respiratory disease. In order to reduce the risk of overestimating malnutrition, the data for serum albumin and DCH were omitted when they appeared to be influenced by non-nutritional factors. Disease duration >2 years, old age and multiple organ dysfunction were independently related to malnutrition. Serum albumin correlated more strongly with the acute phase reactant, serum acid glycoprotein (r = 0.33, P < 0.001) than with the anthropometric variables (r < 0.24). Recalled recent weight loss >5% was found in 34% of the malnourished subjects. Malnourished, in comparison to well nourished patients, exhibited reduced (p < 0.05) recordings for hand grip strength, peak expiratory flow and time of ambulation. Depressive tendencies were seen in malnourished women (p < 0.05).

Nutritional Status in Recently Hospitalized and Free-Living Elderly Subjects

Weight index (WI), triceps skinfold (TSF), serum albumin and delayed cutaneous hypersensitivity reaction (DCH) were measured in 96 hospitalized elderly patients and in 100 age- and sex-matched free-living controls. Using the 10th percentile of data obtained in the controls, WI was subnormal in 35% of the patients. Corresponding findings with regard to TSF, serum albumin and DCH were 32, 50 and 31%, respectively. The findings in the controls were mainly within the range observed in national reference groups. Patients were considered malnourished if they showed at least two variables (of which one was required to be anthropometric) below the cut-off limits used. When these limits were set at the 10th percentile of the recordings in the controls, the occurrence of undernutrition in the patients was 39%. By using the 5th percentile the corresponding figure was 16%. Malnourishment was most pronounced in patients with multiple organ disease and malignancy. It is concluded that low nutritional indices are a common occurrence in elderly subjects admitted to hospital and that undernutrition is related to the nature of the disease rather than age.

Identification of two neutral metabolites of stigmasterol found in human feces: Bile acids and sterols 162

Abstract Feces from human subjects given stigmasterol were found to contain 24β-ethyl-5β-cholest-22-en-3β-ol and 24β-ethyl-5β-cholest-22-en-3-one. These compounds were identified by GLC and mass spectrometric analysis

The Formation of Bile Acids in Patients with Three Types of Hyperlipoproteinemia

Abstract. 14C‐cholic and 3H‐chenodeoxycholic acid were administered orally to patients who were given a standardized diet of the regular type. The total formation of bile acids and the combined cholic and chenodeoxycholic pool in 8 patients with hyper‐β‐lipoproteinaemia (hyperlipoproteinaemia type II) were significantly lower than those recorded for 10 patients with hyperpre‐β‐lipoproteinaemia (hyperlipoproteinaemia type IV) and for 3 patients with combined hyperpre‐β‐lipoproteineamia and hyperchylemicronaemia (hyperlipoproteinaemia type V). These differences were exclusively related to variations of the pool size and turnover of cholic acid. — When compared to a younger group of healthy subjects with a somewhat higher caloric intake, the formation of cholic acid was subnormal in type II and markedly elevated in type TV and V.

The Effect of Cholestyramine on the Elimination of Cholesterol as Bile Acids in Patients with Hyperlipoproteinaemia Type II and IV

Abstract. The turnover of 14C‐oholic acid and 3H‐chenodeoxycholic acid was studied in hyperlipaemic patients before and during treatment with cholestyramine. – In five female patients with hyperlipoproteinaemia type Ila the pool size and turnover of cholic acid as well as the total formation of bile acids were significantly lower than in female normolipae‐mic controls. During treatment with cholestyramine, cholic acid synthesis rose 4–18 fold and the turnover of chenodeoxy‐cholic acid increased about twice. In three of the patients these changes were associated with a normalization of the serum cholesterol levels. Mainly due to the high turnover of cholic acid, total bile acid synthesis was above the normal range in the five male patients with hyperlipoproteinaemia type IV. During treatment with cholestyramine, the serum lipids and cholic acid formation remained unchanged but the turnover of chenodeoxycholic acid increased by a factor of about two. This resulted in a decrease of the abnormally high initial ratio between the formation of cholic acid and chenodeoxycholic acid. The unequal response to cholest‐ramine treatment is taken to be a further indication that hyperlipoproteinaemia type II and type IV are different entities of disease affecting cholesterol and bile acid metabolism.

GALLBLADDER DISEASE IN HYPERLIPOPROTEINÆMIA

Abstract The occurrence of gallbladder disease (G.B.D.) (cholelithiasis, cholecystitis, cholecystectomy) was examined in patients consecutively admitted because of hyperlipoproteinœmia types IIa and IV. Altogether 37 of the 52 patients with the type IIa pattern were women, whereas 56 of the 75 subjects with hyperlipoproteinaemia type IV were men. The overall incidence of G.B.D. in the group with the type IIa was 13% in the males and 22% in the females; the corresponding figures in type IV were 41% and 68 %, respectively. The findings in the major age-group (40-59 years) were compared with those from three necropsy series covering subjects of the same age. The incidence of G.B.D. was then found to be normal in type IIa but abnormally high in type IV. Patients with and without G.B.D. did not differ with regard to body-weight or glucose tolerance.

Prevalence of gallbladder disease in hyperlipoproteinemia

An analysis of the occurrence of gallbladder disease (ie, cholelithiasis, cholecystitis, cholecystectomy) in 210 consecutive patients with primary hyperlipoproteinemia showed that the prevalence of gallbladder disease was 8%, 18%, and 42% in males with type IIa, IIb, and IV hyperlipoproteinemia, and 22%, 48%, and 72% in the corresponding groups of females. The 40–59-year-old patients were compared to three necropsy series from Malmö, Sweden. The occurrence of gallbladder disease was within normal limits in type IIa and abnormally high in type IV hyperlipoproteinemia. There were no differences with regard to age, body weight, glucose intolerance, or ischemic heart disease between type IV patients with and without GBD. It is suggested that certain forms of disturbances of lipoprotein metabolism are associated with an increased risk for development of gallbladder disease.

Feedback regulation of bile acid formation in man

Abstract 3 H-chenodeoxycholic acid was given orally to seven normolipemic subjects, five of whom also received 14 C-cholic acid. The patients were given a standardized diet of the regular type. This procedure was repeated when the subjects had been administered 0.5–1 g nonradioactive cholic acid for 3 wk. During treatment with cholic acid, the pool size of this acid became 2–5 times enlarged, and the concentrations of cholic acid and deoxycholic acid in duodenal bile increased markedly in comparison with that of chenodeoxycholic acid. The pool size and turnover of chenodeoxycholic acid decreased in all subjects on the average by about 50%. It was concluded that this effect was achieved by a feedback control triggered by the administration of cholic acid.

Muscle biopsy studies in patients with moderate liver cirrhosis with special reference to energy-rich phosphagens and electrolytes.

Energy-rich phosphagens, water, and electrolytes were determined in skeletal muscle biopsy specimens from five elderly women and five elderly men with moderate liver cirrhosis. At the time of the study the patients were in their usual condition without evidence of deterioration of the disease. When compared with findings in apparently healthy subjects of similar age, the distribution and level of electrolytes and water were within normal limits in the female patients. The male patients showed increased contents of muscle water, and Mg2+ was reduced. The values calculated for the intracellular concentration of K+ and Mg2+ were also below normal. The pattern and levels of energy-rich phosphagens were abnormal in all but one female patient. As a general finding, ATP and the total level of adenine nucleotides were markedly reduced, as were phosphocreatine, the ATP/ADP ratio, and the energy charge potential.