Larry H. Bernstein

Prealbumin in nutrition evaluation

We compressed 16 test-pattern classes of albumin (ALB), cholesterol (CHOL), and total protein (TPR) in 545 chemistry profiles to 4 classes by converting decision values to a number code to separate malnourished (1 or 2) from nonmalnourished (NM) (0) patients, using as cutoff values for nonmalnourished (0), mild (1), and moderate (2): ALB 35, 27 g/L; TPR 63, 53 g/L; CHOL 3.9, 2.8 mmol/L; and BUN 9.3, 3.6 mmol/L. The BUN was found to have too low an S-value to make a contribution to the compressed classification. The cutoff values for classifying the data were assigned prior to statistical analysis, after examining information in the structured data. The data was obtained by a natural experiment in which the test profiles routinely done by the laboratory were randomly extracted. The analysis identifies the values for the variables used that best classify the data and are not dependent on distributional assumptions. The data were converted to 0, 1, or 2 as outcomes, to create a ternary truth table (each row is nnnn, the n value is 0 to 2). This allows for 3(4) (81) possible patterns, without the inclusion of prealbumin (PAB). The emerging system has much fewer patterns in the information-rich truth table formed (a purposeful, far from random, event). We added PAB, coded, and examined the data for 129 patients. The classes are a compressed truth table of n-coded patients with outcomes of 0, 1, or 2 with protein-energy malnutrition (PEM) increasing from an all-0 to all-2 pattern. Pattern class (F = 154), PAB (F = 35), ALB (F = 56), and CHOL (F = 18) were different across PEM class and predicted PEM class (R2 = 0.7864, F = 119, p < E-5). Kruskal-Wallis analysis of class by ranks was significant for pattern class (1E-18), PAB (6.1E-15), ALB (1E-16), CHOL (9E-10), and TPR (5.3E-13). The medians and standard error (SEM) for PAB, ALB, and CHOL of all four PABCLASSES (NM, mild, moderate, severe) are: PAB = 209, 8.7; 159, 9.3; 137, 10.4; 72, 11.1 mg/L, ALB = 36, 0.7; 30.5, 0.8; 25.0, 0.8; 24.5, 0.8 g/L; CHOL = 4.43, 0.17; 4.04, 0.20; 3.11, 0.21; 2.54, 0.22 mmol/L. PAB and CHOL values show the effect of nutrition support on PAB and CHOL in PEM. Moderately malnourished patients receiving nutrition support have PAB values in the normal range at 137 mg/L and at 159 mg/L when the ALB is at 25 g/L or at 30.5 g/L.

Prediction of respiratory distress syndrome using the Abbott FLM-II amniotic fluid assay.

BACKGROUND Most laboratories using the Abbott FLM-II assay for assessing fetal lung maturity follow the manufacturers recommendations for interpreting the surfactant to albumin ratio (S/A). Thus, values >55 mg/g are considered mature and values <40 mg/g, immature-leaving a wide range of indeterminate values. Little data is available to assist the clinician in interpreting values between 40 and 55 mg/g. The goal of this study was to determine decision levels that would more clearly identify risk for RDS based on S/A results. METHODS Respiratory distress syndrome was identified based on medical record review in 46 infants (born at six hospitals), who had S/A measurements on amniotic fluid within 72 h of delivery. An additional 257 women, who had had the S/A test requested but had non-RDS infants, were also identified for this study. The probability of RDS was calculated based on S/A values and on gestational age. Odds ratios were computed for different S/A ratios and different gestational ages. RESULTS Probability of RDS increased with decreasing S/A and decreasing gestational age. At gestational age >36 weeks, the probability of developing RDS ranged from 1% at S/A>44 mg/g to 39% at S/A</=20 mg/g. At gestational age <34, the probability of developing RDS ranged from 14% at S/A>44 mg/g to 92% at S/A</=20 mg/g. CONCLUSIONS We report a risk-based approach for the clinical interpretation of the results of Abbott FLM-II assays based on a broad range of S/A values and gestational ages.

Immunoradiometric assay of CA 125 in effusions comparison with carcinoembryonic antigen

The levels of CA 125 antigen were measured in 167 effusions from 150 patients using radioimmunoassay, and the results compared with the levels of carcinoembryonic antigen (CEA) in the fluids. This study was carried out to test a hypothesis that measuring the combined levels of selected tumor associated antigens in effusions could predict the primary source of malignancy. The results indicate that an elevated fluid CA 125 level (>14,000 U/ml‐68,000 U/ml) and a negative fluid CEA level (<5 ng/ml) is suggestive of serous and endometrioid carcinoma of ovary, and adenocarcinoma of the endometrium and fallopian tube. Alternatively, an elevated fluid CEA level (14 ng/ml‐600 ng/ml) and a negative CA 125 level (20–5000 U/ml) is seen in metastatic carcinomas of breast, lung, gastrointestinal tract, and mucinous cystadenocarcinoma. Lymphomas, melanomas, and benign effusions are negative for both antigens. The combined use of CEA and CA 125 antigen in fluids is useful in the differential diagnosis of adenocarcinoma of unknown primary. Cancer 59:218–222, 1987.

An Acuity Based Clinical Nutrition Staffing Model Improves Acute Care Clinical Effectiveness and Maintains Program Viability in a Managed Care Environment

Abstract An acuity based clinical nutrition staffing model was developed at a 395-bed, community hospital. The model allowed for the delivery of timely, appropriate, and frequent medical nutrition therapy needed to optimize patient outcomes and reduce the cost of care for patients at high risk for malnutrition. This approach to nutrition care contributed to the organizations strategic clinical effectiveness initiative. The process of identifying high risk for malnutrition and providing nutrition care services included a method of systematic capture of data about the acuity of the patient population and level of care needed. This data were used to determine the clinical staffing required for initial and follow-up interventions based on predictable service intensity. The requirement for clinical dietitian staffing is at a ratio of 3.5 follow-up to initial visits per patient at high risk for malnutrition which, is 17% of the adult hospital population. Patient acuity was based on major and minor complications, functional status on admission, and albumin depression on admission (R 2 =0.8862). These predictors, along with medical diagnostic class, level of nutrition care and number (♯) of dietitian interventions had a strong association with LOS (R 2 =0.6174)(patient acuity chi 2 =29.7; level of nutrition care chi 2 =57.4; ♯ of interventions chi 2 =306.4, p

An informational approach to likelihood of malnutrition.

Unidentified protein-energy malnutrition (PEM) is associated with comorbidities and increased hospital length of stay. We developed a model for identifying severe metabolic stress and likelihood of malnutrition using test patterns of albumin (ALB), cholesterol (CHOL), and total protein (TP) in 545 chemistry profiles. Pattern classes were derived by converting decision values to a number code using cutoff values for nonmalnourished (0), moderate (1), and severe (2) of: ALB 35, 27 g/L; TP 63, 53 g/L; and CHOL 3.9, 2.8 mumol/L. Patterns defined by combinations of normal and abnormal laboratory results had decreased the likelihood of PEM from an all-2 to all-0 pattern. They were compressed to four final classes. ALB (F = 170), CHOL (F = 21), and TP (F = 5.6) predicted PEM class (r2 = 0.806, F = 214; P < E-6), but pattern class was the best predictor (r2 = 0.900, F = 1200, P < E-10). Kruskal-Wallis analysis of class by ranks was significant for pattern class (E-18), ALB (E-18), CHOL (E-14), and TP (2E-16). The means and SEM for tests in three PEM classes (mild, moderate, severe) were: ALB-35.7, 0.8; 30.9, 0.5; 24.2, 0.5 g/L; CHOL-3.93, 0.26; 3.98, 0.16; 3.03, 0.18 mumol/L, and TP-68.8, 1.7; 60.0, 1.0; 50.6, 1.1 g/L. We classified patients at risk of malnutrition using truth table comprehension. The pattern classes formed by the tests are a better classifier than the tests themselves.

The Application of CQI Principles to Services:: The Case for Hospitalized Patients at Risk for Malnutrition

Abstract A multidisciplinary, malnutrition treatment program was developed and implemented at a 395-bed, community hospital to reduce delays in initiating and achieving a therapeutic level of nutrition care for patients identified to have a significant risk for malnutrition (13% of the adult patient population). The project contained a continuous quality improvement (CQI) plan that assessed the effectiveness of the treatment program to achieve these goals. An outcome study was designed to evaluate the impact of nutrition interventions on patient recovery and cost of care. To quantify the impact, the study compared the patient population at high risk for malnutrition both before and after implementation of a malnutrition clinical pathway. Albumin, functional status, and the use of nutrition support (enteral or parenteral) were the variables used to predict outcomes such as length of stay (LOS), discharge disposition and the number of complications. The study required the data sets to be examined and normalized for severity of illness using scaled values of serum albumin. The scaling produced three classes which identified the study population by serum albumin value: (1) >2.7g/dl, (2) 2.3-2.7g/dl, and (3)

What Constitutes a Laboratory Quality Monitoring Program

A program of quality assurance for the laboratory is described that addresses both process and outcome validation. It begins by an analyses of the workload processing sequence, i.e., ordering, collecting, trans porting, analyzing specimens, reporting tests results in a timely manner, and reduction of instrument, staff, and system-related errors in the generation of laboratory information. The observable medical staff requirements for effective utilization of the labora tory is the basis for defining outcome measures.