HOMEPAGE OF AuSPEN

The Australian Society for Parenteral and Enteral Nutrition

This Homepage is being developed by Dr Tom Hartley, who may be contacted at

hartley@southcom.com.au

hartleyt@postoffice.utas.edu.au

Fax +61-3-6231-3145


WARNING

This document contains mathematical expressions and constants which may appear corrupted on some Web Browsers. The divide character used is ACSII 246, multiplication is signified by an asterisk * or is left implicit, and the constant pi is shown as Pi. The chemical amount micro is shown as a lower case u. Superscript numbers are prefixed by a carat ^. The naturally occurring radioactive isotope of potassium is shown as 40^K.

If you intend to use these formulae you should first check the printed version of the Newsletter or the printed version of the source literature.


Newsletter, Jan 1997

NEWS FROM COUNCIL

Over the past four years the journal 'Nutrition' has been the official journal of AuSPEN. Members have received 'Nutrition' as one of the benefits of their subscription to the Society. In 1995, 'Nutrition' underwent a number of important changes including a change in publisher and a change to monthly issues. As a result the cost to the Members of the Society was to increase makedly.

After canvassing opinion from the Membership by way of a questionnaire and at the past three AGMs, it was the concensus of opinion that the Journal was an important benefit of Membership of AuSPEN. Council has worked hard to secure a favourable contract with Elsevier, the publishers of 'Nutrition'. As a result from the start of 1997 Members should receive monthly issues of the Journal. We are fortunate that Baxter have once again agreed to transport and arrange delivery of the Journal to AuSPEN Members.

In this era of political and economic change the Council believes that it is timely to reassess the aims and responsibilities of the Society. To help with this process it has been proposed that a Planning Meeting be conducted in early 1997. We would like to encourage anyone with ideas, suggestions or issues for discussion to contact Margaret Allman or myself.

On behalf of the AuSPEN Council I would like to wish you all a happy and successful 1997.

Dr. Julie Bines President.


CONTACT ADDRESSES

Dr Julie Bines, President of AuSPEN

  • Dept. of Gastroenterology and Clinical Nutrition, Royal Childrenžs Hospital, Melbourne.

  • Ph +61-3-9345-5060. Fax +61-3-9345-6240

  • email gastro@cryptic.rch.unimelb.edu.au

    Dr Margaret Allman, Honorary Secretary of AuSPEN

  • Human Nutrition Unit, Biochemistry Dept.,The University of Sydney, Sydney 2006.

  • Ph +61-2-9351-3758 Fax +61-2-9351-6022

  • email m.allman@biochem.usyd.edu.au

  • NEW NOMINATIONS FOR MEMBERSHIP

                    Jenny Bacon         Diane Chan         Thomas Fong
                    Anne Maree Hurnall  Allison Lauder     Vanessa Carter
                    Narelle Hore        Jan Iggulden       Sue MacDonell
                    Diedre Mathai       Rowena McMenamin   Louise Pryke
                    Lauren Stephens     Mary Wood          Susan Osz
                    Leanne Spratt       Clarissa Wilkes
    

    ERRATA : AWARD WINNERS : 1996

    It was incorrectly reported in the last Newsletter that Alan Spencer was awarded the Bob MacMahon Award. He was in fact awarded an AuSPEN Travel Grant and D J Borovnicar was awarded the Bob MacMahon Award :-

    The Bob MacMahon Award for the Most Original Research Paper was awarded to D J Borovnicar from the Body Composition Laboratory at Monash Medical Centre, for his paper on 'Relationships Between Pulmonary Status, Total Body Nitrogen and Potassium in Children with Cystic Fibrosis'. He and his co-authors R H M Haslam, Julie Bines, D B Stroud, M L Wahlqvist and B J G Strauss described a study of 20 cystic fibrosis patients. 6 of these had no lung disease, 9 had minimal lung disease and 5 had mild lung disease. Total Body Nitrogens were measured by whole body neutron activation and Total Body Potassium was measured by 40^K whole body counting . Both parameters decreased as the degree of lung disease increased but Total Body Nitrogen appeared to decrease proportionately more than Total Body Potassium.


    ORAL NUTRITIONAL SUPPLEMENTS AND HOME ENTERAL NUTRITION FOR ELIGIBLE VETERANS

    Alison Woollacott, Dietitian Lady Davidson Hosptal, NSW

    If you have any elderly patients requiring nutritional supplements or enteral nutrition at home it is worth asking if they have a Department of Veteranžs Affairs (DVA) Health Card : Gold for all Conditions or White for specific conditions.

    Eligibility Gold Card Holders are entitled to nutritional supplements or enteral formula paid for by the DVA. White Card Holders are entitled to a supply of nutritional supplements or enteral formula if they have cancer or the requiremnt is due to a War related disability.

    Supply of Supplements or Enteral Formula

    If you have any queries about eligibility or the procedure to obtain approval, call toll free 1800-552-580 for assistance.

    AUSPEN CONFERENCE 1996 ENTERAL NUTRITION WORKSHOP REPORT

    Susannah King Western Hospital - Footscray

    The pre-conference workshop brought together international and local speakers, presenting on developments in enteral nutrition preparations, new methods for delivering enteral nutrition and the important area of measuring the effectiveness of enteral nut rition.

    Professor Alan Shenkin opened the workshop with a review of trace elements in enteral formulae. In determining requirements for trace elements, both basal requirements and whether the patient's clinical condition increases requirements need to be considered. He highlighted the wide variations in trace element recommendations for healthy people between different countries. Factors which affect absorption of trace elements from enteral nutrition solutions also need to be considered in evaluating solutions. (eg. absorption of Fe^2+ vs Fe^3+ and luminal factors which influence oxidation of Fe^2+).

    Monitoring trace element status of seriously ill patients receiving enteral nutrition is difficult, however, in stable patients plasma measurements may be easier to interpret. Professor Shenkin pointed out that most complete enteral nutrition products contain adequate amounts of all the trace elements required for long term nutritional support. In order to be defined as complete, a product should include zinc, copper, iron, selenium, molybdenum and chromium.

    Kate Cameron from Deakin University presented a review of the literature on fibre in enteral nutrition. In clinical practice fibre-containing enteral nutrition solutions are often used for patients with constipation or diarrhoea, however, few clinical studies have been conducted. Analysis of these studies show conflicting results and the question of efficacy remains. For example, studies which have examined the effect of a fibre- containing formula on transit time have been negative, but there have been mixed results with the effect of fibre on stool weight and stool frequency. Diarrhoea in patients receiving enteral nutrition is strongly associated with antibiotic usage. The literature has so far failed to demonstrate any effect of fibre-containing enteral formulae. Given that enteral formulae contain highly fermentable fibre sources ( eg soy polysaccharide), and antibiotics reduce the potential for fermentation by reducing colonic bacteria numbers, then it would be unlikely that fibre would have any effect on bowel function in antibiotic-related diarrhoea.

    Dr Marios Elia's presentation was entitled "Nutritional Pharmacology". He classifies substances used in Nutritional Therapy into three types.

    'Type 1. Nutrients' are those used in logical doses.

    'Type 2. Nutrients' are those used in pharmacological doses (eg: Arginine has been added to some enteral nutrition solutions because of its perceived effect on immune function).

    'Type 3. Nutrients' are bioactive substances with nutritional properties. Examples given include growth hormone, erythropoietin, lactoferrin and oligosaccharides. Some of these compounds are expensive and their benefit would need to be proven to outweigh their cost.

    Sabita Rajehwar from the Prince of Wales Hospital (Sydney) discussed the important area of developing outcome measures for nutrition interventions. Clinical indicators, length of stay and morbidity/mortality are often used in outcome studies but functional status, quality of life, performance and cost benefits are also important, but difficult to measure. Measuring the outcomes of nutrition interventions, including nutrition support poses a challenge which should be addressed using a multidisciplinary team approach.

    The final three presentations addressed the developing area of feeding patients via the jejunum, who often otherwise would not be candidates for enteral nutrition.

    Professor Robert Thomas (Western Hospital, Melbourne) discussed the use of jejunostomy tubes to allow early feeding of patients who have undergone major upper gastrointestinal tract surgery.

    Maureen Humphrey (Royal Children's Hospital, Melbourne) and Jacqui Osborne (Royal Melbourne Hospital) presented their experiences with enteral nutrition in bone marrow transplant patients. Side effects of treatment in this group of patients often compromise oral intake, with many patients receiving TPN. Maureen discussed how enteral nutrition in these patients has been trialled successfully at the Royal Children's Hospital, in some cases averting the need for TPN.

    Paul Froomes (Austin and Repatriation Medical Centre) presented early results from a trial comparing nasojejunal feeding with nasogastric feeding in ICU patients. The results show success with insertion and retention of nasojejunal tubes and suggest better tolerance of enteral nutrition than for nasogastrically fed patients. Paul also pointed out the relative difficulty of insertion of NJTs compared with NGTs and the need for the endoscopist to gain experience with their insertion.


    SPECIAL INTEREST GROUPS

    Following on from the invitation for subscribers to the Special Interest Groups shown below there have been two items submitted to the Editor. More items are required and can be submitted as handwritten or typed text or on disk as a wordprocessing file - Word and Claris Works documents in DOS or Macintosh formats are acceptable - or as email - or as a fax

    DRUGS AND NUTRITIONAL STATUS

    Yvonne Coleman, Nutrition Consultants, Hawthorn, Victoria.

    Drugs can affect nutritional status by altering appetite, and the absorption, metabolism and excretion of nutrients, and nutritional status can affect the absorption, distribution, metabolism and excretion of drugs.

    Effects on Nutritional Status Mechanisms by which drugs can affect nutritional status include :

    Altered Food Intake - can be by suppression or stimulation of appetite. Drugs associated with increased appetite include antipsychotic agents and some antihistamines such as cyproheptadine, whilst drugs associated with decreased appetite include anticancer agents, and in the elderly antianxiety agents such as the benzodiazepines and chlorpromazine. This is primarily due to side effects such as diarrhoea, constipation, anorexia, nausea, vomiting and altered taste perception. Drugs associated with secondary xerostomia include antidepressants, (particularly tricylic agents), tranquillisers, antihistamines, diuretics, some anthypertensives, antimigraine, antiemetics, antiparkinsonian and antispasmodics; [1]

    Interference With Nutrient Absorption - primarily malabsorption. Drugs include broad spectrum antibiotics such as tetracyclines (Mg, K, Be, B12, Na, Ca, Vit C, Zn, Folate, Vit K, Biotin, Lactose, Nitrogen, Fat, Sucrose), cimetidine (B12, B1, Fe), aluminium containing antacids (P, Ca, B1, Vit D, Vit A, B12, Folate, all vitamins); [2].

    Alteration in Nutrient Metabolism - primarily by antagonism of specific nutrients. Drugs include methotrexate (Ca, B12, Folate, Fat, Xylose, Vits ADEK), penicillamine (B6, Zn, Cu, P, Fe, Na, K, Folate, Vit K), phenytoin (Vit C, B12, Vit D, Mg, Ca, Vit K, Folate); [2]

    Increased Nutrient Excretion - includes aspirin (Vit D, Ca, B12, Fe, K, Vit K, Vit C, Folate, Glucose), the thiazides (K, Mg, Zn, Na, Ca); [2]

    Effects of Nutritional Status

    Drug bioavailability is affected by many factors, including food intake and nutritional status. Concurrent food intake can influence tablet disintegration, drug dissolution, rate of gastric emptying, gastrointestinal secretion, and active transport of drugs. Some drugs show an increased degree of absorption when given with food and include nitrofurantoin, phenytoin, chlorothiazide and hydrochlorothiazide. Absorption of some antibiotics is reduced by concurrent food intake, and includes penicillin, erythromycin (base), tetracycline, rifampicin, isoniazid, and certain cephalosporins; [3].

    Obesity increases the clearance of some drugs from plasma, including diazepam, nitrazepam, prednisolone, paracetamol, lorazepam, propylthiouracil, oxazepam, cimetidine, procainamide, vancomycin, amikacin, gentamicin, tobramicin; [3].

    Malnutrition affects the half life of many drugs, increasing the half life of chloramphenicol and isoniazid and decreasing the half life of sulfadiazine and phenylbutazone; [3].

    Malnutrition can impair the effectiveness of drugs such as chloramphenicol, digoxin, phenylbutazone, warfarin, salicylates and tetracyclines. These drugs are primarily transported by the plasma protein albumin which is generally reduced in malnutrition especially in kwashiorkor type malnutrition.

    Drug metabolism is affected by meal composition. Generally there is an increase with increased protein intake, decrease with increased carbohydrate and with decreased energy (caloric) intake, and minimal change with increased fat intake; [4]

    Food, various beverages and specific nutrients can have a variety of effects on drug action. For example grapefruit juice increases the systemic bioavailability of felodipine and cyclosporin, and prolongs the elimination half life of caffeine; [5], and licorice can cause hypokalaemia in the presence of loop and thiazide diuretics.

    There are nutritional implications when drugs have unpleasant side effects such as gastrointestinal disturbances, appetite changes, dry or sore mouth, or altered taste perceptions. People in distress may alter dietary habits by reducing or eliminating certain foods from the diet, not eat, use žover the counterž drugs to effect relief of the disturbance, or discontinue the use of the drug. Any of these options can result in a compromised nutritional status and altered drug efficacy. They all pose a risk to the consumer; [6]

    Drugs alone, or in combination with dietary intake and polypharmacy, may affect nutritional status, and conversely and individual's nutritional status and dietary intake may alter the efficacy of the drugs consumed.

    References

    [1] Reade, PC, Rich, AM. Dry Mouth: Diagnosing and Treating its Multiple Causes. Modern Med of Aust, (1994), 22-27

    [2] Coleman, Y. Drug - Nutrient Interactions - The Manual, published by Nutrition Consultants, Melbourne.

    [3] Wahlqvist, ML, Truswell, AS. Recent Advances in Clinical Nutrition 2. Proceedings of the Second International Symposium on Clinical Nutrition, Sydney 1985, published by John Libbey, London.

    [4] Speerhas, R. Drug Metabolism in Malnutrition and Obesity : Clinical Concerns. Cleveland Clinic J. Med, (1995), v62, #1, 73-75

    [5] Bailey, DG, Malcolm, J, Arnold, O, Spence, JD. Grapefruit Juice and Drugs. How Significant is the Interaction? Clin Pharmacokinetics, (1994), v26, #2, 91-98 [6] Roe, DA. Drug Nutrient Interactions in the Elderly. Geriatrics, (1984), v41, #3, 57-74.


    FORMULAE USED IN NUTRITIONAL ASSESSMENT

    Dr Tom Hartley Clinical Chemistry Dept Royal Hobart Hospital

    The objective assessment of nutritional status has been a longstanding problem in clinical nutrition and there is a considerable volume of literature on this topic. This in turn means that there is an increasing volume of data and experience which when subjected to statistical and meta analysis are producing increasingly more refined 'formula based tools' for making nutritional assessments in enviroments where it is impractical to apply expensive or invasive measurements techniques such as CAT scans, bioelectric impedence measurements, whole body neutron activation studies or isotope dilution measurements. This article presents a summary of some regularly reported techniques and provides the reader with the opportunity to try the formulae using their own data. The final choice(s) of the formula(e) most appropriate to your purpose(s) can then be selected after making personal evaluations of the various formulae using their own measurements from normal individuals and patients. It is recommended that you focus initially upon evaluating the formulae from the point of view of detecting changes within individuals rather than as tools to make cross sectional classifications. Please contact the author if you would like a computer disk with these formulae as IBM PC programs.

    THE CREATININE HEIGHT INDEX

    This was first proposed by Bistrian et al [1]. It involves the measurement of the patient's 24 hour urinary creatinine excretion and dividing it by the 24 hour creatinine excretion expected for a normal person of the same height as the patient but of ideal weight. The latter is determined for adults aged between 20 and 69 years for men with heights between 157.5 and 193 cm and for women with heights between 147.3 cm and 182.9 cm from Table 1 This quotient is then multiplied by 100 to give an index in percent with a normal range of 90-110%. The factors for determining the creatinine excretions for normal males and females are 203 umol and 159 umol of creatinine per kg body weight respectively.

    The data in Table 1 are based on the Imperial Measurement Tables published in 1979 as part of the Build and Blood Pressure Study commissioned by the American Society of Actuaries. They have been converted to metric units by multiplying the published heights in inches by 2.54 and multiplying the published weights in pounds by 0.45359 The study group comprised several million policy holders of twenty five North American and Canadian insurance companies surveyed in 1950 and 1972.They must have included predominantly middle class people who per se were probably better nourished than a truely randomly selected cross section of the population.

    TABLE 1

    AVERAGE WEIGHT OF AMERICANS BY HEIGHT (cms) AND AGE (yrs)


    	                               M E N
    
    	                            AGE BRACKET
            	    ---------------------------------------------
    	            20      25     30       40      50      60
    	             24      29     39       49      59      69
    	 Height
    	----------
    	   157.5    59      60.8    62.6    63.5    64     63.5
    	   160      61.7    63.5    64.9    65.3    65.8   65.3
    	   162.6    63      64.9    66.7    67.6    68     67.6
    	   165.1    64.9    66.7    68.5    69.9    70.3   69.4
    	   167.6    67.1    68.9    70.8    71.7    72.1   71.7
    	   170.2    69.4    70.8    72.6    73.9    74.4   73.9
    	   172.7    71.2    73      74.8    75.7    76.2   75.7
    	   175.3    73.9    75.3    77.1    78      78.5   78
    	   177.8    75.7    77.6    78.9    79.8    80.3   79.8
    	   180.3    77.6    79.4    81.2    82.1    82.6   82.1
    	   182.9    79.8    82.1    83.5    84.4    84.8   84.4
    	   185.4    82.6    84.4    86.2    87.1    87.5   86.6
    	   188      84.8    86.6    88.5    89.4    89.8   88.9
    	   190.5    87.5    89.4    91.2    92.1    92.5   90.7
    	   193      89.8    91.6    93.4    94.3    94.8   93.9
    
    
    
    	                             W O M E N
    
    	                            AGE BRACKET
    	          --------------------------------------------
    	            20     25     30      40      50      60
    	             24     29     39      49      59      69
    	 Height
    	---------
    	  147.3     47.6   49.9   51.3    53.5    54.9    55.8
    	  149.9     49.9   50.8   52.2    54.9    56.7    57.6
    	  152.4     50.8   51.7   53.5    55.8    57.6    59
    	  154.9     52.6   54     54.9    57.6    59.4    60.3
    	  157.5     54.4   54.9   56.2    58.5    60.3    61.7
    	  160       56.2   56.7   58.1    60.3    62.1    63.5
    	  162.6     57.6   58.1   59.4    61.7    64      64.9
    	  165.1     59     59.9   60.8    63      65.3    66.7
    	  167.6     60.3   60.8   62.1    64.9    66.7    68
    	  170.2     62.1   62.6   64      66.7    68.9    70.3
    	  172.7     64     64.4   65.8    68      70.8    71.7
    	  175.3     66.2   67.1   68      70.3    72.1    73
    	  177.8     67.6   68     69.4    71.7    73.5    73.9
    	  180.3     70.3   70.8   72.1    73.5    75.3    75.7
    	  182.9     71.2   72.1   74.4    76.2    77.6    78
    

    BODY MASS FOR HEIGHT RATIO

    This is calculated by dividing the patient's weight in kgs by their ideal weight for their height and age and expressing this as a percentage. The results are interpreted along the following broad criteria :
    
    		  =<  80%  Thin
    
    		  =<  90%  Underweight
    		      91 - 109%  Normal
    
    		  => 110%  Overweight
    
    
    		  => 120%  Obese
    
       		   > 159%  Superobese
    
    		   > 200%  Morbidly Obese
    

    BODY MASS INDEX

    This is calculated by dividing the patient's weight in kgs by the square of their height in metres. In men the BMI ranges from 19.0 to 33.2 kg/metre squared with a median value of 25.7 kg/metre squared. In women the range is 17.7 to 35.6 kg/metre squared with a median value of 23.2 kg/metre squared. This index is prone to inaccuracy because as people age their height reduces due to sedimentation of the spinal vertebrae. Clearly the index is inappropriate in a person known to have spinal osteoporosis or is suspected to be affected by some degree of post menopausal osteoporosis. Height reduction appears to begin at about 40 years of age and occurs at rates varying from 1mm/5years to 9mms/5years according to the patient's age and sex; [2].

    TOTAL EXCHANGEABLE SODIUM TO TOTAL

    EXCHANGEABLE POTASSIUM RATIO

    Forse et al. [3] derived their equation by multiple linear regression analysis of a series of data collected from radionuclide based body compartment size studies. They postulated that it reflects the ratio of extracellular mass to the body's cell mass. When the latter is wasting away due to malnutrition then the ratio will increase. A normal well nourished individual has a ratio of less than 1.22 when measured using their isotope dilution methods and less than 1.43 when using their prediction equation.
    		     Na/K Ratio = 4.1
    
    				  - 0.033 * Serum Albumin, g/L
    
    				  - 0.018 * Serum Total Protein, g/L
    
    				  - 0.012 * (Weight, kg / Height, m)
    
    				  - 0.007 * (Urine Creat., mg/24Hr)
    					        /(Height, cm)
    
    				  + 0.012 * Triceps skinfold
    					    thickness, mm
    
    				  + 0.26 * Mid arm area in square dm
    
    Normal ranges for the biochemical parameters in this formula are given in Table 2, which also includes other normal range data likely to be of interest during nutritional assesment of a patient.

    In our experience the serum Total Protein concentrations have proved to be good indicators of responses to nutritional support. In a series of 9 children and 78 adults receiving Total Parenteral Nutrition (TPN) support the serum total protein concentrations increased by + 8 g/L and + 5 g/l respectively in 50% of the patients between the start and finish of their TPN. The corresponding changes in their serum albumin concentrations were only half the amounts viz. + 4g/L and + 2 g/L respectively in the children and adults.


    TABLE 2

    NORMAL BIOCHEMISTRY VALUES

    		Serum ALBUMIN            32 - 52      g/L
    		Serum TOTAL PROTEIN      60 - 85      g/L
    		Serum TRANSFERRIN         2.2 - 4.2   g/L
            	Serum C Reactive Protein  < 10       mg/L
    		Serum IgG 		  5 - 16      g/L
    		Serum IgA    		  1.2 - 3.7   g/L
    		Serum IgM          	  0.8 - 2.8   g/L
    
    		Serum CHOLESTEROL  	  < 5.5       mmol/L
                    Serum TRIGLYCERIDES       < 2.0       mmol/L
    
                    Serum SODIUM            132 - 145     mmol/L
                    Serum POTASSIUM           3.3 - 4.5   mmol/L
                    Serum CREATININE         70 - 120     umol/L
                    Serum UREA                2.5 - 7.0   mmol/L
    
                    Serum Fe                 11 - 27      umol/L
                    Serum Zn                 10 - 20      umol/L
                    Serum Cu                 12 - 24      umol/L
                    Serum Se                  0.5 - 1.1   umol/L
    
                    Urine CREATININE         10 - 20      mmol/day
                                            131 - 2262    mg/day
    
                    Urine UREA              167 - 583     mmol/day
                                             10 - 35      g/day
    
                    Urine TOTAL NITROGEN    714 - 1071    mmol/d
                                             10 - 15      g/day
    
    

    The Triceps Skinfold Thickness is measured on the posterior aspect of the right upper arm, midway between the acromium and olecranon in the vertical direction. Typical ranges for this measurement in men and women are

    (See [4])

    The Mid Arm Area is a derived parameter from an actual measurement of the patient's mid arm circumference [5]. Mathematically the circumference of a cylinder is related to radius of the cylinder as follows :

    
                     Circumference  = 2 Pi  ( Radius )
    
                            Radius  = Circumference ÷ 2 Pi
    
                                 A  = Pi ( Radius )^2
    
                       Mid Arm Area = Pi (Mid Arm Circum. ÷ 2 Pi )^2
    
                                  = (Mid Arm Circum.)^2  ÷ 4 Pi ^2
    
                                  = (Mid Arm Circum.)^2 ÷ 12.566
    

    When the mid arm circumference is measured in decimetres ie. cms ÷ 10 then the range of Mid Arm Areas is typically of the order of 0.30 - 0.65 dm^2 with the median in the vicinity of 0.47 dm^2.

    This mathematical manipulation, however, does nothing to improve the accuracy of the base measurement ie. the mid arm circumference and many publications just refer to the base measurement presumeably for that reason. In fact squaring the circumference measurement has the undesirable effect of raising the proportional error implicit in the circumference measurement. A cross sectional area, however, is perhaps easier to visualise than a circumference particularly if the assessor/observer is wishing to get an estimate of the patient's 'bulk' rather than a linear measure.


    PROGNOSTIC NUTRITIONAL INDEX (PNI)

    This is a well known nutritional index proposed originally by Buzby et al.[6] and reviewed more recently by Dempsey et al. [7]. It is a composite index involving biochemical and anthropometric measurements. The result is a percentage risk of post operative complications such that patients with PNIs of

      		<40% are classified as "Low Risk",
                  40 - 50% are at "Intermediate Risk"
                     > 50% are at "High Risk"
    

    Clearly the formula implies that the higher the values are for each parameter then the better the prognosis.

    
                    PNI = 158 - 1.66 * Serum Albumin, g/L
    
                              - 20 * Serum Transferrin, g/L
    
                              - 5.8 * Delayed Hypersensitivity
    
                              - 0.78 * Triceps skinfold
                                       thickness,mm
    

    Delayed hypersensitivity is determined by observing the sites of subdermal injections of three recall antigens:- mumps, streptokinase-streptodornase and candida. Poor nutrition tends to be associated with delayed or reduced inflammatory response at these sites. The site with the most pronounced inflammatory response is then scored as follows :

                                                       SCORE
    
       No inflammation ..................................0
    
       A Less than 5mm diameter
       inflammed area at the site........................1
    
       A More than 5mm diameter
       inflammed area at the site .......................2
    


    NUTRITIONAL RISK INDEX (NRI)

    This index also proposed by Buzby et al [8] relies heavily upon the serum albumin concentration. It was used by the authors to pre-select patients for further nutritional assessment and/or support if their NRI was < 100%.

    NRI = 1.59 * Serum Albumin, g/L + 0.417 * % Usual Body Weight.

    ( If the patient is heavier than usual then the "% Usual Body Weight" is equated to 100%.)


    CLINICAL OUTCOME

    This index was also derived using multiple linear regression analysis of the data collected by Buzby et al [9] as part of their research into the link between nutritional status and clinical outcome. They specified that a normal clinical outcome, (14% complication rate and a 2.8% mortality rate), can be expected if the result is > 2.71. A result less than this is abnormal and was associated with patients in a group with a 27.5% complication rate and a 22% mortality rate.

    Outcome = 0.0363 * Serum Albumin, g/L + 0.0127 * % Usual Body Weight + 0.0119

    Notice that this formula also implies that the higher the serum albumin concentration then the better will be the outcome.


    SUBJECTIVE GLOBAL ASSESSMENT (SGA)

    Each of the nutritional formulae described so far have equal numbers of proponents and critics. Opinion is divided to such an extent that there is now a trend towards making subjective assessments of nutritional status by means of formalised questionaires and physical examinations. These so called Subjective Global Assssments were first decribed by Detsky et al. [10] and more recently applied by groups such as Hirsch et al [11]. The hypothesis is that the subjectivity in nutritional assessment can be removed if assessors all use the same questionaire. This questionaire ensures that certain specific details are recorded before the clinician assigns the patient to

    In the clinical history particular attentions paid to weight change, dietary intake change, gastrointestinal symptoms of more than 2 weeks duration, functional physical capacity and the level of metabolic stress. The physical examination focusses on subcutaneous fat stores, degree of muscle wasting, and the presence of oedema and/or ascites.

    We have been using this approach for more than twelve months as a device for assessing nutritional status before and after Total Parenteral Nutrition. Our adaptations of the questionaire involved making some changes to the wording so that it would apply to the particular circumstances of a hospitalised patient for whom we had received a consult request to provide nutritional support in the form of TPN. SGA will be included as a separate article in a future issue of the Newsletter.

    REFERENCES

    [1] Bistrian, BR, Blackburn, GL, Sherman, M, Scrimshaw, NS, Surg.Gynae.Obstet. 1975, 141:512-516

    [2] Geigy Scientific Tables, 1984, Volume 3, p327.

    [3] Forse, RA, Shizgal, HM, Surgery 1980, 88:17-24

    [4] Cronk, Roche, Am.J.Clin.Nutrit. 1982, 35 : 347

    [5] Chiba, T, Lloyd, DA, Bowen, A'D, Condon-Meyers, A, J. Parenteral & Enteral Nutrit. 1989, 13 : 529-534.

    [6] Buzby, GP, Mullen, JL, Matthews, DC, Hobbs, CL, Rosato, EF, Am.J.Surg. 1980, 139 : 160-167

    [7] Dempsey, DT, Mullen, JL, Buzby,GP, Am.J.Clin.Nutrit. 1988, 47:352-356

    [8] Buzby, GP, Knox, LS, Crosby, LO, isenberg, JM, Haakenson, CM, McNeal, GE, Page, CP, Peterson, OL, Reinhardt, GF, Williford, WO, Am.J.Clin.Nutrit. 1988, 47:366-381

    [9] Buzby, GP, Williford, WO, Peterson, OL, Crosby, LO, Page, CP, Reinhardt, GF, Mullen, JL, Am. J. Clin. Nutrit. 1988, 47:357-365

    [10] Detsky, AS, Baker, JP, O'Rourke, K, Johnston, N, Whitwell, J, Mendelson, RA, Jeejeebhoy, KN, J.P.E.N. 1987, 11 : 440-446

    [11] Hirsch, S, de Obaldia, N, Petermann, M, Rojo, P, Barrientos, C, Iturriaga, H, Bunout, D, Nutrition 1991, 7:35-38


    NEW BOOKS

    Growth Standards, Bone Maturation and Idiopathic Short Stature. 1st Kabi International Growth Study Expert Meeting on Growth and Growth Disorders, Positano, Nov 1995. Edited by M B Ranke and G. Gilli. Published by Karger, 1996, 68p. $Aus 35

    Metabolic Consequences of Changing Dietary Patterns. World Review of Nutrition and Dietetics Vol 79. Edited by A. P. Simopoulos. Published by Karger 1996. 222p. $Aus 279.

    Nutrition in Pregnancy and Growth. Bibliotheca Nutritio et Dieta Num. 53. Edited by M Porrini and P Walker. Published by Karger, 1996, 140p. $Aus 202

    Shock From Molecular and Cellular Level to Whole Body. Proceedings of the 3rd International Shock Congress - 'Shock '95'; Hamamatsu, Japan, Oct '95. Edited by K Okada and H Ogata. Published by Elsevier, 1996, 416p. $Aus 252.

    Vitamins and Hormones : Advances in Research and Applications. Volume 52. Edited by Gerald Litwack. Published by Academic Press, 1996, 204p. $Aus 96


    FROM THE JOURNALS

    Severe Hypocupraemia in a Patient with Extensive Burn Injuries. Sampson, Constantinescu, Chandarana & Cussons. Annals Clin. Biochem. (1996), v33, #5, 462-4, (R)

    Trace Elements in Paediatrics. Gillian Lockitch. J. Internat. Fed. Clin. Chem. (1996), 2, 46-57, (R)

    Laboratory Assessment of Protein Energy Status. Alan Shenkin, Cederblad, Elia & Isaksson.J. Internat. Fed. Clin. Chem. (1996), v9, #2, 58-61, (R)

    Born To Be Fat. Daniella Goldberg. Today's Life Science, (1996), v8, #5, 14-7, (R) (An article on leptins and the genetic basis of obesity)

    Detection and Monitoring Disorders of Essential Trace Elements. Annals Clin Biochem, (1996), v33, #6, 486-510 (R)

    (R) indicates that a reprint is available from the Editor - send a stamped self addressed foolscap envelope to receive a photocopy. This offer is only open to Australian residents.


    MEETINGS CALENDAR

    June 1997 : Medical Research Week, organised by local State Branches of the Australian Society for Medical Research.

    July 23 - 26, 1997. Sixth World Congress on Clinical Nutrition : Antioxidants and Disease, Banff, Alberta, Canada. Contact Tapan Basu, Dept of Agricultural Food and Nutritional Sciences, University of Alberta, Edmonton, AB T6G 2P5, Cananda. (403)-492-4921 . Fax 403-492-9130.

    July 20th - 23rd. 2nd World Congress of Allied Health Professionals : 'Sustainable Health Care in the 21st Century. A Global Perspective'. University of Wolverhampton, Priorslee Hall, Telford, Shropshire, England. email n.birch@wlv.ac.uk

    July 27 - Aug 1 : 16th International Congress of Nutrition. Montreal. Contact Congress Secretariat, IUNS '97, National Research Council Canada, Building M-19, Montreal Road, Ottawa, ON, Canada K1A OR6. (613)993-7271. Fax 613-993-7250.

    September 7th - 11th : Tachykinins in Health and Disease. Cairns, Queensland.

    Home Page = http://iuphar.pharmacology.unimelb.edu.au/iupar/meeting_970907.html

    October 1st - 5th. VIIIth Biennial Meeting of the International Society for Free Radical Research. Contact. Mr Merce Ferrer, Pacifico SA, E Granados, 44 Pral., 08008 Barcelona Spain. Tel +34-3-4545400. Fax +34-3-4517438

    October 16th - 19th : 22nd Australia & New Zealand Intensive Care Society Scientific Meeting, Wrest Point Convention Centre, Hobart, Tasmania. Keynote Speakers : Prof. Michael Pinsley, Dr Stephen Crawford and Ms Karin Mitchell-Supplee. Contact Cartherin Gordon, 22nd Annual Scientific Meeting, PO Box 255, SANDY BAY 7006. Ph 03-6222-8013, Fax 03-6222-8010. Email anzics97@mail.mpx.com.au

    October 24th - 25th. 23rd Annual Scientific Meeting of AuSPEN, at the Esplanade Hotel, Fremantle, Western Australia. Contact Dr Paul Woods, +61-9-346-3333 Ext 1010 or Fax +61-9-386-8541 or Susan Adler Conference Planning Ph/Fax +61-9-384-4213


    INTERNET NEWS

    Following on from the Internet article in the October '96 Newsletter, the Cybernet Cafe in Glenferrie Road, Hawthorn, Vic., has emailed me with a offer for all our members : one hours Internet access at half price if you present a copy of this Newsletter .

    Many people will know of the DA Book Services as being one of the most prominant suppliers of professional books. They are now accessible on the World Wide Web - http://www.dadirect.com.au .

    Visitors to their site between now and 28/2/97 can go into a prize draw for a mobile phone.


    PUBLICATION DATES FOR 1997

    The Newsletter will be published in April, July and October this year. If contributors could get items to the Editor by the middle of the third week of the month preceeding that will assist greatly with the planning of the issue. If copy is not ready at that time but will be by the end of that month please let me know so that I can reserve the space.


    ANNUAL SUBSCRIPTIONS FOR 1997 ARE NOW DUE

    Contact the Treasurer - Kevin Williams, Pharmacy Dept, The Queen Elizabeth Hospital, WOODVILLE, SOUTH AUSTRALIA 5011

    (Ph) +61-8-222-6693 (Fax) +61-8-222-6019


    END OF DOCUMENT : Last Update 31st January 1997 : Next Update 28th April 1997