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1 SMN SURGICAL METABOLISM AND NUTRITION Vol. 4, No. 2, December 203 외과환자영양선별검사및영양평가 허훈ㆍ서경원ㆍ공성호ㆍ박준석ㆍ박지원ㆍ이인규ㆍ황대욱ㆍ이혁준대한외과대사영양학회가이드라인 / 임상시험위원회 - 외과환자의영양상태가환자의치료중합병증및사망률과직접적인관련이있다는것은그동안의여러후향적 (-4) 및전향적 (5-7) 임상연구를통하여밝혀져왔음. - 영양상태의정확한평가를위해객관적인선별검사 (nutritional screening) 와영양평가 (nutritional assessment) 과정이필수적으로요구됨. - 영양선별검사방법에는 Nutritional Risk Screening 2002 와 Malnutrition Screening Tool 등이대표적이며,(8,9) 이를통하여영양지원여부나추가적인영양평가여부가결정됨. - 영양평가는영양지원여부를결정하거나영양지원결정후환자상태를보다정확히파악하기위한기본검사로활용되며, Subjective Global Assessment (SGA), Patient generated SGA (PG-SGA) 그리고 Mini Nutritional Assessment (MNA) 등이현재사용되는대표적인영양평가도구임.(0,) 영양선별검사 (Nutritional screening). 영양선별검사의목적및대상 (Subjects for nutritional screening) ) 선별검사의목적 외과의사가진찰하는환자들의불량한영양상태를확인하여즉시영양지원이필요한환자를가려내기위함. 2 외과의사가진찰하는환자들중영양평가 (nutritional assessment) 가필요한환자들을가려내기위함. 2) 선별대상 : 외과의사가진찰하는모든환자. 2. 영양선별검사의방법 ) 선별검사평가자및평가시기 환자를처음진료하는외과의사혹은의사의지시를받은간호사나영양사에의해서초기평가가이루어져야함. 2 초기진료후 24시간이내에이루어져야함.(2) 2) 선별검사도구들 Nutritional risk screening 2002 (NRS 2002, 표 ) i. 배경 : 영양공급의효용성과관련된 28개의전향적연구들에서사용된환자기본검사도구들을분석하여 책임저자 : 서경원, 부산시서구감천로 , 고신대학교의과대학외과학교실 Tel: , Fax: kwseo.surg@kosin.ac.kr 이논문은 외과대사영양지침서제 판 (ISBN: ) 에게재된내용중일부입니다. 만들어낸영양상태선별검사방법이며, 유럽임상영양대사학회 (European society for clinical nutrition and metabolism, 이하 ESPEN) 에서는원내입원환자의영양선별검사방법으로이를제시하고있음. ii. 도구항목 : 체중감소, 체질량지수 (body mass index), 음식섭취정도, 질환의심각성. iii. 임상연구결과 : 메타분석에서본도구에의해서선별된환자들의영양공급효과의기대비율이.7배상승하는결과를보였음.(8) 2 Malnutrition screening tool i. 배경 : 영양학적기본질문들을조사한뒤영양평가도구인 subjective global assessment (SGA) 를예측할수있는질문들을정리하여만든선별검사도구임. ii. 도구항목 : 최근의식욕, 최근의도하지않은체중의감소. iii. 임상연구결과 : 단일병원에입원한 408명을대상으로본검사도구영양선별검사를시행한결과, 입원후낮은영양학검사지표와입원기간의연장을예측할수있었으며 93% 에서 97% 정도의재현성을나타내었음.(9) 3 Nutritional risk classification i. 배경 : 입원환자를대상으로 48시간이내에환자의영양상태를파악하기위해만든검사도구. ii. 도구항목 : 체중감소여부, 이상체중와비교한현재몸무게, 최근의섭취량및위장관기능의변화여부. 42

2 허훈외 : 외과환자영양선별검사및영양평가 43 표. Nutritional risk screening (NRS 2002) Initial screening Yes No Is BMI<20.5? 2 Has the patient lost weight within the last 3 months? 3 Has the patient had a reduced dietary intake in the last week? 4 Is the patient severely ill? (e.g. in intensive therapy) Yes: If the answer is Yes to any question, the screening in Table 2 is performed. No: If the answer is No to all questions, the patient is re-screened at weekly intervals. If the patient is scheduled for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status. Final screening Absent Score 0 Mild Score Moderate Score 2 Severe Score 3 Impaired nutritional status Normal nutritional status Wt loss>5% in 3 mo OR Food intake below 50 75% of normal requirement in preceding week. Wt loss>5% in 2 mo OR BMI impaired general condition OR Food intake 25 60% of normal requirement in preceding week. Wt loss>5% in mo (>5% in 3 mo) OR BMI <8.5+ impaired general condition OR Food intake 0 25% of normal requirement in preceding week. Score+score=total score. Age if 70 years: add to total score above=age-adjusted total score. Absent Score 0 Mild Score Moderate Score 2 Severe Score 3 Severity of disease Normal nutritional requirements Hip fracture. Chronic patients, in particular with acute complications: cirrhosis. COPD. Chronic hemodialysis, diabetes, oncology. Major abdominal surgery. Stroke. Severe pneumonia. Hematologic malignancy. Head injury. Bone marrow transplantation. Intensive care patients (APACHE>0). Score 3: the patient is nutritionally at-risk and a nutritional care plan is initiated. Score <3: weekly rescreening of the patient. If the patient e.g. is scheduled for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status. iii. 임상연구결과 : 86명을대상으로하여영양사와간호사를조사원으로한재현성연구에서 97.3% 의재현성을나타내었으며 56명을대상으로한전향적유효성연구에서 84.6% 의영양불량을예측하는민감도를나타내었음.(3) 4 Nutritional risk index i. 배경 : 영양상태가불량한수술예정환자를대상으로수술전영양공급여부및공급기간에따른환자의수술후경과를비교하기위한전향적비교임상연구에서연구대상환자선정을위해사용되었던도구. ii. 도구항목 : 최근및현재몸무게, 혈청알부민수치. iii. 임상연구결과 : 본도구에의해서영양상태불량으로판단되어임상시험에등록된환자들중 SGA에의해서심각한불량한영양상태 (severely malnourished patients) 로판단된환자들에서만수술전영양공급이수술후환자들의합병증을줄이는데의미가있었음.(4) 5 Simple screening tool i. 배경 : 고령환자를대상으로영양부족환자를선별하기위한단순한도구를개발하기위해임상연구에서사용된선별검사방법. ii. 도구항목 : 체질량지수 (body mass index), 체중감소정도, 혈청알부민수치. iii. 임상연구결과 : 42명의환자를대상으로세가지항목을이용하여환자들을선별했을때, 영양불량환자를가려내는데있어서 90% 이상의유효성과신뢰도를보여주었음.(5) 6 Short nutritional assessment questionnaire i. 배경 : 영양불량환자를초기에가려내기위한선별검사의유용성과비용효과를보기위한임상연구에사용된질문지를이용한선별검사방법. ii. 도구항목 : 최근몸무게의변화, 최근식욕, 최근경구혹은비위관을통한영양보충력. iii. 임상연구결과 : 297명의환자를대상으로선별검사

3 44 Surgical Metabolism and Nutrition Vol. 4 No. 2, 203 로영양불량상태가판별되어초기에영양보충이이루어지는경우입원기간단축을통한비용감소효과가있었음.(6) 3) 선별검사조사항목 - 선별검사에사용되는도구를이용하기위해다음과같은항목들을조사함. 과거력조사 i. 몸무게 : 평소몸무게및최근 개월, 6개월의몸무게변화와이상체중과의차이를통해영양상태를파악할수있으며, 다음과같은경우영양불량을예측할수있음. a. 최근 개월내에 5% 이상의체중감소가있었던경우. b. 최근 6개월내에 0% 이상의체중감소가있었던경우. c. 이상체중 (ideal body weight) 의 20% 이하의체중을나타내는경우. - 이상체중산출을위한 Hamwi 방법.(7) Men: 48 kg for the first 52 cm+2.7 kg per 2.54 cm over 52 cm Women: 45 kg for the first 52 cm+2.3 kg per 2.54 cm over 52 cm 예 ) 65 cm 남자환자의이상체중 : 48+(65 52) (2.7/2.54)= 약 62 kg - 이상체중산출을위한체질량지수 (body mass index) 이용법. Men: ideal body weight=height (m) 2 22 Women: ideal body weight=height (m) 2 2 예 ) 55 cm 여자환자의이상체중 : (.55.55) 2= 약 50 kg ii. 내과및외과적병력 : 각종내과적, 외과적병력이환자의영향상태에영향을주고영양필요양을증가시킬수있으므로, 감염및패혈증상태, 심혈관계및내분비질환등의내과적병력과심각한화상, 주요수술, 외상및두부손상등외과적병력에대한파악이필요함. iii. 호소증상 : 영양결핍과관련하여환자가호소하는증상에대한파악이필요함. iv. 경구섭취장애정도 : 음식을씹거나삼키는데문제가있는지에대한파악이필요하며, 구토, 복통, 복부팽만등소화기질환과관련된증상이있는지파악이필요함. v. 투약력 : 과거질환및증상으로인하여투약한과거력이있는지와영양섭취에영향을줄수있는투약력이있는지파악이필요함. vi. 최근영양섭취정도 : 최근의경구섭취감소정도와이를해결하기위한영양지원의과거력, 과체중의경우체중감소를위해스스로경구음식섭취감소시킨경험등을파악하고, 최근섭취한식사의종류를파악하여비타민, 미네랄등의섭취부족이없었는지확인함. 후향적인회상과일정기간동안의전향적기록등이영양섭취정도파악의방법이될수있음. vii. 영양결핍정도의예측 : 환자의위장관질환과기능에의하여앞으로영양결핍정도를예측할수있으며, 7 표 2. Parameters and diagnostic criteria for subjective global assessment (SGA) Parameters Grade A Grade B Grade C Food intake No deficiency Definite decrease in intake or liquid diet Weight loss (during the past 6 mo) Gastrointestinal symptoms (nausea, vomit, diarrhea) No weight loss or weight loss > 0% during the past 6 mo but weight gain over the past month None Continuous weight loss of 5% 0% Mild or moderate GI symptoms for less than 2 wk Activities and function No limitation Not normal, but able to do fairly normal activities or do not know most things, but in bed or chair for less than half a day Metabolic stress No fever Temperature >37 o C and <39 o C during the past 72 h Subcutaneous fat loss No Mild to moderate Severe Muscle wasting No Mild to moderate Severe Ankle edema/ascites No Mild to moderate Severe Nutritional status: SGA-A (Normal); SGA-B (Mildly to moderately malnourished); SGA-C (Severely malnourished). Severe deficiency in intake or starvation Continuous weight loss >0% Continuous severe GI symptoms for more than 2 wk Able to do little activity and spend most of the day in bed or chair; or much bedridden, rarely out of bed Continuous temperature 39 o C during the past 72 h

4 허훈외 : 외과환자영양선별검사및영양평가 45 일이상경구섭취가불가능경우영양결핍을예측하여영양보충을결정할수있음. 2 신체조사 i. 체질량지수 (body mass index)= 몸무게 (kg)/ 키 (m) 2 ii. 근력감소 : 신체근육감소에따른핸드그립정도나다리신전정도가영양결핍상태와관련이있을수있으므로이에대한파악이필요함. iii. 기타영양결핍상태를나타내는신체조사결과 : 전신부종, 피부표피탈락, 탈모, 사지근육량감소등이영양결핍상태를시사하므로신체검진을통해이를시행함. 영양평가 (Nutritional assessment). 영양평가의목적및대상 ) 영양평가의목적 영양평가는환자들에대한식사력, 임상적사회적상황등을통하여영양학적위험성을파악하고, 신체검진과체성분분석, 검사실소견을확인하여불충분한영양상태의정도를확인함.(6,8) 2) 영양평가의대상 (subjects for nutritional assessment) 영양선별검사 (nutritional screening) 를통해영양지원이결정된환자를대상으로영양상태를정확히파악하여영양지원의기초자료로활용함. 2 영양선별검사를통해추가적인영양평가가결정된환자를대상으로영양지원여부를결정하고지원전영양상태를파악함. 2. 영양평가방법 ) 영양평가평가자및평가시기 영양평가평가자 : 영양평가는임상영양지원팀소속의의사나의사의지시를받은영양사에의해서이루어져야함. 2 영양평가시기 : 영양선별검사가끝난직후시행되어야함. 2) 영양평가도구 Subjective global assessment (SGA, 표 2) (0) i. 배경 : 주로위장관수술을받게될환자들을대상으로영양불량환자를가려내거나수술후영양불량에빠질가능성이높은환자를예측하기위해개발된도구임. ii. 평가항목 : 모두 8개항목으로식사관련과거력및 체중변화, 현재활동정도및발열, 신체계측사항. iii. 임상결과 a. SGA는소화기질환을갖고있는 262명의환자를대상으로한환자대조군임상연구에서환자들에서입원기간을예측할수있는영양평가도구로인정되었음.(9) b. 438명의외과수술후환자를대상으로한환자대조군연구에서도 Grade C로판정된경우감염관련합병증이증가하는것으로평가되었음.(20) c. 간이식과신장이식등의이식수술에서도임상적적용가능성이제시되었음.(2,22) 2 Patient generated SGA (PG-SGA, 표 3) i. 배경 : SGA를근거로하여암환자에게보다특이적인영양평가도구로서 994년 Ottery 등에의해서개발되었음.(23) ii. 평가항목 : SGA와비교할때, 영양학적증상과가장최근의몸무게의변화를조사하도록되어있으며, 영양학적증상의경우환자에의해서직접작성되도록하고있음. 이를개량한 scored PG-SGA의경우각항목마다 0 4 점수를부여한후총점이 9점이상인경우영양지원이필요한것으로판단하고있음. iii. 임상결과 a. PG-SGA를이용해서위장관수술후합병증예측성을확인하고자다기관에서 275명의환자를등록시켜시행한전향적임상연구에서 PG-SGA는주요합병증의발생과관련이있었음.(24) 3 Mini nutritional assessment (MNA, 표 4) i. 배경 : ESPEN에서고령환자의영양상태파악을목적으로제시한영양평가도구이지만, 영양학적으로불량한영양상태의적절한영양지원과예후향상을위해널리사용되고있음. ii. 평가항목 : MNA는모두 8개항목으로이루어져있으며인체계측사항 (anthropometric parameter) 과식사관련조사사항 (dietary parameter) 등을포함함. iii. 임상결과 a. MNA를이용한 2개의임상연구에등록된 4,49 명의환자를대상으로분석한메타분석에서낮은 MNA 수치는사망률및입원기간의증가와관련이있었으며, 추후혈청단백질및몸무게의변화를예측할수있었음.() b. MNA 수치를근거로한영양지원은환자들의영양

5 46 Surgical Metabolism and Nutrition Vol. 4 No. 2, 203 표 3. Table worksheet for PG-SGA scoring Boxes 4 of the PG-SGA are designed to be completed by the patient. The PG-SGA numerical score is determined using. ) the parenthetical points noted in boxes 4 and 2) the worksheets below for items not marked with parenthetical points. Scores for boxes and 3 are additive within each box and scores for boxes 2 and 4 are based on the highest scored item checked off by the patient. Worksheet - scoring weight (Wt) loss Worksheet 2 scoring criteria for condition To determine score, use month weight data if available. Use 6 month data only if there is no month weight data. Use points below to score weight change and add one extra point if patient has lost weight during the past 2 weeks. Enter total point score in Box of the PG-SGA. Score is derived by adding point for each of the conditions listed below that pertain to the patient. Wt loss in month Points Wt loss in 6 months Category Points 0% or greater 5 9.9% 3 4.9% 2 2.9% 0.9% % or greater 0 9.9% 6 9.9% 2 5.9% 0.9% Cancer AIDG Pulmonary or cardiac cachexia Presence of decubitus, open wound, or fistula Presence of trauma Age greater than 65 years Score for Worksheet Record in Box A Score for Worksheet 2 Record in Box B Worksheet 3 scoring metabolic stress Score for metabolic stress is determined by a number of variables known to increase protein & calorie needs. The score is additive so that a patient who has a fever of >02 degrees (3 points) and is on 0 mg of prednisone chronically (2 points) would have an additive score for this section of 5 points. Stress None (0) Low () Moderate (2) High (3) Fever Fever duration Corticosteroids No fever No fever No corticosteroids >99 and <0 <72 hrs Low dose (<0 mg prednisone equivalents/ day) 0 and <02 72 hrs Moderate dose ( 0 and <30 mg prednisone equivalents/day) 02 >72 hrs High dose steroids ( 30 mg prednisone equivalents/day) Score for Worksheet 3 Record in Box C Worksheet 4 - physical examination Physical exam includes a subjective evaluation of 3 aspects of body composition: fat, muscle, & fluid status. Since this is subjective, each aspect of the exam is rated for degree of deficit. Muscle deficit impacts point score more than fat deficit. Definition of categories: 0=no deficit, +=mild deficit, 2+=moderate deficit, 3+=severe deficit. Rating of deficit in these categories are not additive but are used to clinically assess the degree of deficit (or presence of excess fluid). Fat scores: Orbital fat pads Triceps skin fold Fat overlying lower ribs Global fat deficit rating Muscle scores: Temples (temporalis muscle) Clavicle (pectoralis & deltoids) Shoulders (deltoid) Clavicle (pectoralis & deltoids) Interosseous muscles Tight (quadriceps) Calf (temporalis muscle) Global fat deficit rating Fluid scores: Ankle edema Sacral edema Ascites Global fat deficit rating Point score for the physical exam is determined by the overall subjective rating of total body deficit. No deficit score=0 points Mild deficit score= point Moderate deficit score=2 points Severe deficit score=3 points Score for Worksheet 4 Record in Box D 상태를향상시킬수있었으며, 이를 MNA 수치를통하여확인할수있었음. 4 그밖의평가도구 i. 신체구성 (body composition) a. Anthropometric data: 환자의키와몸무게뿐만이아니라피부두께 (skin fold) 상완둘레의측정이영

6 허훈외 : 외과환자영양선별검사및영양평가 47 표 3. Continued Worksheet 5 - PG-SGA global assessment categories Stage A Stage B Stage C Category Well-nourished Moderately malnouri-shed or suspected malnutrition Weight Nutrient intake No wt loss OR Recent non-fluid wt gain No deficit OR Significant recent improvement 5% wt loss within month (or 0% 6 months) OR No wt stabilization or wt gain (i.e. continued wt loss) Definite decrease in intake Severely malnourished >5% wt loss in month (or >0% in 6 months) OR No wt stabilization or wt gain (i.e. continued wt loss) Severe definite in intake Nutrient impact None OR Presence of nutrition impact Presence of nutrition impact Symptoms Significant recent improvement allowing Symptoms (Box 3 of PG-SGA) Symptoms (Box 3 of PG-SGA) adequate intake Function No deficit OR Significant recent improvement Moderate function deficit OR Recent deterioration Severe function deficit OR Recent deterioration Physical exam No deficit OR Chronic deficit but with recent clinical improvement Evidence of mild to moderate loss of SQ fat &/or muscle mass &/or muscle tone on palpation Obvious signs of malnutrition (e.g. severe loss of SQ tissues, possible edema) Global PG-SGA rating (A, B, or C) 표 4. Initial screening in mini nutritional assessment (MNA) A Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties? 0=severe loss of appetite =moderate loss of appetite 2=no loss of appetite B Weight loss during last months? 0=weight loss greater than 3 kg =does not know 2=weight loss between and 3 kg 3=no weight loss C Mobility? 0=bed or chair bound =able to get out of bed/chair but does not go out 2=goes out D Has suffered physical stress or acute disease in the past 3 months? 0=yes 2=no E Neuropsychological problems? 0=severe dementia or depression =mild dementia 2=no psychological problems F Body Mass Index (BMI) [weight in kg]/[height in m]2 0=BMI less than 9 =BMI 9 to less than 2 2=BMI 2 to less than 23 3=BMI 23 or greater Screening score (total max. 4 points) 2 points or greater Normal not at risk - no need to complement assessment. points or below Possible malnutrition - continue assessment. 양상태파악에도움이될수있으나재연성을위해서는특정도구와훈련을받은평가자에의한측정이필요함.(25) b. Bioelectrical impedance: 신체내의구성성분에따라전류흐름의저항성이다르다는근거에의해서 측정하는방법으로역시특수측정장치를필요로함.(26) c. 기타측정방법 : Dual energy x-ray absorptiometry, computed tomography 혹은 magnetic resonance imaging 등의영상의학적평가가신체구성

7 48 Surgical Metabolism and Nutrition Vol. 4 No. 2, 203 성분계측방법으로활용될수있음. ii. 혈청단백질 (serum protein): 영양학적인상태특히단백질과관련한영양상태평가를위해사용되는대표적인단백질은 albumin이지만, 이외에영양부족상태에서간에서생성되는급성단백질중다음과같은혈청지표들이영양평가에사용될수있음. a. Albumin: 3.0 g/dl 미만의혈청알부민수치 ( 간및신장기능의정상인경우 ) 의경우환자의영양결핍관련합병증과사망을예측할수있는주요예측도구가되지만, 4일이상의긴반감기로인하여영양결핍을진단하기위한감수성과특이도는다소떨어짐.(30,3) b. Transferrin: 단백질손실시떨어져있는수치이지만, 에스트로겐요법이나급성간염등에서는상승하여정확한측정을어렵게할수있음.(27-29) c. Thyroxin binding prealbumin: 혈청 prealbumin 은반감기가짧고체내저장량이적어영양상태예측의주요지표로사용될수있으며, 영양선별검사로영양불량상태로측정이안된경우에도 20 mg/dl 이하의 prealbumin 수치를통하여영양상태의예측이가능함.(27-29) iii. 면역기능 (immune function): 신체의면역반응정도를통하여영양상태를측정하는방법으로다음과같은지표들이사용되지만, 면역상태 ( 면역억제제복용및감염 ) 에따라서영향을받을수있다는제한점이있음. a. Delayed hypersensitivity testing: Cell mediated immunity를나타내는대표적인지표로서피하항원주사후피부에나타나는면역반응을통하여영양학적상태를평가하는방법.(32) b. Total lymphocyte count (TLC): 혈액내면역반응에관여하는림프구수를측정함으로써영양상태를측정하며, 2,000/mm 3 의경우정상으로봄. iv. Nitrogen balance: 체내로흡수되는질소량과배출되는질소량간의균형을확인하여현재단백질공급량이충분한지를확인하는평가도구이며, 소변으로배출되는질소량을측정하므로화상, 설사, 구토등소변외로배출되는질소량이많은경우제한점이될수있음.(33) Nitrogen balance=nitrogen intake nitrogen loss Nitrogen intake=protein intake/6.25 (nitrogen per gram of protein) or appropriate conversion factor Nitrogen loss=urinary urea nitrogen (UUN)+ non-urea urinary nitrogen ( 2 g)+fecal nitrogen ( 2 g)+miscellaneous losses (skin, sweat, etc; g or g/m 2 ) Therefore, Nitrogen balance (in grams)=(protein intake in grams/6.25 or appropriate conversion factor) (UUN excretion in grams+3 5 g) 외과환자영양선별검사및영양평가방법의실제. ESPEN: 2002년가이드라인을통해임상적상황에따른도구적용을추천하고있음.(34) ) 일반적인환자 - 체질량지수, 체중감소정도, 급성질환여부에따른점수를통해영양상태를평가하는 malnutrition universal screening tool (MUST) 라는검사도구를통하여영양지원여부나재평가여부를결정함 ( 그림 ). 2) 병원입원환자나고령환자 - 병원에내원해있는환자의경우 NRS 2002를이용하고, 고령환자의경우 MNA를이용하여선별검사를시행하도록추천하고있음. 그림. Malnutrition universal screening tool (MUST) reprinted from ESPEN Guideline 2002.

8 허훈외 : 외과환자영양선별검사및영양평가 49 그림 2. Nutritional screening and assessment reprinted from Nutritional Support Core Curriculum, ASPEN 미국정맥경장영양학회 (ASPEN): 200년에발표된 Nutritional Support Core Curriculum을통하여영양선별검사및평가도구에대한가이드라인을제시하였음. ) 선별검사로는 6개월내에 0% 이상의체중감소나이상체중의 20% 이하의체중을보이는경우, 최근영양지원의과거력그리고앞으로 7일이상의경구영양섭취불가능이예상되는경우에해당되는지를평가함. 2) 선별검사에서영양결핍의위험군으로판단되는경우추가적인영양평가를통하여상세한과거력과 anthropometric data, biochemical index 그리고신체검사등을시행하여영양지원여부및영양지원계획의기본자료로활용하게됨. 3) 비위험군으로판정되는경우정기적인재선별검사를시행하도록추천하고있음 ( 그림 2). REFERENCES.Engelman DT, Adams DH, Byrne JG, Aranki SF, Collins JJ Jr, Couper GS, et al. Impact of body mass index and albumin on morbidity and mortality after cardiac surgery. J Thorac Cardiovasc Surg 999;8(5): Kama NA, Coskun T, Yuksek YN, Yazgan A. Factors affecting post- operative mortality in malignant biliary tract obstruction. Hepato-Gastroenterology 999;46(25): Koval KJ, Maurer SG, Su ET, Aharonoff GB, Zuckerman JD. The effects of nutritional status on outcome after hip fracture. J Orthop Trauma 999;3(3): Velanovich V. The value of routine preoperative laboratory testing in predicting postoperative complications: a multivariate analysis. Surgery 99;09(3 Pt ): Dannhauser A, Van Zyl JM, Nel CJ. Preoperative nutritional status and prognostic nutritional index in patients with benign disease undergoing abdominal operations-part II. J Am Coll Nutr 995;4(): Malone DL, Genuit T, Tracy JK, Gannon C, Napolitano LM. Surgical site infections: reanalysis of risk factors. J Surg Res 2002;03(): Rey-Ferro M, Castano R, Orozco O, Serna A, Moreno A. Nutritional and immunologic evaluation of patients with gastric cancer before and after surgery. Nutrition 997;3(0): Kondrup J, Rasmussen HH, Hamberg O, Stanga Z. Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr 2003;22(3): Ferguson M, Capra S, Bauer J, Banks M. Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition 999;5(6): Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, Mendelson RA, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr 987;(): Guigoz Y. The Mini Nutritional Assessment (MNA) review of the literature-what does it tell us? J Nutr Health Aging 2006; 0(6):466-85; discussion Joint Commission on Accreditation of Healthcare Organizations Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations Kovacevich DS, Boney AR, Braunschweig CL, Perez A, Stevens M. Nutrition risk classification: a reproducible and valid tool for nurses. Nutrition in clinical practice: official publication of the American Society for Parenteral and Enteral Nutrition 997;2(): Perioperative total parenteral nutrition in surgical patients. The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group. N Engl J Med 99;325(8): Laporte M, Villalon L, Thibodeau J, Payette H. Validity and reliability of simple nutrition screening tools adapted to the elderly population in healthcare facilities. J Nutr Health Aging 200;5(4): Kruizenga HM, Van Tulder MW, Seidell JC, Thijs A, Ader HJ, Van Bokhorst-de van der Schueren MA. Effectiveness and cost-effectiveness of early screening and treatment of malnourished patients. Am J Clin Nutr 2005;82(5): Hamwi G. Changing dietary concepts. In: Danowski TS, ed. Diabetes Mellitus: Diagnosis and Treatment, Vol.. New York, NY: American Diabetes Association. 964; Hammond K. Dietary and clinical assessment. In: Mahan K, Escott-Stump S, eds. Krause s Food, Nutrition, and Diet Therapy. th ed. Philadelphia, PA: Saunders. 2004; Wakahara T, Shiraki M, Murase K, Fukushima H, Matsuura K, Fukao A, et al. Nutritional screening with Subjective Global Assessment predicts hospital stay in patients with digestive diseases. Nutrition 2007;23(9): Pham NV, Cox-Reijven PL, Greve JW, Soeters PB. Application of subjective global assessment as a screening tool for malnutrition in surgical patients in Vietnam. Clin Nutr 2006; 25(): Hasse J, Strong S, Gorman MA, Liepa G. Subjective global assessment: alternative nutrition-assessment technique for liver-transplant candidates. Nutrition 993;9(4): Sezer S, Ozdemir FN, Afsar B, Colak T, Kizay U, Haberal M. Subjective global assessment is a useful method to detect malnutrition in renal transplant patients. Transplant Proc 2006; 38(2): Ottery FD. Rethinking nutritional support of the cancer patient: the new field of nutritional oncology. Semin Oncol 994;2(6):

9 50 Surgical Metabolism and Nutrition Vol. 4 No. 2, Antoun S, Rey A, Beal J, Montange F, Pressoir M, Vasson MP, et al. Nutritional risk factors in planned oncologic surgery: what clinical and biological parameters should be routinely used? World J Surg 2009;33(8): Lean ME, Han TS, Deurenberg P. Predicting body composition by densitometry from simple anthropometric measurements. Am J Clin Nutr 996;63(): Jebb SA, Elia M. Techniques for the measurement of body composition: a practical guide. Int J Obes Relat Metab Disord 993;7(): Gabay C, Kushner I. Acute-phase proteins and other systemic responses to inflammation. N Engl J Med 999;340(6): McClave SA, Mitoraj TE, Thielmeier KA, Greenburg RA. Differentiating subtypes (hypoalbuminemic vs marasmic) of protein-calorie malnutrition: incidence and clinical significance in a university hospital setting. JPEN J Parenter Enteral Nutr 992;6(4): Sganga G, Siegel JH, Brown G, Coleman B, Wiles CE 3rd, Belzberg H, et al. Reprioritization of hepatic plasma protein release in trauma and sepsis. Arch Surg 985;20(2): Jensen GL. Inflammation as the key interface of the medical and nutrition universes: a provocative examination of the future of clinical nutrition and medicine. JPEN J Parenter Enteral Nutr 2006;30(5): Jensen GL, Bistrian B, Roubenoff R, Heimburger DC. Malnutrition syndromes: a conundrum vs continuum. JPEN J Parenter Enteral Nutr 2009;33(6): Ingenbleek Y, Carpentier YA. A prognostic inflammatory and nutritional index scoring critically ill patients. Int J Vitam Nutr Res 985;55(): Hoffenberg R, Black E, Brock JF. Albumin and gamma-globulin tracer studies in protein depletion states. J Clin Invest 966; 45(): Kondrup J, Allison SP, Elia M, Vellas B, Plauth M. ESPEN guidelines for nutrition screening Clin Nutr 2003;22(4): 45-2.

한국성인에서초기황반변성질환과 연관된위험요인연구

한국성인에서초기황반변성질환과 연관된위험요인연구 한국성인에서초기황반변성질환과 연관된위험요인연구 - - i - - i - - ii - - iii - - iv - χ - v - - vi - - 1 - - 2 - - 3 - - 4 - 그림 1. 연구대상자선정도표 - 5 - - 6 - - 7 - - 8 - 그림 2. 연구의틀 χ - 9 - - 10 - - 11 -