Diagnostic criteria for malnutrition - An ESPEN Consensus Statement

Body impedance analysis to estimate malnutrition in inflammatory bowel disease patients - A cross-sectional study

OBJECTIVE

Malnutrition is a common clinical problem in patients with inflammatory bowel diseases (IBD). However, a gold standard for the detection of malnutrition in IBD patients is lacking.

METHODS

A cross-sectional study to assess malnutrition in patients with IBD and healthy controls (HCs). Clinical characteristics (Montreal classification, disease activity, previous surgery) and mutations in the NOD2 gene in patients with Crohn's disease (CD) were obtained. We performed a nutritional assessment with screening for nutritional risk and diagnosis for malnutrition (Malnutrition Universal Screening Tool [MUST]) score, NRS-2002, European Society for Clinical Nutrition and Metabolism (ESPEN), and Global Leadership Initiative on Malnutrition (GLIM) criteria and performed body impedance analysis (BIA).

RESULTS

101 IBD patients (57 CD and 44 ulcerative colitis (UC) and 50 HC were included in a single northern German tertiary center. GLIM criteria detected malnutrition significantly more often compared to the ESPEN criteria. Active disease, a long-standing disease course, and previous surgery were associated with reduced muscle mass. IBD patients had a higher fat mass index compared to HC. Mutations in the NOD2 gene had no effect on nutritional status.

CONCLUSIONS

The GLIM criteria detect malnutrition at a higher rate compared to ESPEN. Specific disease factors might put IBD patients at a higher risk for the development of malnutrition, so these patients might benefit from a frequently performed screening, which might result in a favorable disease course.

A scoping review of malnutrition in patients undergoing interventions for peripheral arterial disease

BACKGROUND

Peripheral arterial disease (PAD) is associated with comorbid conditions and frailty. The role of preoperative nutrition in patients with PAD has not been well characterized. In the present scoping review, we sought to describe the prevalence and prognostic implications of preoperative malnutrition in patients undergoing vascular interventions for claudication or chronic limb-threatening ischemia (CLTI).

METHODS

We systematically searched for studies across six databases from inception to August 2021. Studies that had focused on patients with claudication or CLTI who had undergone open or endovascular procedures were included if preoperative nutrition had been measured and correlated with a clinical outcome.

RESULTS

Of 4186 records identified, 24 studies had addressed the prevalence or prognostic effects of malnutrition in patients who had undergone interventions for PAD. The proportion of women included in these studies ranged from 6% to 58%. The prevalence of preoperative malnutrition ranged from 14.6% to 72%. Seven different malnutrition assessments had been used in these studies. Across all the scales, preoperative malnutrition was associated with at least one of the following outcomes: mortality, postoperative complications, length of stay, readmission rates, and delayed wound healing.

CONCLUSIONS

A variety of tools were used to measure malnutrition in patients undergoing interventions for PAD. Our findings suggest that preoperative malnutrition is associated with adverse clinical outcomes for patients undergoing open and endovascular procedures for claudication or CLTI and that consensus is lacking regarding which tool to use. Clinicians and surgeons should be sensitized to the importance of assessing for malnutrition preoperatively in adults undergoing interventions for PAD.

Low muscle mass in COVID-19 critically-ill patients: Prognostic significance and surrogate markers for assessment

INTRODUCTION

Low muscle mass is a common condition in the critically ill population and is associated with adverse clinical outcomes. The primary aim of this study was to analyze the prognostic significance of low muscle mass using computed tomography (CT) scans in COVID-19 critically ill patients. A second objective was to determine the accuracy and agreement in low muscle mass identification using diverse markers compared to CT as the gold standard.

METHODS

This was a prospective cohort study of COVID-19 critically ill patients. Skeletal muscle area at the third lumbar vertebra was measured. Clinical outcomes (intensive care unit [ICU] and hospital length of stay [LOS], tracheostomy, days on mechanical ventilation [MV], and in-hospital mortality) were assessed. Phase angle, estimated fat-free mass index, calf circumference, and mid-upper arm circumference were measured as surrogate markers of muscle mass.

RESULTS

Eighty-six patients were included (mean age ± SD: 48.6 ± 12.9; 74% males). Patients with low muscle mass (48%) had a higher rate of tracheostomy (50 vs 20%, p = 0.01), prolonged ICU (adjusted HR 0.53, 95%CI 0.30-0.92, p = 0.024) and hospital LOS (adjusted HR 0.50, 95% CI 0.29-0.86, p = 0.014). Bedside markers of muscle mass showed poor to fair agreement and accuracy compared to CT-assessed low muscle mass.

CONCLUSION

Low muscle mass at admission was associated with prolonged length of ICU and hospital stays. Further studies are needed to establish targeted nutritional interventions to halt and correct the catabolic impact of COVID-19 in critically ill patients, based on standardized and reliable measurements of body composition.

Chinese Clinical Practice Guideline for the Management of "CKD-PeriDialysis"-the Periods Prior to and in the Early-Stage of Initial Dialysis

The National Experts Group on Nephrology have developed these guidelines to improve the management of pre-dialysis and initial dialysis patients with chronic kidney disease (CKD) (two periods contiguous with dialysis initiation termed here 'PeriDialysis CKD'). The pre-dialysis period is variable, whereas the initial dialysis period is more fixed at 3 months to 6 months after initiating dialysis. The new concept and characteristics of 'CKD-PeriDialysis' are proposed in the guideline. During the CKD-PeriDialysis period, the incidence rate of complications, mortality and treatment cost significantly increases and the glomerular filtration rate (GFR) rapidly decreases, which requires intensive management. The guideline systematically and comprehensively elaborates the recommendations for indicators to be used in for disease evaluation, timing and mode selection of renal replacement therapy, dialysis adequacy evaluation, and diagnosis and treatment of common PeriDialysis complications. Finally, future research directions of CKD-PeriDialysis are proposed. CKD-PeriDialysis management is a difficult clinical issue in kidney disease, and the development and implementation of these guidelines is important to improve the management of CKD-PeriDialysis patients in China, which could ultimately improve survival rates and quality of life, and reduce the medical burden.

Body mass index and Mini Nutritional Assessment-Short Form as predictors of in-geriatric hospital mortality in older adults with COVID-19

BACKGROUND & AIMS

Overweight and obesity have been consistently reported to carry an increased risk for poorer outcomes in coronavirus disease 2019 (COVID-19) in adults. Existing reports mainly focus on in-hospital and intensive care unit mortality in patient cohorts usually not representative of the population with the highest mortality, i.e. the very old and frail patients. Accordingly, little is known about the risk patterns related to body mass and nutrition in very old patients. Our aim was to assess the relationship between body mass index (BMI), nutritional status and in-geriatric hospital mortality among geriatric patients treated for COVID-19. As a reference, the analyses were performed also in patients treated for other diagnoses than COVID-19.

METHODS

We analyzed up to 10,031 geriatric patients with a median age of 83 years of which 1409 (14%) were hospitalized for COVID-19 and 8622 (86%) for other diagnoses in seven geriatric hospitals in the Stockholm region, Sweden during March 2020-January 2021. Data were available in electronic hospital records. The associations between 1) BMI and 2) nutritional status, assessed using the Mini-Nutritional Assessment - Short Form (MNA-SF) scale, and short-term in-geriatric hospital mortality were analyzed using logistic regression.

RESULTS

After adjusting for age, sex, comorbidity, polypharmacy, frailty and the wave of the pandemic (first vs. second), underweight defined as BMI<18.5 increased the risk of in-hospital mortality in COVID-19 patients (odds ratio [OR] = 2.30; confidence interval [CI] = 1.17-4.31). Overweight and obesity were not associated with in-hospital mortality. Malnutrition; i.e. MNA-SF 0-7 points, increased the risk of in-hospital mortality in patients treated for COVID-19 (OR = 2.03; CI = 1.16-3.68) and other causes (OR = 6.01; CI = 2.73-15.91).

CONCLUSIONS

Our results indicate that obesity is not a risk factor for very old patients with COVID-19, but emphasize the role of underweight and malnutrition for in-hospital mortality in geriatric patients with COVID-19.

Are Undernutrition and Obesity Associated with Post-Discharge Mortality and Re-Hospitalization after Hospitalization with Community-Acquired Pneumonia?

Undernutrition is associated with increased mortality after hospitalization with community-acquired pneumonia (CAP), whereas obesity is associated with decreased mortality in most studies. We aimed to determine whether undernutrition and obesity are associated with increased risk of re-hospitalization and post-discharge mortality after hospitalization. This study was nested within the Surviving Pneumonia cohort, which is a prospective cohort of adults hospitalized with CAP. Patients were categorized as undernourished, well-nourished, overweight, or obese. Undernutrition was based on diagnostic criteria by the European Society for Clinical Nutrition and Metabolism. Risk of mortality was investigated using multivariate logistic regression and re-hospitalization with competing risk Cox regression where death was the competing event. Compared to well-nourished patients, undernourished patients had a higher risk of 90-day (OR 3.0, 95% CI 1.0; 21.4) mortality, but a similar 30-day and 180-day mortality risk. Obese patients had a similar re-hospitalization and mortality risk as well-nourished patients. In conclusion, among patients with CAP, undernutrition was associated with increased risk of mortality. Undernourished patients are high-risk patients, and our results indicate that in-hospital screening of undernutrition should be implemented to identify patients at mortality risk. Studies are required to investigate whether nutritional therapy after hospitalization with CAP would improve survival.

Effect of an enteral amino acid blend on muscle and gut functionality in critically ill patients: a proof-of-concept randomized controlled trial

Background

A defining feature of prolonged critical illness is muscle wasting, leading to impaired recovery. Supplementation with a tailored blend of amino acids may bolster the innate gut defence, promote intestinal mucosa repair and limit muscle loss.

Methods

This was a monocentric, randomized, double-blind, placebo-controlled study that included patients with sepsis or acute respiratory distress syndrome. Patients received a specific combination of five amino acids or placebo mixed with enteral feeding for 21 days. Markers of renal function, gut barrier structure and functionality were collected at baseline and 1, 2, 3 and 8 weeks after randomization. Muscle structure and function were assessed through MRI measurements of the anterior quadriceps volume and by twitch airway pressure. Data were compared between groups relative to the baseline.

Results

Thirty-five critically ill patients were randomized. The amino acid blend did not impair urine output, blood creatinine levels or creatinine clearance. Plasma citrulline levels increased significantly along the treatment period in the amino acid group (difference in means [95% CI] 5.86 [1.72; 10.00] nmol/mL P = 0.007). Alanine aminotransferase and alkaline phosphatase concentrations were lower in the amino acid group than in the placebo group at one week (ratio of means 0.5 [0.29; 0.86] (P = 0.015) and 0.73 [0.57; 0.94] (P = 0.015), respectively). Twitch airway pressure and volume of the anterior quadriceps were greater in the amino acid group than in the placebo group 3 weeks after randomization (difference in means 10.6 [0.99; 20.20] cmH₂0 (P = 0.035) and 3.12 [0.5; 5.73] cm³/kg (P = 0.022), respectively).

Conclusions

Amino acid supplementation increased plasma citrulline levels, reduced alanine aminotransferase and alkaline phosphatase levels, and improved twitch airway pressure and anterior quadriceps volume.

Trial registration ClinicalTrials.gov, NCT02968836. Registered November 21, 2016.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04232-5.

The Mini Nutritional Assessment tool's applicability for the elderly in Ethiopia: validation study

Background

The Mini Nutrition Assessment (MNA) is a widely used and valid tool for screening and assessment of malnutrition among the elderly population worldwide. However, MNA has not been validated among the Ethiopian elderly population and this study assessed the validity of the tool for the target population.

Methods

Cross-sectional validation study design employed to validate MNA in Meki town, East Ethiopia. This study included 176 randomly selected elders living in the community, whereas amputated, bedridden, visible deformity, known liver and/or renal disorders were excluded. The original MNA questionnaires were translated to local language and administered to each participant after doing the pretest. The anthropometric, self-perception of nutritional status and serum albumin concentrations were measured. Reliability, validity, sensitivity, specificity, Positive Predictive Value (PPV), and Negative Predictive Value (NPV) were calculated. Receiver-operating characteristic (ROC) curve analysis was plotted to identify the area under the curve (AUC) and optimal cut-off value for the prediction of malnutrition.

Result

A total of one hundred and seventy-six elders participated in this study. Of the total participants, 78(44.3%) were males. The mean (SD) age of the participants was 67.6 (±5.8) years and ranged from 60 to 84 years. The prevalence of malnutrition based on the MNA criteria (MNA < 17 points) was 18.2%, and 13.1% based on serum albumin concentration (<3 g/dl).The MNA had an overall Internal consistency of Cronbach's alpha 0.61. The tool also demonstrated significant criterion-related validity (0.75, p < 0.001) and concurrent validity (0.51, p < 0.001) with serum albumin concentration and self-perception of nutritional status respectively. Using the original cut-off point, the sensitivity, specificity, PPV and NPV of the tool were 93.5%, 44.6%, 65.4% and 86.0%, respectively. By modifying, the cut-off point to a value of <20.5, the sensitivity and specificity of the tool increases to 97.6% and 82.8% respectively. The AUC (95%CI) showed an overall accuracy of 92.7% (88.5, 96.9).

Conclusion

The MNA tool can be used as a valid malnutrition screening tool for the Ethiopian elderly population by modifying the original cut-off point.

Body composition and energy expenditure in anorexia nervosa: preliminary data of outpatients with recovering and active disease

BACKGROUND

In Anorexia Nervosa (AN) recovery, body mass index (BMI) may not reflect body composition. To investigate recovery, bioelectrical impedance (BIA) parameters and energy expenditure were investigated in patients with active and recovering AN, with emphasis on phase angle (PA), a BIA parameter.

METHODS

BMI, PA, indirect BIA parameters (fat free mass, fat mass, total body water, fat free mass index, fat mass index) and resting metabolic rate (RMR) were obtained. Data from subjects distributed to active AN (ANact, n = 9), recovered AN (ANrec, n = 9) and healthy individuals (HI) (n = 16) were compared employing univariate methods and ordinal logistic regression.

RESULTS

In univariate comparison, the BMI would not distinguish recovered individuals; this distinction was observed for the PA (p =  < 0,001). PA showed a good capacity to discriminate, between ANrec and HI (AUC = 0.792; CI = 0.564- 1.000; p = 0.017). In 2 models of ordinal logistic regression PA (OR = 0.123; 95% CI 0.030; 0.503 and OR = 0.091; 95% CI 0.016; 0.528) remained as a significant independent variable, indicating that increases in PA are related to higher probabilities of moving from ANact, to ANrec and to HI group. Bivariate regression indicated the presence of a relationship between PA and (R2 = 0.266, p = 0.002).

CONCLUSIONS

Changes in body composition and energy expenditure were observed in recovered anorexics with normal BMI. PA can play an important role in the assessment of recovering anorexic patients.

Utility of muscle ultrasound in nutritional assessment of children with nephrotic syndrome

BACKGROUND

Nutritional status assessment in children with nephrotic syndrome (NS) is critical for identifying patients who are at risk of protein-energy wasting (PEW) and for determining their nutritional needs and monitoring nutritional intervention outcomes.

METHODS

In a case-control study, we enrolled 40 children (age range: 2-16 years) with NS and 40 apparently healthy children (age and sex-matched) as a control group. Anthropometric data, as well as demographic, clinical, and laboratory data, were collected. A dietary intake assessment using a 3-day food intake record was done, and the quadriceps rectus femoris thickness (QRFT) and quadriceps vastus intermedius thickness (QVIT) were assessed using B-mode ultrasound and compared between both groups.

RESULTS

Children with NS had lower QRFT and QVIT measurements than control groups (p < 0.001). Inadequacy in protein intake occurred in 62.5% and 27.5% of the NS and control groups, respectively (p = 0.002). The thickness of the rectus and vastus muscles by ultrasound was significantly associated with the percentage of protein intake (p < 0.001). The ROC curve revealed that the best cutoff value of QRFT for the prediction of the patient at risk of malnutrition was ≤ 1.195 with an area under curve of 0.907, with p < 0.001.

CONCLUSION

In children with NS, skeletal muscle ultrasound is a simple and easy-to-use bedside technique for the identification of patients at risk of malnutrition. A higher resolution version of the Graphical abstract is available as Supplementary information.

Preoperative Rapid Weight Loss as a Prognostic Predictor After Surgical Resection for Pancreatic Cancer

OBJECTIVE

The aim of the study is to evaluate the influence of cachexia at the time of diagnosis of pancreatic ductal adenocarcinoma (PDAC) on prognosis in patients undergoing surgical resection.

METHODS

Patients with data on preoperative body weight (BW) change followed by surgical resection during 2008-2017 were selected. Large BW loss was defined as weight loss >5% or >2% in individuals with body mass index less than 20 kg/m2 within 1 year preoperatively. Influence of large BW loss, ΔBW defined as preoperative BW change (%) per month, prognostic nutrition index, and indices of sarcopenia.

RESULTS

We evaluated 165 patients with PDAC. Preoperatively, 78 patients were categorized as having large BW loss. ΔBW was ≤ -1.34% per month (rapid) and > -1.34% per month (slow) in 95 and 70 patients, respectively. The median postoperative overall survival of rapid and slow ΔBW groups was 1.4 and 4.4 years, respectively (P < 0.001). In multivariate analyses rapid ΔBW (hazard ratio [HR], 3.88); intraoperative blood loss ≥430 mL (HR, 1.89); tumor size ≥2.9 cm (HR, 1.74); and R1/2 resection (HR, 1.77) were independent predictors of worse survival.

CONCLUSIONS

Preoperative rapid BW loss ≥1.34% per month was an independent predictor of worse survival of patients with PDAC.

Hypoalbuminemia is associated with 30-day mortality in hip fracture patients independently of Body Mass Index

The aim of this study was to assess the possible association between P-Albumin and 30-day mortality in hip fracture patients. The study is based on information from a database of hip fracture patients, established and collected at Bispebjerg University Hospital (Copenhagen, Denmark). This database includes all femoral neck (DS720), pertrochanteric (DS721) and subtrochanteric fractures (DS722) admitted to Bispebjerg Hospital between 1996 and 2012. We further identified all surgically treated hip fracture patients aged >60 years with an available P-Albumin at admission. 1856 patients were eligible for inclusion in this study (73.7% female, 26.3% male). 11.8% of these had died within 30 days. Differences between continuous variables were tested using unpaired t-tests while differences in the distribution of categorical variables were tested using chi square tests. After adjusting for co-variates in a logistic regression model, the association between P-Albumin and 30-day mortality remained increased, (OR 1.09, 95% CI 1.05;1.11 (p < 0.0001)). This study shows an increased 30-day mortality risk among surgically treated hip fracture patients with decreasing levels of P-Albumin even after adjusting for age, sex, BMI, CCI and fracture type. Routine screening of patients for hypoalbuminemia at hospital admission may be beneficial in the management of hip fracture patients.

Surgical treatment of spinal deformities in spinal muscular atrophy: a single-center experience from China

PURPOSE

To report the clinical characteristics and surgical outcomes of scoliosis in patients with spinal muscular atrophy (SMA) from Mainland China.

METHODS

Nineteen patients were retrospectively analyzed. Demographic, anthropometric and respiratory parameters were collected preoperatively. Surgical program was analyzed. Radiographic data were measured perioperatively. Motor status, ventilation support, sitting ability and respiratory symptoms were evaluated preoperatively and at final follow-up.

RESULTS

Age at surgery was 17.08 (12.83, 20.08) years. More than 40% of patients were diagnosed with low weight. Pulmonary dysfunction was observed in all patients. All patients received posterior spinal fusion (PSF). Sacroiliac fixation with sacral-2 alar iliac technique was used in 16 patients. Major curve correction rate was 54.87 ± 16.14%. Pelvic obliquity correction rate was 63.84 ± 23.70%. T1-T12 height, space-available-for-lung ratio and thoracic transverse diameter were increased (p < 0.001). Percentage of patients capable of sitting independently increased from 26.32% preoperatively to 73.68% at final follow-up. Cumulative scores of sitting-related items in muscular dystrophy spine questionnaire improved from 19.11 ± 5.40 preoperatively to 26.21 ± 5.20 at final follow-up. Total scores of symptomatic domains in St. George's Respiratory Questionnaire decreased from 4 (2, 12) preoperatively to 1 (0, 3) at final follow-up.

CONCLUSIONS

SMA patients in China always present severe scoliosis at late adolescence, accompanied with high proportion of low weight and pulmonary dysfunction. PSF is effective for the correction of scoliosis and pelvic obliquity and the improvement of thoracic morphology. Sitting ability and respiratory symptoms were improved postoperatively.

Associations between serum mitokine levels and outcomes in stable COPD: an observational prospective study

Mitokines (Humanin (HN), GDF15 and FGF21) are produced as a result of mitochondrial dysfunction and may have major roles in chronic inflammation, malnutrition and exercise capacity in people with COPD. Except for GDF15, studies on this subject are lacking. A total of 165 patients with stable COPD and 49 smokers without COPD were enrolled. We assessed their serum mitokine levels and clinical characteristics at baseline. We recorded moderate and severe exacerbation for the next 12 months. Baseline serum HN (p = 0.037) and GDF-15 (p = 0.013) levels were higher in the COPD group. High HN levels were independently associated with a high risk of exacerbation (HRE) (OR 2.798, 95% CI 1.266-6.187, p = 0.011), malnutrition (OR 6.645, 95% CI 1.859-23.749, p = 0.004), and 6MWD (OR 0.995, 95% CI 0.991-0.999, p = 0.008), and future moderate (HR 1.826, 95% CI 1.181-2.822, p = 0.007) and severe exacerbations (HR 3.445, 95% CI 1.357-8.740, p = 0.009). High GDF15 levels were associated with HRE (OR 3.028, 95% CI 1.134-8.083, p = 0.027), 6MWD (OR 0.995, 95% CI 0.990-0.999, p = 0.017) and predicted desaturation in 6MWT (OR 3.999, 95% CI 1.487-10.757, p = 0.006). High FGF21 levels were associated with HRE (OR 2.144, 95% CI 1.000-4.600, p = 0.05), and predicted future severe exacerbation (HR 4.217, 95% CI 1.459-12.193, p = 0.008). The mitokine levels were higher in patients with COPD than smokers without COPD, and were associated with important clinical outcomes such as exercise capacity and COPD exacerbation. Among the mitokines, HN showed the strongest association with COPD and may serve as a future risk biomarker in this disease.Trial registation NCT04449419.

Underweight Body Mass Index Is Associated With Increased In-Hospital Complications and Length of Stay After Revision Total Joint Arthroplasty

INTRODUCTION

The purpose of this study was to assess the impact of underweight status on in-hospital postoperative outcomes and complications after revision total joint arthroplasty (rTJA) of the hip and knee.

METHODS

Data from the National Inpatient Sample were used to identify all patients undergoing rTJA in the United States between 2006 and 2015. Patients were divided into two groups based on a concomitant diagnosis of underweight body mass index and a control normal weight group. Propensity score analysis was performed to determine whether underweight body mass index was a risk factor for in-hospital postoperative complications and resource utilization.

RESULTS

A total of 865,993 rTJAs were analyzed. Within the study cohort, 2,272 patients were classified as underweight, whereas 863,721 were classified as a normal weight control group. Underweight patients had significantly higher rates of several comorbidities compared with the control cohort. Underweight patients had significantly higher rates of any complication (49.98% versus 33.68%, P = 0.0004) than normal weight patients. Underweight patients also had significantly greater length of stay compared with normal weight patients (6.50 versus 4.87 days, P < 0.0001).

CONCLUSION

Underweight patients have notably higher rates of any complication and longer length of stay after rTJA than those who are not underweight. These results have important implications in preoperative patient discussions and perioperative management. Standardized preoperative protocols should be developed and instituted to improve outcomes in this patient cohort.

The effects of synbiotic supplementation on enteral feeding tolerance, protein homeostasis, and muscle wasting of critically ill adult patients: a randomized controlled trial

Background

Enteral feeding intolerance, energy-protein malnutrition, and muscle wasting are common conditions in the critical care setting. The primary aim of this study was to investigate the effect of synbiotic supplementation on enteral feed volume, energy and protein homeostasis, and muscle mass maintenance in critically ill adult patients.

Methods

A consecutive of 42 patients admitted to the Edalatian Medical ICU, requiring enteral nutrition (EN), were prospectively randomized to receive the synbiotic capsule (containing a combination of Lactobacillus, Bifidobacterium, Streptococcus, and fructooligosaccharides) or placebo (21 patients in each group) for a maximum of 14 days. Enteral intolerance and energy homeostasis were evaluated on a daily basis. Nitrogen balance and 24-h urine creatinine excretion were recorded on days 1 and 14. Mid-arm circumference was recorded every 3 days.

Results

Mean EN volume, energy, and protein intake per day were 962.5 ± 533.82 ml, 770 ± 427.05 kcal, and 38.5 ± 21.35 g (fourth day) vs. 590 ± 321.1 ml, 472 ± 256.81 kcal, and 23.6 ± 12.84 g (first day) in the synbiotic group (p < 0.05). Changes in the placebo group were not statistically significant. On day 1, nitrogen balance (NB) was − 19.84 ± 8.03 in the synbiotic vs. − 10.99 ± 9.12 in the placebo group (p = 0.003). On day 14, NB was − 14.18 ± 13.05 in the synbiotic and − 9.59 ± 7.71 in the placebo group (p = 0.41). Mid-arm circumference (MAC), 24-h urine creatinine, and creatinine-height index were almost steady in the synbiotic group, while they decreased in the placebo group.

Conclusion

Overall, it can be concluded that enteral nutrition supplemented with synbiotics has no statistically significant effect on energy and protein homeostasis and muscle mass maintenance of critically ill patients on day 14, but it can increase enteral feed volume and energy and protein intake during the first 4 days of ICU admission.

Trial registration

The trial protocol has been approved in Iranian Registry of Clinical Trials on March 17, 2019. The registration reference is IRCT20190227042857N1.

The prevalence of hyperuricemia and its correlates in Zhuang nationality, Nanning, Guangxi Province

BACKGROUND

Hyperuricemia has an increasing incidence in various regions year by year, in this study, we evaluated the prevalence of hyperuricemia in a routine physical examination in Nanning, Guangxi Province, and analyzed the influencing factors of hyperuricemia, aiming to provide evidence for the prevention and treatment of hyperuricemia and related diseases.

METHODS

Data were collected from 1957 patients who underwent physical examinations at the First Affiliated Hospital of Guangxi Medical University in China since 2017. Questionnaires were structured, including subjects' demographics, lifestyle, personal history, chronic disease history, medication history, etc. UA (uricase method), TC (cholesterol oxidase method), TG (glycerol phosphate oxidase method), HDL-C (direct method), LDL-C (direct method), BUN (rate method), creatinine (sarine oxidase method), and GLU (oxidase-peroxidase method) were detected. Independent risk factors for hyperuricemia were determined by bivariate non-conditional logistic regression analysis.

RESULTS

The overall prevalence of hyperuricemia was 16.6% (19.5% in males and 14.9% in females). Gender, waist circumference, BMI, the proportion of drinking, hypertension, high education, serum concentrations of TC, TG, LDL-C, BUN, and creatinine were significantly higher and the serum concentration of HDL-C was significantly lower in patients with and without hyperuricemia (all p < 0.05). Waist circumference, BMI, BUN, and creatinine were independent risk factors for hyperuricemia.

CONCLUSION

The prevalence of hyperuricemia is very high in Guangxi. Public health lectures should be conducted to encourage people to establish a healthy lifestyle and strengthen early intervention for hyperuricemia to reduce the risk of cardio-cerebrovascular and other related diseases.

Malnutrition diagnosed by the Global Leadership Initiative on Malnutrition criteria as a predictor of gait ability in patients with hip fracture

AIM

Malnutrition is common in patients with hip fractures and is associated with poor clinical outcomes. The Global Leadership Initiative on Malnutrition (GLIM) and the European Society for Clinical Nutrition and Metabolism (ESPEN) criteria are widely used to diagnose malnutrition. However, the criteria regarding the prediction of gait ability in patients with hip fractures during the acute phase remain unclear. We aimed to determine whether GLIM or ESPEN criteria were more appropriate for predicting gait ability at discharge from an acute hospital.

METHODS

This retrospective observational study included hip fracture patients aged ≥ 65 years. Patients were classified as malnourished or non-malnourished according to the GLIM and ESPEN criteria at admission. The primary outcome was gait ability, which was evaluated using functional ambulation categories (FAC) at discharge. We categorized into those with (FAC score ≥ 3 points) and without (< 3 points) improved gait ability. Logistic regression analysis for FAC was performed to determine whether GLIM or ESPEN was predictive of gait ability at discharge.

RESULTS

Overall 157 patients were included; the median age was 84 years, and 75.3% were female. The prevalence of malnutrition was 73.9% and 25.5% according to the GLIM and ESPEN criteria, respectively. Logistic regression analysis showed that malnutrition evaluated using the GLIM criteria were predictive of lower FAC at discharge (odds ratio, 0.394; 95% CI, 0.164-0.946), while ESPEN criteria did not show statistically significant differences (odds ratio, 0.625; 95% CI, 0.292-1.335).

CONCLUSION

GLIM criteria are useful for predicting gait ability at discharge during acute hospitalization in patients with hip fractures.

Dietary management of adults with IBD - the emerging role of dietary therapy

Historically, dietitians played a minor part in the management of inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis. Patients were commonly referred for consequences of uncontrolled disease, such as malnutrition and bowel obstruction risk. Today, dietitians are fundamental members of the multidisciplinary IBD team, from educating on the role of diet at diagnosis and throughout the lifespan of a patient with IBD to guiding primary induction therapy. This aspect is reflected in published guidelines for IBD management, which previously placed diet as only a minor factor, but now have diet-specific publications. This Review describes a four-step approach in a dietitian's assessment and management of diet in patients with IBD: (1) identifying and correcting nutritional gaps and dietary imbalances; (2) considering diet to treat active disease with the use of exclusive enteral nutrition (EEN) or emerging diets that could replace EEN; (3) using therapeutic diets to control existing complications of IBD, such as reduced fibre to prevent bowel obstruction in stricturing disease or a fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet to manage co-existing functional gut symptoms; and (4) considering the role of diet in preventing IBD development in high-risk populations.

Nutritional intake and malnutrition in institutionalised and non-institutionalised older adults

Malnutrition (synonym: undernutrition) is prevalent among older adults, which may be partly related to changes in dietary intake, but evidence on the link between malnutrition and diet is scarce. The aims of this study were to estimate the association between energy/nutrients intake and malnutrition, and to characterise nutritional inadequacy in institutionalised and non-institutionalised older adults. A national survey was conducted including a Portuguese representative sample of nursing home (NH) residents (n 563) and community-dwellers (n 837) aged ≥ 65 years. Data included socio-demographic characteristics, self-reported health, loneliness feelings, nutritional status (Mini Nutritional Assessment^®) and dietary intake (two non-consecutive 24-h recalls). A higher energy intake was associated with lower odds of malnutrition risk (being 'at risk of malnutrition' or 'malnourished') in both settings, but only significant among NH residents after adjusting for confounders (NH: OR = 0·66, 95 % CI 0·50, 0·86; community: OR = 0·64, 95 % CI 0·37, 1·10). The intake of carbohydrates, fat, fibre, vitamin C, Na, K and Mg was inversely associated with malnutrition risk in NH residents, and protein, fat, vitamin B₆, folates, Na, K, Ca and Mg intake in community-dwellers. After additional adjustment for total energy, only Na and Mg intake of community-dwellers remained significantly associated. The prevalence of inadequate nutrient intake was generally higher for the malnutrition risk group, which was particularly evident among community-dwellers. The effect of dietary intake on nutritional status seems more dependent on total energy and carbohydrates intake in institutionalised elders, whereas among community-dwellers protein and some micronutrients appear to have a greater impact.

Predictive value of the preoperative prognostic nutritional index for postoperative progression in patients with pancreatic neuroendocrine neoplasms

Objective

The preoperative nutritional status of cancer patients is closely related to prognosis. The prognostic nutritional index (PNI) has been shown to predict the prognosis of a variety of tumors, but its study in pancreatic neuroendocrine neoplasms (pNENs) is lacking. The aim of the present study is to investigate the predictive value of the preoperative PNI for postoperative progression in patients with pNENs.

Methods

The medical records of 181 patients with pNENs, who underwent surgery, were retrospectively analyzed. A time-dependent receiver operating characteristic (ROC) curve was plotted to determine the optimal cut-off value of the preoperative PNI. Correlations between the preoperative PNI and clinicopathological parameters were analyzed using multiple linear regression. A Kaplan-Meier curve was applied to assess the progression-free survival (PFS) rate, which was tested using a log rank. Univariate and multivariate Cox proportional risk regression models were used to analyze the predictive value of the preoperative PNI on prognosis.

Results

The optimal cut-off value of the preoperative PNI was 48.275. The patients were divided into a high PNI group (PNI > 48.275, n = 92) and a low PNI group (PNI ≤ 48.275, n = 89). The proportion of patients with tumor progression after surgery was significantly higher in the low PNI group compared with that in the high PNI group (P = 0.004). The Kaplan-Meier curve showed that the PFS rate after surgery was significantly lower in the low PNI group compared with that in the high PNI group (P = 0.026). The preoperative PNI was an independent predictor of PFS (HR: 2.727, 95% CI: 1.174∼6.333, P = 0.020).

Conclusion

The preoperative PNI has a predictive value for postoperative progression in patients with pNENs.

Intradialytic parenteral nutrition using a standard amino acid solution not for renal failure in maintenance hemodialysis patients with malnutrition: a multicenter pilot study

Background

Standard amino acid solutions have recently been removed from the contraindications for use in dialysis patients in Japan. However, the details of their safety and efficacy in these patients are still not known. In this study, we investigated the safety and efficacy of intradialytic parenteral nutrition (IDPN) using ENEFLUID® injection containing standard amino acids, glucose, electrolytes, fats, and water-soluble vitamins in maintenance hemodialysis patients with malnutrition.

Methods

This clinical trial was designed as a multicenter, prospective, non-randomized, open-label, single-arm, observational pilot study. The participants were patients on maintenance hemodialysis who were in the nutritional high-risk group according to the Nutritional Risk Index for Japanese Hemodialysis Patients. One bag of ENEFLUID® injection was administered during every hemodialysis session for 12 weeks. The primary endpoint was change in serum transthyretin levels between before and after the 12-week period. As safety endpoints, we evaluated changes in body fluid volume and blood biochemical tests, including blood urea nitrogen and electrolytes, as well as blood glucose variability using flash glucose monitoring (FGM).

Results

The mean age and body mass index of the 13 participants were 79.0 ± 10.7 years and 18.0 ± 1.7 kg/m2, respectively. No significant changes were observed in nutritional parameters, including serum transthyretin, between before and after the start of the study. After IDPN initiation, there was no obvious fluid overload or significant changes in blood biochemical tests, including electrolytes, and the treatment could be safely continued for 12 weeks. In the FGM analysis, asymptomatic hypoglycemia during hemodialysis was observed at the beginning of the study, but there was a trend toward improvement after 12 weeks (area over the curve < 70 mg/dl per dialysis session: 747.5 ± 1333.9 to 21.6 ± 54.3, P = 0.09).

Conclusions

IDPN using ENEFLUID® injection can be safely continued, although it does not significantly improve markers of nutritional status. It also showed the potential to ameliorate asymptomatic hypoglycemia during hemodialysis sessions. More detailed studies of the improvement in nutritional indicators are needed.

Trial registration: This study was registered with the University Hospital Medical Information Network-Clinical Trials Registry (UMIN-CTR) on May 9, 2021 (registration ID, UMIN000044051).

PROtein enriched MEDiterranean diet to combat undernutrition and promote healthy neuroCOGnitive ageing in older adults: The PROMED-COG consortium project

Dementia is a major public health challenge owing to its increasing prevalence and recognised impact on disability among older adults. Observational data indicate that weight loss is associated with increased dementia risk of 30%-40% and precedes a diagnosis of cognitive impairment or dementia by at least one decade. Although relatively little is known about the mechanisms of unintentional weight loss in dementia, this provides a window of opportunity to intervene with strategies to counteract undernutrition and delay, or prevent, the onset of dementia. This article provides an overview of the PROMED-COG project and associated work packages. The project aimes to (1) strengthen the epidemiologic evidence to better understand the potential benefits of combating undernutrition for healthy neurocognitive ageing; (2) increase scientific knowledge on the balance between a protein enriched Mediterranean diet (PROMED) and physical exercise to prevent undernutrition and promote healthy neurocognitive ageing, and generate data on mechanistic pathways; (3) stimulate collaboration and capacity building for nutrition and neurocognitive ageing research in Europe; and (4) develop public and practice recommendations to combat undernutrition and promote healthy neurocognitive ageing in older adults. Findings will provide new and critical insights into the role of undernutrition in neurocognitive ageing, how this role can differ by sex, genetic risk and timing of undernutrition exposure, and how modifications of dietary and physical activity behaviour can reduce the burden of undernutrition and neurodegeneration. The research outcomes will be useful to inform policy and practice about the dietary guidelines of older people and provide insight to industry for the development of food-based solutions to prevent undernutrition.

Association between body composition and survival in head and neck cancer patients undergoing radiotherapy

BACKGROUND

Body composition may influence the prognosis of head and neck cancer (HNC) patients. To find out the most crucial factors in this relationship, we explored the association between body composition and survival.

METHODS

In this prospective longitudinal study, HNC patients who underwent radiotherapy (RT) from March 2017 to December 2018 were recruited. The association between body composition and survival was analyzed using Cox proportional hazard regression.

RESULTS

Final analysis included 316 patients, with a median follow-up of 34.4 months. Multivariable analysis revealed that weight loss 6 months before RT and body composition changes during RT did not affect the survival outcome. However, patients with low appendicular skeletal muscle mass index (ASMI) before RT exhibited poor overall survival (OS). ASMI before RT was an independent prognostic factor for OS.

CONCLUSIONS

Body composition loss was common during RT, and ASMI before RT independently influenced the survival outcomes of HNC patients.

Objective and Subjective Appetite Assessment in Patients with Gynecological Cancer: A Pre- and Post-Operative Pilot Study

Although appetite and its disorders have been implicated in disease progression and outcomes, ghrelin concentrations, an objective appetite measure, are rarely assessed in patients with gynecological malignancies. The present study aimed to assess changes in post-operative versus pre-operative appetite levels in patients with gynecological cancers scheduled for tumor removal surgery (N = 53). Acylated ghrelin concentrations were assessed as an objective appetite proxy, whereas the Council of Nutrition appetite questionnaire (CNAQ) was employed as a subjective appetite measure. Ghrelin concentrations were increased post-operatively (median: 12.1 pg/mL, IQR: 0.67 to 23.5, p-value = 0.001) but the perceived appetite of patients (CNAQ) remained unchanged (median: -1, IQR: -3 to 1). Tumor removal surgery decreased all anthropometric indices (body weight, body mass index, waist and hips circumferences, triceps skinfolds, body fat, fat mass and fat mass index, p-value ≤ 0.001 for all) and doubled the risk of malnutrition among patients. No difference was recorded in the change in participants' objective and subjective appetite when they were classified according to the tumor type. No correlation was observed between ghrelin concentrations and CNAQ score pre-operatively (Spearman's rho correlation coefficient = -0.181, p-value = 0.298) or post-operatively (Spearman's rho correlation coefficient = 0.071, p-value = 0.684). The observed post-operative rise in ghrelin concentrations is associated with body weight loss and consists of a possible defense mechanism of the human body, aiming to prolong survival.

The Outcomes of Nutritional Support Techniques in Patients with Gastrointestinal Cancers

Gastrointestinal cancers represent a major cause of morbidity and mortality worldwide. A significant issue regarding the therapeutic management of these patients consists of metabolic disturbances and malnutrition. Nutritional deficiencies have a negative impact on both the death rates of these patients and the results of surgical or oncological treatments. Thus, current guidelines recommend the inclusion of a nutritional profile in the therapeutic management of patients with gastrointestinal cancers. The development of digestive endoscopy techniques has led to the possibility of ensuring the enteral nutrition of cancer patients without oral feeding through minimally invasive techniques and the avoidance of surgeries, which involve more risks. The enteral nutrition modalities consist of endoscopy-guided nasoenteric tube (ENET), percutaneous endoscopic gastrostomy (PEG), percutaneous endoscopic gastrostomy with jejunal tube extension (PEG-J), direct percutaneous endoscopic jejunostomy (DPEJ) or endoscopic ultrasound (EUS)-guided gastroenterostomy.

Prevention, identification and management of malnutrition in older people in the community

Malnutrition, specifically undernutrition, is a significant health concern among older people, yet it is under-detected and under-treated in the community. The causes of malnutrition are complex and multifactorial, and the risk has been exacerbated by the coronavirus disease 2019 (COVID-19) pandemic due to social isolation and loneliness, which can affect older people's appetite and thus reduce their nutritional intake. This article discusses the causes and consequences of malnutrition in older people and describes what is involved in malnutrition screening, person-centred care planning and treatment. The author considers various approaches to overcoming the barriers associated with identifying malnutrition in older people in the community and outlines the role of the nurse in the effective management of malnutrition in this population.

Machine learning for infection risk prediction in postoperative patients with non-mechanical ventilation and intravenous neurotargeted drugs

Drug efficacy can be improved by understanding the effects of anesthesia on the neurovascular system. In this study, we used machine learning algorithms to predict the risk of infection in postoperative intensive care unit (ICU) patients who are on non-mechanical ventilation and are receiving hydromorphone analgesia. In this retrospective study, 130 patients were divided into high and low dose groups of hydromorphone analgesic pump patients admitted after surgery. The white blood cells (WBC) count and incidence rate of infection was significantly higher in the high hydromorphone dosage group compared to the low hydromorphone dosage groups (p < 0.05). Furthermore, significant differences in age (P = 0.006), body mass index (BMI) (P = 0.001), WBC count (P = 0.019), C-reactive protein (CRP) (P = 0.038), hydromorphone dosage (P = 0.014), and biological sex (P = 0.024) were seen between the infected and non-infected groups. The infected group also had a longer hospital stay and an extended stay in the intensive care unit compared to the non-infected group. We identified important risk factors for the development of postoperative infections by using machine learning algorithms, including hydromorphone dosage, age, biological sex, BMI, and WBC count. Logistic regression analysis was applied to incorporate these variables to construct infection prediction models and nomograms. The area under curves (AUC) of the model were 0.835, 0.747, and 0.818 in the training group, validation group, and overall pairwise column group, respectively. Therefore, we determined that hydromorphone dosage, age, biological sex, BMI, WBC count, and CRP are significant risk factors in developing postoperative infections.

Guidance for assessment of the muscle mass phenotypic criterion for the Global Leadership Initiative on Malnutrition diagnosis of malnutrition

The Global Leadership Initiative on Malnutrition (GLIM) provides consensus criteria for the diagnosis of malnutrition that can be widely applied. The GLIM approach is based on the assessment of three phenotypic (weight loss, low body mass index, and low skeletal muscle mass) and two etiologic (low food intake and presence of disease with systemic inflammation) criteria, with diagnosis confirmed by any combination of one phenotypic and one etiologic criterion fulfilled. Assessment of muscle mass is less commonly performed than other phenotypic malnutrition criteria, and its interpretation may be less straightforward, particularly in settings that lack access to skilled clinical nutrition practitioners and/or to body composition methodologies. In order to promote the widespread assessment of skeletal muscle mass as an integral part of the GLIM diagnosis of malnutrition, the GLIM consortium appointed a working group to provide consensus-based guidance on assessment of skeletal muscle mass. When such methods and skills are available, quantitative assessment of muscle mass should be measured or estimated using dual-energy x-ray absorptiometry, computerized tomography, or bioelectrical impedance analysis. For settings where these resources are not available, then the use of anthropometric measures and physical examination are also endorsed. Validated ethnic- and sex-specific cutoff values for each measurement and tool are recommended when available. Measurement of skeletal muscle function is not advised as surrogate measurement of muscle mass. However, once malnutrition is diagnosed, skeletal muscle function should be investigated as a relevant component of sarcopenia and for complete nutrition assessment of persons with malnutrition.

Towards developing a Core Outcome Set for malnutrition intervention studies in older adults: a scoping review to identify frequently used research outcomes

PURPOSE

To conduct a scoping review to provide a systematic overview of outcomes used in nutritional intervention studies focused on the treatment of protein-energy malnutrition in older adults.

METHODS

A systematic search of four electronic databases (Medline, EMBASE, CINAHL and Cochrane Central Register of Controlled Trials (CENTRAL) was performed to retrieve randomized controlled trials (RCTs), published until March 9, 2020, that evaluated the effect of nutritional interventions to treat protein-energy malnutrition in older adults and those at risk for malnutrition. Two authors screened titles, abstracts and full texts independently. One author extracted data that were cross-checked by another author.

RESULTS

Sixty-three articles reporting 60 RCTs were identified. Most frequently used outcomes included body weight/body mass index (75.0% of RCTs), dietary intake (61.7%), functional limitations (48.3%), handgrip strength (46.7%), and body circumference (40.0%). The frequencies differed by setting (community, hospital and long-term care). For some outcomes there was a preferred assessment method (e.g., Barthel index for functional limitations), while for other outcomes (e.g., functional performance) a much greater variation was observed.

CONCLUSION

A large variation in outcomes, not only across but also within settings, was identified in nutritional intervention studies in malnourished older adults and those at risk. Furthermore, for many outcomes there was a large variation in the used assessment method. These results highlight the need for developing a Core Outcome Set for malnutrition intervention studies in older adults to facilitate future meta-analyses that may enhance our understanding on the effectiveness of treatment.

Gut microbial characteristics in poor appetite and undernutrition: a cohort of older adults and microbiota transfer in germ-free mice

BACKGROUND

Older adults are particularly prone to the development of poor appetite and undernutrition. Possibly, this is partly due to the aged gut microbiota. We aimed to evaluate the gut microbiota in relation to both poor appetite and undernutrition in community-dwelling older adults. Furthermore, we studied the causal effects of the microbiota on body weight and body composition by transferring faecal microbiota from cohort participants into germ-free mice.

METHODS

First, we conducted a cross-sectional cohort study of 358 well-phenotyped Dutch community-dwelling older adults from the Longitudinal Aging Study Amsterdam. Data collection included body measurements, a faecal and blood sample, as well as extensive questionnaires on appetite, dietary intake, and nutritional status. Appetite was assessed by the Council of Nutrition Appetite Questionnaire (CNAQ) and undernutrition was defined by either a low body mass index (BMI) (BMI < 20 kg/m² if <70 years or BMI < 22 kg/m² if ≥70 years) or >5% body weight loss averaged over the last 2 years. Gut microbiota composition was determined with 16S rRNA sequencing. Next, we transferred faecal microbiota from 12 cohort participants with and without low BMI or recent weight loss into a total of 41 germ-free mice to study the potential causal effects of the gut microbiota on host BMI and body composition.

RESULTS

The mean age (range) of our cohort was 73 (65-93); 58.4% was male. Seventy-seven participants were undernourished and 21 participants had poor appetite (CNAQ < 28). A lower abundance of the genus Blautia was associated with undernutrition (log2 fold change = -0.57, Benjamini-Hochberg-adjusted P = 0.008), whereas higher abundances of taxa from Lachnospiraceae, Ruminococcaceae UCG-002, Parabacteroides merdae, and Dorea formicigenerans were associated with poor appetite. Furthermore, participants with poor appetite or undernutrition had reduced levels of faecal acetate (P = 0.006 and 0.026, respectively). Finally, there was a trend for the mice that received faecal microbiota from older adults with low BMI to weigh 1.26 g less after 3 weeks (P = 0.086) and have 6.13% more lean mass (in % body weight, P = 0.067) than the mice that received faecal microbiota from older adults without low BMI or recent weight loss.

CONCLUSIONS

This study demonstrates several associations of the gut microbiota with both poor appetite and undernutrition in older adults. Moreover, it is the first to explore a causal relation between the aged gut microbiota and body weight and body composition in the host. Possibly, microbiota-manipulating strategies will benefit older adults prone to undernutrition.

Machine Learning-Based Prediction of In-Hospital Complications in Elderly Patients Using GLIM-, SGA-, and ESPEN 2015-Diagnosed Malnutrition as a Factor

Background: Malnutrition is prevalent in elderly inpatients and is associated with various adverse outcomes during their hospital stay, but the diagnosis of malnutrition still lacks widely applicable criteria. This study aimed to investigate the association of malnutrition diagnosed with the SGA, ESPEN 2015, and GLIM criteria, respectively, with in-hospital complications in elderly patients. Method: Hospitalized patients over 65 years old who had been assessed with the SGA guideline for malnutrition at admission were retrospectively recruited from a large observational cohort study conducted in 34 level-A tertiary hospitals in 18 cities in China from June to September 2014. Malnutrition was then retrospectively diagnosed using the GLIM and ESPEN 2015 criteria, respectively, for comparison with the results of the SGA scale. The risk factors for malnutrition were analyzed using logistic regression, and the value of the three diagnostic criteria in predicting the in-hospital complications was subsequently explored using multivariate regression and the random forest machine learning algorithm. Results: A total of 2526 subjects who met the inclusion and exclusion criteria of the study were selected from the 7122 patients in the dataset, with an average age of 74.63 ± 7.12 years, 59.2% male, and 94.2% married. According to the GLIM, SGA, and ESPEN 2015 criteria, the detection rates of malnutrition were 37.8% (956 subjects), 32.8% (829 subjects), and 17.0% (429 subjects), respectively. The diagnostic consistency between the GLIM and the SGA criteria is better than that between the ESPEN 2015 and the SGA criteria (Kappa statistics, 0.890 vs. 0.590). Logistic regression showed that the risk of developing complications in the GLIM-defined malnutrition patients is 2.414 times higher than that of normal patients, higher than those of the ESPEN 2015 and SGA criteria (1.786 and 1.745 times, respectively). The random forest classifications show that the GLIM criteria have a higher ability to predict complications in these elderly patients than the SGA and ESPEN 2015 criteria with a mean decrease in accuracy of 12.929, 10.251, and 5.819, respectively, and a mean decrease in Gini of 2.055, 1.817, and 1.614, respectively. Conclusion: The prevalence of malnutrition diagnosed with the GLIM criteria is higher than that of the SGA and the ESPEN 2015 criteria. The GLIM criteria are better than the SGA and the ESPEN 2015 criteria for predicting in-hospital complications in elderly patients.

Ageing with Interstitial lung disease: preserving health and well being

PURPOSE OF REVIEW

Ageing, the accrual of molecular and cellular damage over a lifetime confers progressive physiologic dysfunction of bodily systems, leaving the body in a heightened state of vulnerability to biophysical and psychosocial stressors. The inflection point is frailty which easily leads to disability and death. Interstitial lung disease (ILD) creates biophysical and psychosocial stresses difficult for even optimally fit patients to cope with. With evolving ILD treatment pathways, people with ILD are living longer.

RECENT FINDINGS

ILD and ageing are bi-directionally influential: ILD, its treatments, complications, and collateral systemic extra-pulmonary damage (hypoxic and oxidative stress) wear on the ageing person and ageing impacts a person's tolerance of ILD. ILD extent may proportionally accelerate age-related vulnerabilities. ILD related to inflammatory systemic diseases, e.g. connective tissue diseases or sarcoidosis, exert an even more complex biophysical impact on the body.

SUMMARY

The present review stresses goals of preventing frailty in ILD and preserving general health and well being of people living with ILD of any age, from time of diagnosis and as they age. The development of a prediction score is proposed to classify those at risk of frailty and guide interventions that preserve successful ageing for all levels of ILD severity.

VIDEO ABSTRACT

http://links.lww.com/COPM/A32.

A Nomogram to Predict Critical Weight Loss in Patients with Nasopharyngeal Carcinoma During (Chemo) Radiotherapy

Background:

Weight loss is an important side effect of long-term anticancer treatment for nasopharyngeal carcinoma patients. The decline in body function will cause many adverse effects, such as local recurrence and distant metastasis, and reduce the patient’s quality of life. Therefore, this study developed a predictive model for the probability of critical weight loss to provide timely appropriate nutritional interventions and prevent serious side effects.

Methods:

A 20-week prospective follow-up study of 137 nasopharyngeal carcinoma patients in West China Hospital of Sichuan University undergoing radiotherapy and chemotherapy from February 2018 to March 2020 was conducted to collect relevant clinical data. The clinical usefulness and calibration of the prediction model were assessed using the C-index, calibration plot, receiver operating curve, and decision curve analysis. Internal validation was assessed using bootstrapping validation.

Results:

The nomogram consisted of sex, smoking status, physical status, chemotherapy regimen, and body mass index. Good calibration was observed for the cohort, with an area under the curve of 0.924. Five independent prognostic factors were included in the nomogram, which showed a high C-index value of 0.815 in the interval validation. Decision curve analysis showed that the nomogram was clinically useful when the intervention was decided at the critical weight loss possibility threshold in the 0% to 97% range.

Conclusions:

We constructed and validated a nomogram for predicting the incidence of critical weight loss in nasopharyngeal cancer patients undergoing chemotherapy and radiotherapy.

Early enteral vs. oral nutrition after Whipple procedure: Study protocol for a multicentric randomized controlled trial (NUTRIWHI trial)

Background

Malnutrition has been shown to be a risk factor for postoperative complications after pancreatoduodenectomy (PD). In addition, patients needing a PD, such as patients with pancreatic cancer or chronic pancreatitis, often are malnourished. The best route of postoperative nutrition after PD remains unknown. The aim of this randomized controlled trial is to evaluate if early postoperative enteral nutrition can decrease complications after PD compared to oral nutrition.

Methods

This multicenter, open-label, randomized controlled trial will include 128 patients undergoing PD with a nutritional risk screening ≥3. Patients will be randomized 1:1 using variable block randomization stratified by center to receive either early enteral nutrition (intervention group) or oral nutrition (control group) after PD. Patients in the intervention group will receive enteral nutrition since the first night of the operation (250 ml/12 h), and enteral nutrition will be increased daily if tolerated until 1000 ml/12 h. The primary outcome will be the Comprehensive Complication Index (CCI) at 90 days after PD.

Discussion

This study with its multicentric and randomized design will permit to establish if early postoperative enteral nutrition after PD improves postoperative outcomes compared to oral nutrition in malnourished patients.

Clinical trial registration

https://clinicaltrials.gov/(NCT05042882) Registration date: September 2021.

The clinical application value of phase angle of six parts in nutritional evaluation of tumor patients

OBJECTIVES

The purpose of this study was to explore the clinical application value of phase angle (PA) of six parts in the nutritional evaluation and construct a prediction model for diagnosing malnutrition of tumor patients.

METHODS

A total of 1129 patients with malignant tumors were analyzed retrospectively. The age, sex, tumor location and body mass index (BMI) of the patients were collected, and PA of six parts was measured. The Patient Subjective Global Assessment (PG-SGA) was used to evaluate the nutritional status of each patient.

RESULTS

According to the PG-SGA, 66.5% (n = 750) of the patients were evaluated as malnourished. Patients under the age of 65 had higher PA values. The PA value of men was higher than that of women (except PA-RL). In different disease groups, the PA-RA and PA-TR values were significantly different. In our study, PA value increases with BMI and decreases with PG-SGA (except PG-SGA 0-1 group). Multivariate regression analysis indicates that the age (HR = 1.051, 95% CI 1.037-1.066, P < 0.001), BMI (HR = 0.885, 95% CI 0.849-0.924, P < 0.001), and PA-WB (HR = 0.615, 95% CI 0.546-0.692, P < 0.001) were independent significant predictors associated with malnutrition. The AUC of the prediction model is 0.7631 (p < 0.001), indicating that the model including age, BMI, and PA-WB has certain diagnostic value for the diagnosis of malnutrition.

CONCLUSION

The PA-WB is an independent prognostic factor of malnutrition. The prediction model constructed by age, BMI, and PA-WB can be used as a useful tool for nutritional evaluation of tumor patients.

TRIAL REGISTRATION

Clinical Trial No.: ChiCTR2100047858.

Nomograms for Predicting Coexisting Cardiovascular Disease and Prognosis in Chronic Obstructive Pulmonary Disease: A Study Based on NHANES Data

Background

Chronic obstructive pulmonary disease (COPD) is a common chronic disease. Progression is further exacerbated by the coexistence of cardiovascular disease (CVD). We aim to construct a diagnostic nomogram for predicting the risk of coexisting CVD and a prognostic nomogram for predicting long-term survival in COPD.

Methods

The 540 eligible participants selected from the NHANES 2005-2010 were included in this study. Logistic regression analysis was used to construct a diagnostic nomogram for the diagnosis of coexisting CVD in COPD. Cox regression analyses were used to construct a prognostic nomogram for COPD. A risk stratification system was developed based on the total score generated from the prognostic nomogram. We used C-index and ROC curves to evaluate the discriminant ability of the newly built nomograms. The models were also validated utilizing calibration curves. Survival curves were made using the Kaplan-Meier method and compared by the Log-rank test.

Results

Logistic regression analysis showed that gender, age, neutrophil, RDW, LDH, and HbA1c were independent predictors of coexisting CVD and were included in the diagnostic model. Cox regression analysis indicated that CVD, gender, age, BMI, RDW, albumin, LDH, creatinine, and NLR were independent predictors of COPD prognosis and were incorporated into the prognostic model. The C-index and ROC curves revealed the good discrimination abilities of the models. And the calibration curves implied that the predicted values by the nomograms were in good agreement with the actual observed values. In addition, we found that coexisting with CVD had a worse prognosis compared to those without CVD, and the prognosis of the low-risk group was better than that of the high-risk group in COPD.

Conclusions

The nomograms we developed can help clinicians and patients to identify COPD coexisting CVD early and predict the 5-year and 10-year survival rates of COPD patients, which has some clinical practical values.

Current Insights in Nutrition Assessment and Intervention for Malnutrition or Muscle Loss in People with Lung Cancer: A Narrative Review

Up to 70% of people with lung cancer may be affected by cancer-related malnutrition or muscle loss, depending on treatment modality and disease stage. This narrative review explores recent studies on malnutrition and muscle loss as well as nutritional and multimodal interventions to treat these conditions in the context of the changing treatment landscape in lung cancer. Various types of interventions, including individualized counseling, protein and other specific nutrient supplementation, as well as multimodal interventions to treat malnutrition and muscle loss, have been investigated. Overall, individualized dietary counseling, increasing protein intake, and supplementation with omega-3 (n-3) fatty acids appear to be beneficial for some, albeit varying, patient outcomes. Multimodal interventions, generally including a nutrition and exercise component, show promising results; however, the impact on patient outcomes is mixed. A key finding of this review is a lack of large, randomized trials to guide nutrition intervention specifically in people with lung cancer. Despite the high prevalence of malnutrition and muscle loss in people with lung cancer and the known adverse outcomes, current evidence for nutrition intervention is limited. A targeted effort is required to improve the quality of evidence for nutrition intervention in this population to provide support for clinicians to deliver effective nutrition care.

Preoperative Phase Angle as a Risk Indicator in Cardiac Surgery-A Prospective Observational Study

Background: The phase angle (PhA) can be used for prognostic assessments in critically ill patients. This study describes the perioperative course of PhA and associated risk indicators in a cohort of elective cardiac surgical patients. Methods: The PhA was measured in 168 patients once daily until postoperative day (POD) seven. Patients were split into two groups depending on their median preoperative PhA and analyzed for several clinical outcomes; logistic regression models were used. Results: The PhA decreased from preoperative (6.1° ± 1.9°) to a nadir on POD 2 (3.5° ± 2.5°, mean difference −2.6° (95% CI, −3.0°; −2.1°; p < 0.0001)). Patients with lower preoperative PhA were older (71.0 ± 9.1 vs. 60.9 ± 12.0 years; p < 0.0001) and frailer (3.1 ± 1.3 vs. 2.3 ± 1.1; p < 0.0001), needed more fluids (8388 ± 3168 vs. 7417 ± 2459 mL, p = 0.0287), and stayed longer in the ICU (3.7 ± 4.5 vs. 2.6 ± 3.8 days, p = 0.0182). Preoperative PhA was independently influenced by frailty (OR 0.77; 95% CI 0.61; 0.98; p = 0.0344) and cardiac function (OR 1.85; 95%CI 1.07; 3.19; p = 0.028), whereas the postoperative PhA decline was independently influenced by higher fluid balances (OR 0.86; 95% CI 0.75; 0.99; p = 0.0371) and longer cardiopulmonary bypass times (OR 0.99; 95% CI 0.98; 0.99; p = 0.0344). Conclusion: Perioperative PhA measurement is an easy-to-use bedside method that may critically influence risk evaluation for the outcome of cardiac surgery patients.

Malnutrition Screening and Assessment

Malnutrition is a serious problem with a negative impact on the quality of life and the evolution of patients, contributing to an increase in morbidity, length of hospital stay, mortality, and health spending. Early identification is fundamental to implement the necessary therapeutic actions, involving adequate nutritional support to prevent or reverse malnutrition. This review presents two complementary methods of fighting malnutrition: nutritional screening and nutritional assessment. Nutritional risk screening is conducted using simple, quick-to-perform tools, and is the first line of action in detecting at-risk patients. It should be implemented systematically and periodically on admission to hospital or residential care, as well as on an outpatient basis for patients with chronic conditions. Once patients with a nutritional risk are detected, they should undergo a more detailed nutritional assessment to identify and quantify the type and degree of malnutrition. This should include health history and clinical examination, dietary history, anthropometric measurements, evaluation of the degree of aggression determined by the disease, functional assessment, and, whenever possible, some method of measuring body composition.

Worsening or improving hypoalbuminemia during continuous renal replacement therapy is predictive of patient outcome: a single-center retrospective study

Background

Hypoalbuminemia at the initiation of continuous renal replacement therapy (CRRT) is a risk factor for poor patient outcomes. However, it is unknown whether the patterns of changes in serum albumin levels during CRRT can be used to predict patient outcomes.

Methods

This retrospective study analyzed data that had been consecutively collected from January 2016 to December 2020 at the Third Affiliated Hospital. We included patients with acute kidney injury who received CRRT for ≥ 72 h. We divided the patients into four groups based on their serum albumin levels (albumin ≥ 3.0 g/dL or < 3.0 g/dL) at the initiation and termination of CRRT.

Results

The 793 patients in this study were categorized into the following albumin groups: persistently low, 299 patients (37.7%); increasing, 85 patients (10.4%); decreasing, 195 patients (24.6%); and persistently high, 214 patients (27.1%). In-hospital mortality rates were highest in the persistently low and decreasing groups, followed by the increasing and persistently high groups. The hazard ratio for in-hospital mortality was 0.481 (0.340–0.680) in the increasing group compared to the persistently low group; it was 1.911 (1.394–2.620) in the decreasing group compared to the persistently high group. The length of ICU stay was 3.55 days longer in the persistently low group than in the persistently high group.

Conclusions

Serum albumin levels changed during CRRT, and monitoring of patterns of change in serum albumin levels is useful for predicting in-hospital mortality and the length of ICU stay.

Poor Nutritional Status and Dynapenia Are Highly Prevalent in Post-Acute COVID-19

Poor nutritional status is common (estimated prevalence 5–69%) in acute coronavirus disease-2019 (COVID-19), and has been associated with hospitalization, the need for intensive care, and mortality. Body composition (BC) and muscle function have also been related in such patients to poor disease outcomes.

As the evidence in the literature is limited, a cross-sectional study was carried out to determine the frequency of malnutrition in a cohort of post-acute COVID-19 patients referred to a rehabilitation center after hospital discharge. BC and muscle strength were assessed and the differences between bedridden and not bedridden patients were specifically evaluated.

The study sample was composed of 144 post-acute COVID-19 patients (mean age 64.8 years; males = 95), 37% of whom were bedridden (males = 60%). Nutritional status was evaluated with Mini-Nutritional Assessment (MNA) and Controlling Nutritional status (CONUT). Fat-free mass (FFM) and skeletal muscle mass (SM) were estimated using bioelectrical impedance analysis (BIA). Raw BIA variables (phase angle = PhA and impedance ratios = IRs) were also determined and handgrip strength (HGS) was measured. Dynapenia was identified according to the 2019 EWGSOP criteria.

According to MNA, 18% (n. 26) of patients were malnourished and 62% (n. 89) were at risk of malnutrition. As for CONUT, 21% (n. 31) of cases had moderate–severe malnutrition and 58% (n. 83) had light malnutrition. Abnormalities of raw BIA variables (low PhA and high IRs) and low HGS were more common in bedridden patients, in those who were malnourished, or had low FFM or SM. Dynapenic patients were 65% men and 47% women.

In conclusion, malnutrition, BC alterations, and low HGS occur in post-acute COVID-19 patients and are more common in bedridden patients. Further studies are needed to identify reliable algorithms for assessing nutritional status in post-acute COVID-19 patients undergoing rehabilitation.

Preoperative Nutritional Status and Risk Factors Associated with Delayed Discharge in Geriatric Patients Undergoing Gastrectomy: A Single-Center Retrospective Study

Objective

Preoperative malnutrition is an independent risk factor for postoperative complications and survival for gastric cancer patients. The study is aimed at investigating the prevalence of malnutrition, perioperative nutritional support, and the risk factors associated with delayed discharge of geriatric patients undergoing gastrectomy.

Methods

A retrospective study of gastric cancer patients (age ≥ 65) who underwent gastrectomy at Zhongshan Hospital from January 2018 to May 2020 was conducted. Clinical data, including demographic information, medical history, surgery-related factors, and perioperative nutritional management, were collected and analyzed. Postoperative complications were assessed according to the Clavien-Dindo grading system, and the prognostic nutritional index (PNI) was calculated. The risk factors affecting the prolongation of postoperative hospital stay were analyzed.

Results

A total of 783 patients were reviewed. The overall frequency of malnutrition was 31.3% (249/783). The albumin, prealbumin, and hemoglobin levels were lower in the malnutrition group than in the well-nourished group. The proportion of patients who received preoperative total parenteral nutritional support in the malnutrition group was significantly higher than in the well-nourished group (12.4% vs. 3.7%, P < 0.001). All patients received postoperative parenteral nutrition (PN); the proportion of patients who received total nutrient admixture (TNA) in the malnutrition group was lower than in the well-nourished group (22.1% vs. 33.5%, P = 0.001). No significant difference was found in the duration of postoperative nutrition between groups (P > 0.05). The malnutrition group was associated with a higher rate of postoperative complications (P < 0.001). Univariate and multivariate regressions revealed that age > 70 years (OR = 1.216, 95% CI 1.048-1.411, P = 0.010), operation time > 180 min (OR = 1.431, 95% CI 1.237-1.656, P < 0.001), PNI < 44.5 (OR = 1.792, 95% CI 1.058-3.032, P = 0.030), and postoperative complications (OR = 2.191, 95% CI 1.604-2.991, P < 0.001) were significant risk factors associated with delayed discharge.

Conclusion

Malnutrition is relatively common in elderly patients undergoing gastrectomy. Advanced age, duration of surgery, lower levels of PNI, and postoperative complications were risk factors associated with delay discharge. Elderly gastric cancer patients with risk factors urgently require specific attention for reducing hospital stay.

Prevalence of Malnutrition, Its Risk Factors, and the Use of Nutrition Support in Patients with Inflammatory Bowel Disease

BACKGROUND

Malnutrition is prevalent among patients with inflammatory bowel disease (IBD). Nutritional profiles among Asian patients with IBD have seldom been investigated. We assessed the prevalence of and risk factors for malnutrition, use of nutrition support, and sociopsychological status associated with malnutrition among patients with IBD in China.

METHODS

Patients with ulcerative colitis and Crohn's disease (CD) recruited from 43 tertiary referral hospitals were screened for malnutrition and nutrient deficiencies in this cross-sectional study. The use of nutrition support was recorded. The sociopsychological status was assessed by subjective questionnaires. Factors associated with malnutrition were analyzed, and multivariate regression was used to determine independent predictors for malnutrition.

RESULTS

We recruited 1013 patients with a median age of 35.0 years, 58.5% of them had CD, and 61.4% of all patients were male. Overall, 49.5% (n = 501) of patients were diagnosed with malnutrition, including 57.0% of patients with CD, 38.8% of patients with ulcerative colitis, and 44.1% of patients with quiescent or mildly active disease. Nutrient deficiencies were prevalent despite the absence of malnutrition. Malnutrition was associated with adverse sociopsychological status, including decreased social support, higher perceived stress, and impaired quality of life. Moderate to severe disease activity and extensive disease were 2 independent risk factors for malnutrition. In total, 41.6% of patients received nutrition support, and patients with risk factors were more likely to receive nutrition support.

CONCLUSIONS

Malnutrition was highly prevalent and associated with adverse consequences in Chinese patients with IBD. Malnutrition screening and early initiation of nutrition support are essential components in IBD care.

A simple assessment model based on phase angle for malnutrition and prognosis in hospitalized cancer patients

BACKGROUND & AIMS

Malnutrition in cancer patients is a common but under-diagnosed condition that has negative effects on clinical outcomes. The development of an easy and reliable malnutrition assessment tool is thus critical for identification and nutritional support. We aimed to develop a phase angle (PA)-based prediction model of malnutrition and evaluate it in patient prognosis.

METHODS

A retrospective cohort of data consisting of demographic, clinical parameter and PA test from 702 adult hospitalized cancer patients between June 2020 to February 2021 was analysed. PAs for 6 body sites were measured by a body composition analyser. Patient-generated subjective global assessment (PG-SGA) scale was used as the diagnostic standard of nutritional status (PG-SGA ≥ 4 points defined as malnutrition). Decision tree, mean decrease accuracy of random forest, stepAIC strategy and test of generalized likelihood ratio were employed to select important variables and develop models for predicting PG-SGA binary classification (PG-SGA < 4 or ≥ 4 as a split). Survival curves were plotted by using the Kaplan-Meier method.

RESULTS

In all, 490 (69.8%) patients were malnourished according to their actual PG-SGA scores. Except for age, tumor type and body mass index (BMI), PA of the left arm was found to influence malnutrition classification and incorporated in the final predictive model. The model achieved good performance with an AUC of 0.813, 75.9% sensitivity and 73.3% specificity. The actual and predicted survival curves were almost overlapped.

CONCLUSION

This study provides a simple nutritional assessment tool which may be used to facilitate oncology physicians to identify cancer patients at nutritional risk and potentially implement nutritional support.

CLINICAL TRIAL NO

ChiCTR2100047858.