ESPEN guidelines on nutritional support for polymorbid internal medicine patients

Nutritional intervention in chronic heart failure patients: A randomized controlled clinical trial

BACKGROUND AND OBJECTIVES

Malnutrition is common in patients with heart failure (HF) and is associated with poor prognosis. We evaluated the prognostic and clinical impact of a nutritional intervention in malnourished patients with chronic HF.

METHODS

A randomized controlled clinical trial was carried out in patients with chronic HF who were malnourished or at risk. Participants were randomized to receive an individualized nutritional intervention or conventional management. The primary endpoint was a composite of all-cause mortality or time-to-first HF hospitalizations at the 12-month follow-up. The secondary endpoints were changes in nutritional status and functional capacity.

RESULTS

We screened 225 patients, 86 of whom had some degree of malnutrition and were randomized. At 12 months, the primary outcome occurred in 10 patients (23.8%) in the intervention group and in 22 patients (50.0%) in the control group (HR=0.39; 95% CI, 0.19-0.83). This effect was mainly related to a lower risk of hospitalization for HF in the intervention group: 8 patients (19.0%) versus 18 patients (40.9%) in the control group (HR=0.39; 95% CI=0.17-0.89). We observed an improvement in nutritional status and functional capacity in the intervention group versus the control group.

CONCLUSIONS

In patients with chronic HF and some degree of malnutrition, individualized nutritional intervention may reduce the risk of all-cause mortality or HF hospitalisations and improve nutritional status and functional capacity. These results underline the need for further randomized controlled trials with this approach to confirm the potential prognostic benefit.

Food Supplements Marketed Worldwide: A Comparative Analysis Between the European and the U.S. Regulatory Frameworks

In recent decades, a new health paradigm emerged which increasingly places diet and nutrition at the center of citizens' healthcare. The resulting evolution of the food market has prompted country governments to adapt their regulatory frameworks to ensure product safety and preserve the health of citizens. Dietary supplements (DS) are products which are increasingly occupying a significant market share in Western countries, contributing to meeting the nutritional and physiological needs of a large portion of the global population. Food supplements must be safe for use by the final consumer who has access to the global market, but currently they are framed by a different legislation worldwide. This search aimed of comparing the legislative frameworks currently in force in the European Union (EU) and in the United States (USA), the two main markets in which DS are purchased, to focus on the strengths, similarities and possible shortcomings, against the backdrop of a global market which often transcends the regulatory barriers of individual countries. Both in the EU and the USA, food supplements are governed by specific regulations to ensure their safety and quality. However, the regulatory approaches differ sharply in some cases. It is expected that more and more operators will launch new DS in Western markets. As a result, it is crucial for competent authorities in food safety to deepen and develop additional regulatory tools aimed to control and safeguard the DS market.

ESPEN practical guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease

BACKGROUND AND AIMS

Hospitalized patients often have acute kidney disease (AKD) or chronic kidney disease (CKD), with important metabolic and nutritional consequences. Moreover, in case kidney replacement therapy (KRT) is started, the possible impact on nutritional requirements cannot be neglected. On this regard, the present guideline aims to provide evidence-based recommendations for clinical nutrition in hospitalized patients with KD.

METHODS

The standard operating procedure for ESPEN guidelines was used. Clinical questions were defined in both the PICO format, and organized in subtopics when needed, and in non-PICO questions for the more general topics. The literature search was from January 1st, 1999 until January 1st, 2020. Each question led to one or more recommendation/statement and related commentaries. Existing evidence was graded, as well as recommendations and statements were developed and agreed upon in a multistage consensus process.

RESULTS

The present guideline provides 32 evidence-based recommendations and 8 statements, defining how to assess nutritional status, how to define patients at risk, how to choose the route of feeding, and how to integrate nutrition with KRT. In the final online voting, a strong consensus was reached in 84% at least of recommendations and 100% of statements.

CONCLUSION

The presence of KD in hospitalized patients identifies a highly heterogeneous group of subjects with widely varying nutrient needs and intakes. Considering the high nutritional risk related with this clinical condition, an individualized approach consisting of nutritional status evaluation and monitoring, frequent evaluation of nutritional requirements, and careful integration with KRT should be planned to avoid both underfeeding and overfeeding. Practical recommendations and statements were developed, aiming at defining suggestions for everyday clinical practice in the individualization of nutritional support in this patient setting. Literature areas with scarce or without evidence were also identified, thus requiring further basic or clinical research.

Nutritional support in hospitalised patients with diabetes and risk for malnutrition: a secondary analysis of an investigator-initiated, Swiss, randomised controlled multicentre trial

OBJECTIVES

The main objective of this study was to investigate the effects of nutritional support on mortality in hospitalised patients with diabetes and nutritional risk participating in the Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) trial.

DESIGN

Secondary analysis of a Swiss-wide multicentre, randomised controlled trial.

PARTICIPANTS

Patients with diabetes and risk for malnutrition.

INTERVENTIONS

Individualised nutritional support versus usual care.

PRIMARY OUTCOME MEASURE

30-day all-cause mortality.

RESULTS

Of the 2028 patients included in the original trial, 445 patients were diagnosed with diabetes and included in this analysis. In terms of efficacy of nutritional therapy, there was a 25% lower risk for mortality in patients with diabetes receiving nutritional support compared with controls (7% vs 10%, adjusted HR 0.75 (95% CI 0.39 to 1.43)), a finding that was not statistically significant but similar to the overall trial effects with no evidence of interaction (p=0.92). Regarding safety of nutritional therapy, there was no increase in diabetes-specific complications associated with nutritional support, particularly there was no increase in risk for hyperglycaemia (adjusted OR 0.97, 95% CI 0.56 to 1.67 p=0.90).

CONCLUSION

Patients with diabetes and malnutrition in the hospital setting have a particularly high risk for adverse outcomes and mortality. Individualised nutritional support reduced mortality in this secondary analysis of a randomized trial, but this effect was not significant calling for further large-scale trials in this vhighly ulnerable patient population.

TRIAL REGISTRATION NUMBER

NCT02517476.

Nutritional Aspects of Wound Care

Malnutrition is a collective term that includes both undernutrition and malnutrition. Malnutrition presents with and without inflammation, is reported in underweight, normal weight, and overweight individuals, and is associated with undesirable alterations in body composition, and diminished functional status. Older adults commonly experience dwindling nutritional status as evidenced by insidious weight loss, insufficient dietary intake, loss of muscle mass, quality, and strength, declining functional status, and other physical and emotional decline indicators. Sustained pressure, acute trauma, malnutrition, and inflammatory-driven chronic conditions increase the risk for skin integrity issues.

Should handgrip strength be considered when choosing the administration mode of oral nutritional supplements in geriatric patients? A secondary analysis of the MEDPass Trial

OBJECTIVE

It is important to individualize nutrition therapy and to identify whether certain patient groups benefit from a specific intervention such as oral nutritional supplements (ONS). This study investigated whether patients with weak handgrip strength (HGS) benefit better from ONS administration in the Medication Pass Nutritional Supplement Program (MEDPass) mode regarding the individual coverage of energy and protein requirements throughout their hospitalization.

METHODS

A secondary analysis of the intention-to-treat data set of the randomized controlled MEDPass trial was conducted. Weak HGS was defined as <27 kg for men and <16 kg for women. Linear mixed-effect models adjusted for the stratification factors energy density of ONS and nutritional risk screening 2002 score were used to address the aim of the study.

RESULTS

We included 188 participants. Energy and protein coverage did not differ between the patients with weak or normal HGS depending on ONS administration mode (P = 0.084, P = 0.108). Patients with weak HGS and MEDPass administration mode tended to have the lowest energy and protein coverage (estimated mean, 77.2%; 95% confidence interval [CI], 69.3%-85% and estimated mean, 95.1%; 95% CI, 85.3%-105%, respectively). Patients with weak HGS and conventional ONS administration had the highest energy and protein coverage (estimated mean, 90%; 95% CI, 82.8%-97.2% and estimated mean, 110.2%; 95% CI, 101.3%-119%, respectively).

CONCLUSION

No clear recommendations regarding the mode of ONS administration depending on HGS can be made. In clinical practice, appetite and satiety in patients with weak HGS should be monitored, and the ONS administration mode should be adjusted accordingly.

Pulmonary rehabilitation: A cohort study assessing the effectiveness of a multi-professional nutrition intervention

BACKGROUND

Limited benefit of pulmonary exercise rehabilitation has been associated with fulfilment of energy and protein requirements.

OBJECTIVES

The aim was to enhance dietary intake towards requirements and to maintain changes after a pulmonary rehabilitation program.

METHODS

This single arm intervention study included multidisciplinary focus on nutrition and three sessions of individual dietary counselling during a 10-week pulmonary exercise rehabilitation in five municipalities centers. Data were collected at baseline (P0), at the end of intervention (P1) and for two municipalities at three months post intervention (P2).

RESULTS

Of the 111 included participants, (mean age 70.8 (±9)) 99 (89%) completed the rehabilitation including the three individual dietary counselling's. A very large variation in body composition including body mass index and exercise abilities was found. Protein intake improved from 64 (±22 g) (P0) to 88 (±25 g) (P1) (p < 0.001) and energy intake from 1676 (±505 kcal) (P0) to 1941 (±553 kcal) (p < 0.001) (P1) and Muscle Mass Index increased from 10.6 (±3.2) (P0) to 10.9 (±3.2) (P1) (p = 0.007); number of 30 s chair stand test improved from 10.9 (±2.8) repetitions (P0) to 14.1 (±4.3) repetitions (P1) (p < 0.001), distance in six-minut walking test improved from 377.2 (±131.2 m) (P0) to 404.1 (±128.6 m) (P1) (p < 0.001). Two municipalities completed the three months follow-up. For those, dietary improvements remained stable, including protein intake.

CONCLUSION

Including three sessions of dietary counselling in a multi-professional effort was associated with improved individualized dietary intake, as well as physical function. Benefits remained almost unchanged after three months. Improvements in function could not be fully explained by improved intakes.

Albumin-dNLR score could be an etiological criterion to determine inflammation burden for GLIM in medical inpatients over 70 years old: A multicenter retrospective study

Aim

To validate the role of the albumin-derived neutrophil-to-lymphocyte (ALB-dNLR) score in diagnosing malnutrition in medical inpatients over 70 years old.

Methods

This is a retrospective cross-sectional study involving 7 departments from 14 Chinese hospitals. The ALB-dNLR score was calculated, and outcomes between groups with positive and negative ALB-dNLR scores were compared after propensity score matching (PSM). Afterwards, the outcomes were compared between the groups receiving nutrition support and those not receiving support among malnourished patients diagnosed using the Global Leadership Initiative Malnutrition (GLIM) criteria after PSM.

Results

Out of 10,184 cases, 6165 were eligible. 2200 cases were in the positive ALB-dNLR score group. After PSM, 1458 pairs were analyzed, showing lower in-hospital mortality (0.8 % vs. 2.1 %, p = 0.005) and a lower nosocomial infection rate (5.9 % vs. 11.0 %, p < 0.001) in the negative ALB-dNLR score group. In malnourished patients, 259 pairs were analyzed after PSM. It showed better outcomes in mortality (0.8 % vs. 3.5 %, p = 0.033), nosocomial infection rate (5.4 % vs. 15.4 %, p < 0.001), length of stay (LOS) (13.8 ± 10.3 vs. 18.4 ± 14.1, p < 0.001), and total hospital cost (3315.3 ± 2946.4 vs. 4795.3 ± 4198.2, p < 0.001) in the support group. In malnourished patients with ALB-dNLR score as the sole etiological criterion, 94 pairs were calculated. It showed better outcomes in mortality (0.0 % vs. 6.4 %, p = 0.029), nosocomial infection rate (7.4 % vs. 18.1 %, p = 0.029), LOS (13.7 ± 8.3 vs. 19.8 ± 15.2, p = 0.001), and total hospital cost (3379.3 ± 2955.6 vs. 4471.2 ± 4782.4, p = 0.029) in the support group.

Conclusions

The ALB-dNLR score was validated to predict in-hospital mortality in medical inpatients over 70 years old. Malnutrition patients diagnosed by the GLIM criteria and using the ALB-dNLR score might benefit from nutrition support.

Development and evaluation of a deep learning framework for the diagnosis of malnutrition using a 3D facial points cloud: A cross-sectional study

BACKGROUND

The feasibility of diagnosing malnutrition using facial features has been validated. A tool to integrate all facial features associated with malnutrition for disease screening is still demanded. This work aims to develop and evaluate a deep learning (DL) framework to accurately determine malnutrition based on a 3D facial points cloud.

METHODS

A group of 482 patients were studied in this perspective work. The 3D facial data were obtained using a 3D camera and represented as a 3D facial points cloud. A DL model, PointNet++, was trained and evaluated using the points cloud as inputs and classified the malnutrition states. The performance was evaluated with the area under the receiver operating characteristic curve, accuracy, specificity, sensitivity, and F1 score.

RESULTS

Among the 482 patients, 150 patients (31.1%) were diagnosed as having moderate malnutrition and 54 patients (11.2%) as having severe malnutrition. The DL model achieved the performance with an area under the receiver operating characteristic curve of 0.7240 ± 0.0416.

CONCLUSION

The DL model achieved encouraging performance in accurately classifying nutrition states based on a points cloud of 3D facial information of patients with malnutrition.

Effectiveness of Nutritional Intervention Led by Clinical Dietitian in Patients at Risk of Malnutrition at the Primary Healthcare Level in Slovenia - Evaluation Study

Introduction

Clinical dietitians play a crucial role in the nutritional support of patients at risk of malnutrition in primary care settings. The study aimed to evaluate the effect of an individualized nutritional intervention on clinically relevant outcomes for patients with chronic disease at nutritional risk.

Methods

A longitudinal evaluation study was conducted in two Slovenian primary health centres. We used pre-test and post-test design. Patients with chronic disease were screened using the Malnutrition Universal Screening Tool and additional risk factors (≥70 years and BMI <22 kg/m2; lower food intake in the last five days). Patients at nutritional risk were referred to a clinical dietitian for individual nutritional intervention. The effect of the nutritional intervention was assessed six months after the patients' first visit with a clinical dietitian.

Results

The sample included 94 patients. Nutritional risk was reduced significantly in high-risk and moderate-risk patients. In a subgroup of patients with a MUST score ≥1 (77 patients), body weight, BMI, Fat-Free Mass Index (FFMI), energy intake, and protein intake increased significantly (p<0.001). At the same time, the phase angle significantly increased (p<0.001), but there were no statistically significant changes in the improvement of grip strength. In a subgroup of patients with MUST score 0 (17 patients), we observed an increase in their median daily energy intake (p<0.001) and median protein intake (p=0.003).

Conclusion

Nutritional intervention delivered by a clinical dietitian improved patients' nutritional intake and nutritional and functional status.

Clinical nutrition in primary care: ESPEN position paper

Primary care healthcare professionals (PCHPs) are pivotal in managing chronic diseases and present a unique opportunity for nutrition-related disease prevention. However, the active involvement of PCHPs in nutritional care is limited, influenced by factors like insufficient education, lack of resources, and time constraints. In this position paper The European Society for Clinical Nutrition and Metabolism (ESPEN) promotes the active engagement of PCHPs in nutritional care. We emphasize the importance of early detection of malnutrition by screening and diagnosis, particularly in all individuals presenting with risk factors such as older age, chronic disease, post-acute disease conditions and after hospitalization for any cause. ESPEN proposes a strategic roadmap to empower PCHPs in clinical nutrition, focusing on education, tools, and multidisciplinary collaboration. The aim is to integrate nutrition into medical curricula, provide simple screening tools for primary care, and establish referral pathways to address malnutrition systematically. In conclusion, we urge for collaboration with PCHP organizations to raise awareness, enhance nutrition skills, facilitate dietitian accessibility, establish multidisciplinary teams, and promote referral pathways, thereby addressing the underestimated clinical challenge of malnutrition in primary care.

[Comprehensive nutrition therapy in hospitals - Wishful thinking or reality? A survey-based cross-sectional study of the nutritional therapy in hospitals of Baden-Württemberg]

INTRODUCTION

Malnutrition is widespread in German hospitals, has a negative impact on therapeutic success and quality of life, and it leads to increasing costs. An individualized nutritional support by nutritional professionals in accordance with current guidelines was shown to reduce mortality of malnourished inpatients. Ideally, nutritional support is conducted by an interdisciplinary nutrition support team. Current data on the nutritional therapy in German hospitals is missing.

METHODS

In order to ascertain the current status of nutritional support in hospitals in the federal state of Baden-Württemberg, clinic managements of all hospitals in Baden-Württemberg received an online questionnaire. Affiliated hospitals, specialist hospitals, as well as hospitals with less than 50 beds were excluded from the analysis.

RESULTS

The response rate was 84% (n = 94). The presence of a nutrition support team was reported by 34% of the hospitals. Twelve percent of the hospitals meet the structural characteristic of the OPS Code 8-98j Ernährungsmedizinische Komplexbehandlung, which means that their nutrition support team includes a physician. A validated nutritional risk screening is performed in 72% of the hospitals. Only 40% of the hospitals report that this is performed throughout every department. Nutrition support teams are more often concerned with malnutrition, enteral and parenteral nutrition as compared to nutritionists who are not organized in a team. Moreover, nutrition support teams have a wider range of tasks and more often a physician as a team member. Also, nutritional risk screenings are more often applied in hospitals with nutrition support teams.

DISCUSSION

Compared with a nationwide survey from 2004, there are markedly more nutrition support teams available in hospitals in Baden-Württemberg. When compared internationally, however, the rate of nutrition support teams is still low. In addition, there is no comprehensive nutritional care available. High-quality nutritional support is more often found in hospitals with nutrition support teams.

CONCLUSION

There is still a great potential of improving clinical nutritional care in hospitals in Baden-Württemberg. Moreover, an increase in nutrition support teams, also comprising medical members, should be achieved. Therefore, legal regulations and a sufficient refinancing are indispensable.

Prognostic implications of the arginine metabolism in patients at nutritional risk: A secondary analysis of the randomized EFFORT trial

BACKGROUND

Arginine, a conditionally essential amino acid, is key component in metabolic pathways including immune regulation and protein synthesis. Depletion of arginine contributes to worse outcomes in severely ill and surgical patient populations. We assessed prognostic implications of arginine levels and its metabolites and ratios in polymorbid medical inpatients at nutritional risk regarding clinical outcomes and treatment response.

METHODS

Within this secondary analysis of the randomized controlled Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT), we investigated the association of arginine, its metabolites and ratios (i.e., ADMA and SDMA, ratios of arginine/ADMA, arginine/ornithine, and global arginine bioavailability ratio) measured on hospital admission with short-term and long-term mortality by means of regression analysis.

RESULTS

Among the 231 patients with available measurements, low arginine levels ≤90.05 μmol/l (n = 86; 37 %) were associated with higher all-cause mortality at 30 days (primary endpoint, adjusted HR 3.27, 95 % CI 1.86 to 5.75, p < 0.001) and at 5 years (adjusted HR 1.50, 95 % CI 1.07 to 2.12, p = 0.020). Arginine metabolites and ratios were also associated with adverse outcome, but had lower prognostic value. There was, however, no evidence that treatment response was influenced by admission arginine levels.

CONCLUSION

This secondary analysis focusing on medical inpatients at nutritional risk confirms a strong association of low plasma arginine levels and worse clinical courses. The potential effects of arginine-enriched nutritional supplements should be investigated in this population of patients.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov as NCT02517476 (registered 7 August 2015).

ESPEN practical guideline: Nutritional support for polymorbid medical inpatients

BACKGROUND

Disease-related malnutrition in polymorbid medical inpatients is a highly prevalent syndrome associated with significantly increased morbidity, disability, short- and long-term mortality, impaired recovery from illness, and healthcare costs.

AIM

As there are uncertainties in applying disease-specific guidelines to patients with multiple conditions, our aim was to provide evidence-based recommendations on nutritional support for the polymorbid patient population hospitalized in medical wards.

METHODS

The 2023 update adheres to the standard operating procedures for ESPEN guidelines. We undertook a systematic literature search for 15 clinical questions in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g., published guidelines), until July 12th, 2022. Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations (including SIGN grading), which was followed by submission to Delphi voting. Here, the practical version of the guideline is presented which has been shortened and equipped with flow charts for patients care.

RESULTS

32 recommendations (7× A, 11× B, 10× O and 4× GPP), which encompass different aspects of nutritional support were included from the scientific guideline including indication, route of feeding, energy and protein requirements, micronutrient requirements, disease-specific nutrients, timing, monitoring and procedure of intervention. Here, the practical version of the guideline is presented which has been shortened and equipped with flow charts for patients care.

CONCLUSIONS

Recent high-quality trials have provided increasing evidence that nutritional support can reduce morbidity and other complications associated with malnutrition in polymorbid patients. The timely screening of patients for risk of malnutrition at hospital admission followed by individualized nutritional support interventions for at-risk patients should be part of routine clinical care and multimodal treatment in hospitals worldwide. Use of this updated practical guideline offers an evidence-based nutritional approach to polymorbid medical inpatients and may improve their outcomes.

The influence of patients' nutritional risk, nutritional status, and energy density in MEDPass versus conventional administration of oral nutritional supplements - A secondary analysis of a randomized controlled trial

OBJECTIVES

The clinical influence of nutritional risk, nutritional status, and energy density of oral nutritional supplements (ONS) in MEDPass versus conventional administration of ONS is currently unknown. The aim of this analysis was to examine whether these variables have an impact on clinical outcomes.

METHODS

Secondary analysis of the intention to treat dataset of the randomized controlled MEDPass Trial in geriatric and medical inpatients. Patients in the intervention group received 4 × 50 ml ONS during the medication rounds (MEDPass mode), while those in the control group received ONS in a non-standardized manner. The examined endpoints included energy and protein coverage, ONS intake, handgrip strength (HGS), weight, appetite nausea and 30-day mortality. Three subgroup analyses for NRS 2002 total score (3, 4 or 5-7 points), NRS 2002 impaired nutritional status score (0, 1, 2 or 3 points) and energy density of the ONS (1.5 kcal/mL or 2 kcal/mL) were performed using linear and logistic regression with interaction and mixed effect models.

RESULTS

The data of 202 patients (103 women and 99 men) at nutritional risk (NRS total 2002 score ≥3), mean (SD) age 82.2 (6.5) years were included. There was no significant difference between the groups in the primary endpoint energy coverage in all three subgroup analyses. There were also no significant differences between the groups in the secondary endpoints of protein coverage, ONS intake, HGS, weight, appetite, nausea, and 30-day mortality.

CONCLUSION

The MEDPass mode of ONS administration was not superior to the conventional mode of administration in this study. ONS with high energy density (≥2 kcal/mL) should be offered since current evidence shows a tendency towards improved appetite, increased ONS and increased energy intake.

Adaptation of nutritional risk screening tools may better predict response to nutritional treatment: a secondary analysis of the randomized controlled trial Effect of early nutritional therapy on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT)

BACKGROUND

Nutritional screening tools have proven valuable for predicting clinical outcomes but have failed to determine which patients would be most likely to benefit from nourishment interventions. The Nutritional Risk Screening 2002 (NRS) and the Mini Nutritional Assessment (MNA) are 2 of these tools, which are based on both nutritional parameters and parameters reflecting disease severity.

OBJECTIVES

We hypothesized that the adaptation of nutritional risk scores, by removing parameters reflecting disease severity, would improve their predictive value regarding response to a nutritional intervention while providing similar prognostic information regarding mortality at short and long terms.

METHODS

We reanalyzed data of 2028 patients included in the Swiss-wide multicenter, randomized controlled trial EFFORT (Effect of early nutritional therapy on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial) comparing individualized nutritional support with usual care nutrition in medical inpatients. The primary endpoint was 30-d all-cause mortality.

RESULTS

Although stratifying patients by high compared with low NRS score showed no difference in response to nutritional support, patients with high adapted NRS showed substantial benefit, whereas patients with low adapted NRS showed no survival benefit [adjusted hazard ratio: 0.55 [95% confidence interval (CI): 0.37, 0.80]] compared with 1.17 (95% CI: 0.70, 1.93), a finding that was significant in an interaction analysis [coefficient: 0.48 (95% CI: 0.25, 0.94), P = 0.031]. A similar effect regarding treatment response was found when stratifying patients on the basis of MNA compared with the adapted MNA. Regarding the prognostic performance, both original scores were slightly superior in predicting mortality than the adapted scores.

CONCLUSIONS

Adapting the NRS and MNA by including nutritional parameters only improves their ability to predict response to a nutrition intervention, but slightly reduces their overall prognostic performance. Scores dependent on disease severity may best be considered prognostic scores, whereas nutritional risk scores not including parameters reflecting disease severity may indeed improve a more personalized treatment approach for nourishment interventions. The trial was registered at clinicaltrials.gov as NCT02517476.

Prevalence of the use of oral nutritional supplements among acute inpatients at risk of malnutrition and associated patient characteristics

AIM

To provide a snapshot of the current use of oral nutritional supplements, its association with inpatient characteristics, and with a focus on the role of nursing monitoring of food intake and implementing nutritional interventions for patients with low intake.

DESIGN

Retrospective cohort study.

METHODS

The study collected data from a hospital database regarding oral nutritional supplement initiation and variables of patients hospitalised in internal medicine departments, who did not receive enteral or parenteral nutrition.

RESULTS

Of the 5155 admissions, 1087 fulfilled the inclusion criteria (47% female; mean age, 72.4 ± 14.6 years; mean length of stay, 14.6 ± 11.4 days). Sufficient food intake reporting was noted in 74.6% of the patients; of these 17% had decreased intake. Oral nutritional supplements and non-oral nutritional supplements groups did not differ in terms of sex, age, length of stay, Charlson Comorbidity Index, proportion of nursing reports, and absence of intake monitoring. Oral nutritional supplements were initiated in 31.9% of patients with a Malnutrition Universal Screening Tool score ≥2 and in 34.6% with decreased food intake. On multivariable analysis, hypoalbuminemia (adjusted odds ratio, 3.70), decreased food intake (adjusted odds ratio, 3.38), Malnutrition Universal Screening Tool score ≥2 (adjusted odds ratio, 2.10), and age <70 years (adjusted odds ratio, 1.56) were significantly associated with oral nutritional supplements use.

CONCLUSION

The prevalence of oral nutritional intervention was suboptimal in patients at risk of malnutrition during acute hospitalisation, although decreased food intake and Malnutrition Universal Screening Tool score ≥2 independently increased the probability of oral nutritional supplements initiation.

RELEVANCE IN CLINICAL PRACTICE

Understanding the clinical practice and nursing impact of care management in relation to nutritional intervention can assist in reviewing and improving patient care. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE IMPACT (ADDRESSING): This study informs clinical management and influences nursing practice standards related to assessing, monitoring, and managing malnutrition risk.

IMPACT

The study impacts the quality of care for patients at risk of malnutrition.

REPORTING METHOD

We adhered to the STROBE Checklist for cohort studies.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Association of tryptophan pathway metabolites with mortality and effectiveness of nutritional support among patients at nutritional risk: secondary analysis of a randomized clinical trial

Tryptophan is an essential amino acid and is the precursor of many important metabolites and neurotransmitters. In malnutrition, the availability of tryptophan is reduced, potentially putting patients at increased risks. Herein, we investigated the prognostic implications of the tryptophan metabolism in a secondary analysis of the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), a randomized, controlled trial comparing individualized nutritional support to usual care in patients at risk for malnutrition. Among 238 patients with available measurements, low plasma levels of metabolites were independently associated with 30-day mortality with adjusted hazard ratios (HR) of 1.77 [95% CI 1.05-2.99, p 0.034] for tryptophan, 3.49 [95% CI 1.81-6.74, p < 0.001] for kynurenine and 2.51 [95% CI 1.37-4.63, p 0.003] for serotonin. Nutritional support had more beneficial effects on mortality in patients with high tryptophan compared to patients with low tryptophan levels (adjusted HR 0.61 [95% CI 0.29-1.29] vs. HR 1.72 [95% CI 0.79-3.70], p for interaction 0.047). These results suggest that sufficient circulating levels of tryptophan might be a metabolic prerequisite for the beneficial effect of nutritional interventions in this highly vulnerable patient population.

[Commitment of Asunción. A call to action]

Introduction

The Latin American Federation of Nutritional Therapy, Clinical Nutrition, and Metabolism - FELANPE, was founded in 1988. It brings together interdisciplinary societies and associations in Clinical Nutrition and Nutritional Therapy from Latin America and the Caribbean, as well as Spain and Portugal. Currently, it comprises representations from 18 countries. The objectives of the Federation are described, taking into account the assumed commitment. This is an observational cross-sectional, multicenter study that included 132 hospitals with more than 100 beds, of high complexity, both state-owned and private, from 14 countries in Latin America that are members of FELANPE. The study assessed hospital characteristics, implementation of nutritional assessment, nutritional diagnosis of patients, the team responsible for nutritional therapy, nutritional therapy (oral, enteral, and parenteral), monitoring, and nutritional follow-up. For this purpose, a digital questionnaire and an explanatory video were designed and validated to ensure the quality of the collected data. Validation was carried out through a pilot study conducted in Paraguay, approved by the Ethics Committee for Research at the Faculty of Medical Sciences of the National University of Asunción. The current research has the approval of the Research Ethics Committee of the Faculty of Chemical Sciences of the National University of Asunción and the Ethics Committee of FELANPE. The results presented at the XVIII Latin American Congress of FELANPE in Asunción, Paraguay, on October 12, 2023, serve as a basis for characterizing the implementation of Parenteral and Enteral Nutritional Therapy (medical nutritional therapy) in hospitals in Latin America and are used as technical support for the present Asunción Commitment.

Red blood cell distribution width (RDW) - A new nutritional biomarker to assess nutritional risk and response to nutritional therapy?

BACKGROUND & AIMS

Red cell distribution width (RDW) has been proposed as a surrogate marker for acute and chronic diseases and may be influenced by nutritional deficits. We assessed the prognostic value of RDW regarding clinical outcomes and nutritional treatment response among medical inpatients at nutritional risk.

METHODS

This is a secondary analysis of EFFORT, a randomized, controlled, prospective, multicenter trial investigating the effects of nutritional support in patients at nutritional risk in eight Swiss hospitals. We examined the association between RDW and mortality in regression analysis.

RESULTS

Among 1,244 included patients (median age 75 years, 46.6 % female), high RDW (≥15 %) levels were found in 38 % of patients (n = 473) with a significant association of higher malnutrition risk [OR 1.48 (95%CI 1.1 to 1.98); p = 0.009]. Patients with high RDW had a more than doubling in short-term (30 days) mortality risk [adjusted HR 2.12 (95%CI 1.44 to 3.12); p < 0.001] and a signficant increase in long-term (5 years) mortality risk [adjusted HR 1.73 (95%CI 1.49 to 2.01); p < 0.001]. Among patients with high RDW, nutritional support reduced morality within 30 days [adjusted OR 0.56 (95%CI 0.33 to 0.96); p = 0.035], while the effect of the nutritional intervention in patients with low RDW was markedly smaller.

CONCLUSIONS

Among medical patients at nutritional risk, RDW correlated with several nutritional parameters and was a strong prognostic marker for adverse clinical outcomes at short- and long-term, respectively. Patients with high baseline RDW levels also showed a strong benefit from the nutritional intervention. Further research is needed to understand whether monitoring of RDW over time severs as a nutritional biomarker to assess effectiveness of nutritional treatment in the long run.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02517476.

Management of disease-related malnutrition: a real-world experience with a novel concentrated high-protein energy-dense oral nutritional supplement

OBJECTIVE

Despite the availability of a wide range of oral nutritional supplements (ONS) offerings, individuals with malnutrition are still struggling to meet their nutritional targets. A new concentrated and high-protein energy-dense ONS (≥2.1 kcal/mL;32 g protein/200 mL) with high-quality protein (60% whey protein) has emerged as a pivotal formula to reach the patient's energy-protein requirements, enhance compliance, and maximize stimulation of muscle protein synthesis, key factors driving better nutritional, functional, and clinical outcomes. The purpose of this article is to provide our clinical experience using this new nutritionally concentrated ONS as a therapeutic strategy for patients with DRM.

METHODS

Three clinical cases have been examined using new assessment procedures and a new form of nutritional therapy, and their impact on the nutritional and functional outcomes in patients with moderate-to-severe DRM.

RESULTS

A tailored individualized nutritional interventions improved anthropometric, biochemical, and functional outcomes (Case 1,2, and 3) assessed using hand grip strength, bioimpedance and muscle ultrasound, and as well as good gastrointestinal tolerance (Case 1) and compliance to the ONS in patients with DRM (Case 1,2,3).

CONCLUSION

The use of this novel high-protein energy-dense formula with high-quality protein source (≥2.1 kcal/mL; 32 g protein/200 mL; 60% whey protein) overcome common practical challenges in the medical nutrition therapy of patients with DRM, either because these patients require a highly concentrated formulation to meet nutritional requirements due to loss of appetite, lack of interest in food, and high caloric-protein needs due to disease, and a large quantity and quality of protein to optimize muscle recovery due to sarcopenia, common in patients with moderate-severe malnutrition.

Inflammation and response to nutrition interventions

The complex interplay between nutrition and inflammation has become a major focus of research in recent years across different clinical settings and patient populations. Inflammation has been identified as a key driver for disease-related malnutrition promoting anorexia, reduced food intake, muscle loss, and on a cellular level, insulin resistance, which together stimulate catabolism. However, these effects may well be bidirectional, and there is strong evidence showing that nutrition influences inflammation. Several single nutrients and dietary patterns with either proinflammatory or anti-inflammatory properties have been studied, such as the long-chain ω-3 fatty acids eicosapentaenoic acid or docosahexaenoic acid. The Mediterranean diet combines several such nutrients and has been shown to improve medical outcomes in the outpatient setting. In addition, there is increasing evidence suggesting that inflammation affects the metabolism and modulates the response to nutrition support interventions. In fact, recent studies from the medical inpatient setting suggest that inflammation, mirrored by high levels of C-reactive protein, diminishes the positive effects of nutrition support. This may explain the lack of positive effects of some nutrition trials in severely ill patients, whereas similar approaches to nutritional support have shown positive results in less severely ill patients. The use of biomarkers, such as C-reactive protein, may help to identify patients with a lower response to nutrition, in whom other treatment options need to be used. There is need for additional research to understand how to best address the malnourished patient with inflammation by specifically lowering inflammation through anti-inflammatory medical treatments and/or nutrition interventions.

Evidence mapping of clinical practice guidelines on nutritional management for pressure injuries and their quality

CONTEXT

The safety and efficacy of nutritional management for pressure injuries (PIs) have been the subjects of ongoing interest. Some evidence demonstrated that nutrition is essential for skin and tissue viability, supporting tissue repair for healing the pressure injury.

OBJECTIVE

This investigation aimed to systematically review clinical practice guidelines (CPGs) for the nutritional management of PIs and furnish an evidence map to assess research trends and CPG gaps.

METHODS

The PubMed, Embase, and guidelines databases, and society websites were searched for CPGs for the nutritional management of PIs. The basic recommendations for the nutritional management of PIs, method quality, and reporting CPGs quality were identified and imported into Excel. Four researchers independently elucidated each CPG's quality via the Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument and the Reporting Items for Practice Guidelines in Healthcare (RIGHT) checklist. All bubble charts were generated using Excel software.

RESULTS

This review included 12 CPGs with a combined 23 recommendations. The nutrition screening and assessment were summarized on the basis of the PI recommendations for 6 major items, 12 items on nutrition management, and 3 on PI education. The assessed CPGs had mixed quality, and the highest score  ± standard deviation based on the clarity of presentation was 83.46 ± 7.62, whereas the lowest mean score based on AGREE II applicability was 53.31 ± 16.90. Field 1 (basic information) in the RIGHT checklist had the greatest reporting rate (68.06%), whereas field 5 (review and quality assurance) had the lowest CPGs quality (41.67%).

CONCLUSION

This investigation furnishes an evidence map and provides new perspectives on the CPGs for the nutritional management of PIs. However, the CPGs included still need improvement, especially in the applicability and editorial independence domains.

Influence of the Results of Control of Intakes, Proteins and Anthropometry Nutritional Screening, Sarcopenia and Body Composition on the Clinical Evolution of Hospitalized Patients

(1) Background: Hospital malnutrition and sarcopenia are common in inpatients and are associated with worse prognosis. Our objective is to determine the association of the positivity of CIPA (Control of Intakes, Proteins and Anthropometry) nutrition screening tool and sarcopenia and evaluate its prognostic implications (length of stay, readmissions and mortality) as well as different components of body composition. (2) Methodology: Cross-sectional single-center study and prospective six months follow-up for prognostic variables. On admission, CIPA and EWGSOP2 criteria were assessed. (3) Results: Four hundred inpatients, a median of 65.71 years old and 83.6% with high comorbidity, were evaluated. In total, 34.8% had positive CIPA and 19.3% sarcopenia. Positive CIPA and sarcopenia had worse results in body composition (fat mass (FM), fat-free mass (FFM) and appendicular skeletal muscle mass index (ASMI)) and dynamometry. Positive CIPA is significantly associated with worse prognosis (mortality (OR = 1.99), readmissions (OR = 1.86) and length of stay (B = 0.19)). Positive CIPA and sarcopenia combined are associated with a tendency to higher mortality (OR = 2.1, p = 0.088). Low hand grip strength (HGS) is significantly related to a higher length of stay (B = -0.12). (4) Conclusions: In hospitalized patients, malnutrition independently and combined with sarcopenia is associated with a worse prognosis but not body composition. Low HGS is related to a higher length of stay.

Lipid profiles and lifestyle habits of stroke survivors in the east coast region of peninsular Malaysia: Preliminary findings

Background: Stroke survivors are at high risk for recurrent cardiovascular events if no prevention strategies are undertaken. Aim: This study aimed to investigate the fasting serum lipid profiles and lifestyle habits in stroke survivors, and the factors associated with suboptimal lipid profiles. Methods: A cross-sectional retrospective study was conducted in three public hospitals in Malaysia. Stroke survivors' data regarding the socio-demographic characteristics, clinical profiles, fasting serum lipid profiles, dietary adherence, and physical activity levels were acquired. Binary logistic regression was used to examine the factors associated with suboptimal lipid goals. Results: A total of 104 stroke survivors were recruited from patients attending the neurology and rehabilitation departments. Only 22% of the stroke survivors attained the targeted low-density lipoprotein cholesterol level (LDL-C < 1.8 mmol/L). Meanwhile, more than two thirds of patients achieved the targeted total cholesterol, triglyceride, and high-density lipoprotein cholesterol goals. Patients with a longer stroke duration (Adjusted odds ratio, AOR 3.33, 95% confidence intervals, CI: 1.09, 10.13, p  =  0.034), elevated blood pressure (AOR 4.74, 95% CI: 1.65, 13.62, p  =  0.004), chronic kidney disease (AOR 3.30, 95% CI: 1.05, 10.34, p  =  0.041), abdominal obesity (AOR 3.14, 95% CI: 1.20, 8.21, p  =  0.020), excessive energy intake (AOR 2.72, 95% CI: 1.07, 6.91, p  =  0.036), and excessive saturated fatty acids intake (AOR 2.85, 95% CI: 1.02, 7.93, p  =  0.045) were significantly associated with suboptimal lipid profiles. Conclusion: The lipid goals attainment was low, particularly the LDL-C levels among Malaysian stroke survivors. Greater efforts are warranted to fully utilise the lipid-lowering therapy and the lifestyle changes in these high-risk patients.

Impact of diabetes, malnutrition and sarcopenia on the prognosis of patients admitted to internal medicine

OBJECTIVE

To describe patients hospitalized in internal medicine in terms of malnutrition and sarcopenia, depending on the presence or absence of type 2 diabetes mellitus (DM2), as well as to evaluate short- and long-term mortality related to both.

METHODS

Cross-sectional, single-center study, which included consecutive patients admitted to internal medicine in May and October 2021. Malnutrition was determined using the Mini Nutritional Assessment-Short Form (MNA-SF) and sarcopenia using SARC-F and handgrip strength. Patients hospitalized for more than 48 h are excluded.

RESULTS

511 patients were analyzed, 49.1% male, mean age 75.2 +/- 15 years, 210 (41.1%) DM2. 6 groups (2 × 3 design) are generated based on the presence of DM2 and the nutritional status according to the result of the MNA-SF: 12-14 points, without risk; MNA-SF 8-12 points, high risk; MNA-SF 0-7 points, malnourished. Malnourished patients with DM2 had significantly higher sarcopenia, comorbidity, inflammation, and pressure ulcers. The main determinants of in-hospital mortality were sarcopenia (OR 1.27, 95%CI 1.06-1.54, p = 0.01), comorbidity (OR 1.27, 95%CI 1,08-1,49, p = 0.003) and inflammation (OR 1.01, 95%CI 1.00-1.02, p = 0.02). The 120-day prognosis was worse among malnourished patients (p = 0.042).

CONCLUSION

Patients admitted with DM2 have a similar degree of malnutrition than the rest, but with greater sarcopenia. This sarcopenia, together with inflammation and comorbidity determine a worse prognosis. The active and early identification of malnutrition and sarcopenia and their subsequent approach could improve the prognosis of patients.

Malnutrition in COVID-19 survivors: prevalence and risk factors

BACKGROUND

Nutritional status is a critical factor throughout COVID-19 disease course. Malnutrition is associated with poor outcomes in hospitalized COVID-19 patients.

AIM

To assess the prevalence of malnutrition and identify its associated factors in COVID-19 survivors.

METHODS

Study cohort included 1230 COVID-19 survivors aged 18-86 attending a post-COVID-19 outpatient service. Data on clinical parameters, anthropometry, acute COVID-19 symptoms, lifestyle habits were collected through a comprehensive medical assessment. Malnutrition was assessed according to Global Leadership Initiative on Malnutrition (GLIM) criteria.

RESULTS

Prevalence of malnutrition was 22% at 4-5 months after acute disease. Participants who were not hospitalized during acute COVID-19 showed a higher frequency of malnutrition compared to those who needed hospitalization (26% versus 19%, p < 0.01). Malnutrition was found in 25% COVID-19 survivors over 65 years of age compared to 21% younger participants (p < 0.01). After multivariable adjustment, the likelihood of being malnourished increased progressively and independently with advancing age (Odds ratio [OR] 1.02; 95% CI 1.01-1.03) and in male participants (OR 5.56; 95% CI 3.53-8.74). Malnutrition was associated with loss of appetite (OR 2.50; 95% CI 1.73-3.62), and dysgeusia (OR 4.05; 95% CI 2.30-7.21) during acute COVID-19.

DISCUSSION

In the present investigation we showed that malnutrition was highly prevalent in a large cohort of COVID-19 survivors at 4-5 months from acute illness.

CONCLUSIONS

Our findings highlight the need to implement comprehensive nutritional assessment and therapy as an integral part of care for COVID-19 patients.

"More2Eat" in patients at nutritional risk during hospital stay lowers the risk of three-month mortality

BACKGROUND & AIMS

Malnutrition is a common problem among hospitalized patients due to increased nutrient requirements and reduced food intake or uptake of nutrients. The aim of this prospective cohort study was to investigate the association of nutritional risk status (at or not at risk by NRS-2002) as well as energy and protein intake, use of oral nutritional supplements (ONS) and snack meals in at risk patients during hospitalization and adverse outcomes (length of stay (LOS), readmissions and mortality) at three-months follow-up.

METHODS

Data were collected at baseline and at three-months follow-up in patients hospitalized at 31 units at a Danish University Hospital. Diet records were performed at baseline by using the nurses' quartile nutrition recording methods. Data about disease and clinical outcomes were collected from electronic medical records at baseline and three-months follow-up.

RESULTS

A total of 318 patients were included. Patients at nutritional risk (n = 149, 47%) had higher risk of longer LOS (≥20 days (OR = 4.24 [1.81;9.95] and ≥30 days OR = 2.50 [1.22;5.14])), having one readmission (OR = 1.86 [1.15;3.01]) and death (OR = 2.56 [1.27;5.20]) compared to patients not at nutritional risk (n = 169, 53%). A longer LOS was associated with patients who achieved ≥75% of energy and protein requirements, consumed snack meals incl. and excl. oral nutritional supplements. Readmissions in patients at nutritional risk during the three-months were not associated with food intake during the index hospitalization. Mortality was observed in 43 of the 318 (13.5%) hospitalized patients. A lower mortality was associated with increased energy and protein intake in patients at nutritional risk.

CONCLUSIONS

The results of this study indicate a longer LOS, higher readmission rate and increased mortality in patients at nutritional risk compared to patients not at risk. Patients at nutritional risk had lower risk of three-month mortality and longer LOS during index hospitalization with increased energy and protein intake. Readmissions in patients at nutritional risk were not affected by food intake. The association of nutritional risk with poorer outcomes indicates that good nutritional care including constant attention to food-intake during hospitalization can be beneficial regarding mortality.

ESPEN guideline on nutritional support for polymorbid medical inpatients

BACKGROUND

Disease-related malnutrition in polymorbid medical inpatients is a highly prevalent syndrome associated with significantly increased morbidity, disability, short- and long-term mortality, impaired recovery from illness, and cost of care.

AIM

As there are uncertainties in applying disease-specific guidelines to patients with multiple conditions, our aim was to provide evidence-based recommendations on nutritional support for the polymorbid patient population hospitalized in medical wards.

METHODS

This update adheres to the standard operating procedures for ESPEN guidelines. We did a systematic literature search for 15 clinical questions in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g. published guidelines), until July 12th. Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations (incl. SIGN grading), which was followed by submission to Delphi voting.

RESULTS

From a total of 3527 retrieved abstracts, 60 new relevant studies were analyzed and used to generate a guideline draft that proposed 32 recommendations (7x A, 11x B, 10x O and 4x GPP), which encompass different aspects of nutritional support including indication, route of feeding, energy and protein requirements, micronutrient requirements, disease-specific nutrients, timing, monitoring and procedure of intervention. The results of the first online voting showed a strong consensus (agreement of >90%) on 100% of the recommendations. Therefore, no final consensus conference was needed.

CONCLUSIONS

Recent high-quality trials have provided increasing evidence that nutritional support can reduce morbidity and other complications associated with malnutrition in polymorbid patients. The timely screening of patients for risk of malnutrition at hospital admission followed by individualized nutritional support interventions for at-risk patients should be part of routine clinical care and multimodal treatment in hospitals worldwide. Use of this updated guideline offers an evidence-based nutritional approach to the polymorbid medical inpatients and may improve their outcomes.

An Umbrella Review and Meta-analysis of Interventions, Excluding Enteral and Parenteral Nutrition, Initiated in the Hospital for Adults with or at Risk of Malnutrition

BACKGROUND

Multiple systematic reviews and meta-analyses (SRMAs) on various nutritional interventions in hospitalized patients with or at risk of malnutrition are available, but disagreements among findings raise questions about their validity in guiding practice.

OBJECTIVES

We conducted an umbrella review (a systematic review of systematic reviews in which all appropriate studies included in SRMAs are combined) to assess the quality of reviews, identify the types of interventions available (excluding enteral and parenteral nutrition), and re-analyze the effectiveness of interventions.

METHODS

The databases MEDLINE/PubMed, CINAHL, Embase, The Cochrane Library, and Google Scholar were searched. AMSTAR-2 was used for quality assessment and GRADE for certainty of evidence. Updated meta-analyses with risk of bias (ROB) by Cochrane ROB 2.0 were performed. Pooled effects were reported as relative risk (RR), with zero-events and publication bias adjustments, and trial sequential analysis (TSA) performed for mortality, readmissions, complications, length of stay, and quality of life.

RESULTS

A total of 66 randomized controlled trials were cited by the 19 SRMAs included in this umbrella review, and their data extracted and analyzed. Most clinical outcomes were discordant with variable effect sizes in both directions. In trials with low ROB, interventions targeting nutritional intake reduce mortality at 30 d (15 studies, n: 4156, RR: 0.72, 95% CI: 0.55, 0.94, P: 0.02, I2: 6%, Certainty: High), 6 mo (27 studies, n: 6387, RR: 0.81, 95% CI: 0.71, 0.92, P = 0.001, I2: 4%, Certainty: Moderate), and 12 mo (27 studies, n: 6387, RR: 0.80, 95% CI: 0.67, 0.95, P: 0.01, I2: 33%, Certainty: Moderate), with TSA verifying an adequate sample size and robustness of the meta-analysis.

CONCLUSION

Existing evidence is sufficient to show that nutritional intervention is effective for mortality outcomes at 30 d, 6 mo, and 12 mo. Future clinical trials should focus on the effect of nutritional interventions on other clinical outcomes.

TRIAL REGISTRATION NUMBER

The protocol is registered on PROSPERO (CRD42022341031).

[ESPEN practical guideline: Home enteral nutrition]

Introduction

This ESPEN practical guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home enteral nutrition (HEN) providers in a concise way about the indications and contraindications for HEN, as well as its implementation and monitoring. This guideline will also inform interested patients requiring HEN. Home parenteral nutrition is not included but will be addressed in a separate ESPEN guideline. The guideline is based on the ESPEN scientific guideline published before, which consists of 61 recommendations that have been reproduced and renumbered, along with the associated commentaries that have been shorted compared to the scientific guideline. Evidence grades and consensus levels are indicated. The guideline was commissioned and financially supported by ESPEN and the members of the guideline group were selected by ESPEN.

Disease-related malnutrition with inflammation and cachexia

In 2010, the definition of cachexia was jointly developed by the European Society for Clinical Nutrition and Metabolism (ESPEN) Special Interest Groups (SIG) "Cachexia-anorexia in chronic wasting diseases" and "Nutrition in geriatrics". Cachexia was considered as a synonym of disease-related malnutrition (DRM) with inflammation by the ESPEN guidelines on definitions and terminology of clinical nutrition. Starting from these concepts and taking into account the available evidence the SIG "Cachexia-anorexia in chronic wasting diseases" conducted several meetings throughout 2020-2022 to discuss the similarities and differences between cachexia and DRM, the role of inflammation in DRM, and how it can be assessed. Moreover, in line with the Global Leadership Initiative on Malnutrition (GLIM) framework, in the future the SIG proposes to develop a prediction score to quantify the individual and combined effect(s) of multiple muscle and fat catabolic mechanisms, reduced food intake or assimilation and inflammation, which variably contribute to the cachectic/malnourished phenotype. This DRM/cachexia risk prediction score could consider the factors related to the direct mechanisms of muscle catabolism separately from those related to the reduction of nutrient intake and assimilation. Novel perspectives in the field of DRM with inflammation and cachexia were identified and described in the report.

Metabolic and nutritional aspects in continuous renal replacement therapy

Nutrition is one of the foundations for supporting and treating critically ill patients. Nutritional support provides calories, protein, electrolytes, vitamins, and trace elements via the enteral or parenteral route. Acute kidney injury (AKI) is a common and devastating problem in critically ill patients and has significant metabolic and nutritional consequences. Moreover, renal replacement therapy (RRT), whatever the modality used, also profoundly impacts metabolism. RRT and of the extracorporeal circuit impede 'effect the evaluation of a patient's energy requirements by clinicians. Substrates added and removed within the extracorporeal treatment are not always taken into consideration, making treatment even more challenging. Furthermore, evidence on nutritional support during continuous renal replacement therapy (CRRT) is scarce, and there are no clinical guidelines for nutrition adaptations during CRRT in critically ill patients. Most recommendations are based on expert opinions. This review discusses the complex interaction between nutritional support and CRRT and presents some milestones for nutritional support in critically ill patients on CRRT.

Outcome of Application of Cryopreserved Amniotic Membrane Grafts in the Treatment of Chronic Nonhealing Wounds of Different Origins in Polymorbid Patients: A Prospective Multicenter Study

To compare the therapeutic efficacy of cryopreserved amniotic membrane (AM) grafts and standard of care (SOC) in treating nonhealing wounds (NHW) through a prospective multicenter clinical trial, 42 patients (76% polymorbid) with 54 nonhealing wounds of various etiologies (mainly venous) and an average baseline size of 20 cm2 were included. All patients were treated for at least 6 weeks in the center before they were involved in the study. In the SOC group, 29 patients (36 wounds) were treated. If the wound healed less than 20% of the baseline size after 6 weeks, the patient was transferred to the AM group (35 patients, 43 wounds). Weekly visits included an assessment of the patient's condition, photo documentation, wound debridement, and dressing. Quality of life and the pain degree were subjectively reported by patients. After SOC, 7 wounds were healed completely, 1 defect partially, and 28 defects remained unhealed. AM application led to the complete closure of 24 wounds, partial healing occurred in 10, and 9 remained unhealed. The degree of pain and the quality of life improved significantly in all patients after AM application. This study demonstrates the effectiveness of cryopreserved AM grafts in the healing of NHW of polymorbid patients and associated pain reduction.

Clinical and functional assessment in patients admitted with pluripathological dysphagia according to the mode of feeding: Through a gastrostomy tube or oral

INTRODUCTION

Multipathological patients are a vulnerable population with high comorbidity, functional impairment, and nutritional risk. Almost 50% of these hospitalized patients have dysphagia. There is no consensus on whether placement of a percutaneous endoscopic gastrostomy (PEG) tube provides greater clinical benefit. The purpose of this study was to know and compare 2 groups of multipathological patients with dysphagia according to the mode of feeding: PEG vs. oral.

METHOD

Retrospective descriptive study with hospitalized patients (2016-19), pluripathological, with dysphagia, nutritional risk, over 50 years with diagnoses of: dementia, cerebrovascular accident (CVA), neurological disease, or oropharyngeal neoplasia. Terminally ill patients with jejunostomy tube or parenteral nutrition were excluded. Sociodemographic variables, clinical situation, and comorbidities were evaluated. Bivariate analysis was performed to compare both groups according to their diet, establishing a significance level of p < .05.

RESULTS

1928 multipathological patients. The PEG group consisted of 84 patients (n122). A total of 84 were randomly selected to form the non-PEG group (n434). This group had less history of bronchoaspiration/pneumonia (p = .008), its main diagnosis was stroke versus dementia in the PEG group (p < .001). Both groups had more than a 45% risk of comorbidity (p = .77).

CONCLUSIONS

multipathological patients with dysphagia with PEG usually have dementia as their main diagnosis, however, stroke is the most relevant pathology in those fed orally. Both groups have associated risk factors, high comorbidity, and dependence. This causes their vital prognosis to be limited regardless of the mode of feeding.

Nutritional State, Immunological and Biochemical Parameters, and Mortality in the ICU: An Analytical Study

Intensive care unit (ICU) hospitalization involves critically ill patients with multiple diseases and possible complications, including malnutrition, which increases hospital stay and mortality. Therefore, identifying the patient's prior nutritional state, following up during hospitalization, and implementing early intervention positively affect patient's vital situations at discharge. The objective of this study is to determine the nutritional state of patients admitted to an ICU in Cali (Colombia) in 2019 and its association with immunological and biochemical parameters and mortality observed during hospitalization. This was an observational, analytical, and retrospective study of patients admitted to an ICU in a clinic in Cali (Colombia) from 1 January to 31 March 2019. The association between their nutritional state and outcome variables such as hospital stay, immunological and biochemical function, and mortality was analyzed. Logistic regression was used to predict patients' vital status at hospital discharge. In terms of the nutritional level, low weight was observed in 17.5% patients, and overweight/obesity was observed in 53.5% of the population. Nutritional state was associated with leukocytosis. The patients with lymphocytosis had longer hospital stays than those with normal lymphocyte ranges. Age, blood leukocytes, and creatinine and potassium levels increased the risk of mortality. Lymphocyte values have been used as predictors of severity and hospitalization time. The scientific literature has also evidenced a higher leukocyte count in people with obesity, and such leukocytosis is associated with the risk of mortality. The results of blood and laboratory tests determining kidney function and blood electrolytes allow for the prediction of mortality risk in critically ill patients.

Predictive value of multiple variable models including nutritional risk score (NRS 2002) on mortality and length of stay of patients with covid-19 infections. The INCOVO study

BACKGROUND AND AIMS

This study aimed at evaluating associations between nutritional status and outcomes in patients with Covid-19 and to identify statistical models including nutritional parameters associated with in-hospital mortality and length of stay.

METHODS

Data of 5707 adult patients hospitalized in the University Hospital of Lausanne between March 2020 and March 2021 were screened retrospectively 920 patients (35% female) with confirmed Covid-19 and complete data including nutritional risk score (NRS 2002), were included. This cohort was divided into three subgroups: NRS <3: no risk of malnutrition; NRS ≥3 to <5: moderate risk malnutrition; and NRS ≥5: severe risk of malnutrition. The primary outcome was the percentage of in-hospital deaths in the different NRS subgroups. The secondary outcomes were the length of hospital stay (LOS), the percentage of admissions to intensive care units (ICU), and the length of stay in the ICU (ILOS). Logistic regression was performed to identify risk factors associated with in-hospital mortality and hospital stay. Multivariate clinical-biological models were developed to study predictions of mortality and very long length of stay.

RESULTS

The mean age of the cohort was 69.7 years. The death rate was 4 times higher in the subgroup with a NRS ≥ 5 (44%), and 3 times higher with a NRS ≥ 3 to <5 (33%) compared to the patients with a NRS<3 (10%) (p < 0.001). LOS was significantly higher in the NRS ≥ 5 and NRS ≥ 3 to <5 subgroups (26.0 days; CI [21; 30.9]; and 24.9; CI [22.5; 27.1] respectively) versus 13.4; CI [12; 14.8] for NRS<3 (p < 0.001). The mean ILOS was significantly higher in the NRS ≥ 5 (5.9 days; versus 2.8 for NRS ≥ 3 to <5, and 1.58 for NRS<3 (p < 0.001)). In logistic regression, NRS ≥ 3 was significantly associated with the risk of mortality (OR: 4.8; CI [3.3; 7.1]; p < 0.001) and very long in-hospital stay (>12 days) (OR: 2.5; CI [1.9; 3.3]; p < 0.001). Statistical models that included a NRS ≥ 3 and albumin revealed to be strong predictors for mortality and LOS (area under the curve 0.800 and 0.715).

CONCLUSION

NRS was found to be an independent risk factor for in-hospital death and LOS in hospitalized Covid-19 patients. Patients with a NRS ≥ 5 had a significant increase in ILOS and mortality. Statistical models including NRS are strong predictors for an increased risk of death and LOS.

Mobile nutrition and health management platform for perioperative recovery: an interdisciplinary research achievement using WeChat Applet

Background

In recent years, the number of people using mobile applications to promote health and welfare has exponentially increased. However, there are fewer applications in the field of ERAS. How to promote the rapid rehabilitation of patients with malignant tumor surgery during perioperative period and the mastery of its long-term nutritional state is a problem to be solved.

Objective

The purpose of this study is to design and develop a mobile application, and use Internet technology to better manage nutritional health to achieve rapid recovery of patients with malignant tumor surgery.

Methods

This study is divided into three stages: (1) Design: use participating design to make the MHEALTH APP adapt to the clinical practice of nutritional health management; (2) Development: the WeChat Applet of Nutrition and Health Assessment (WANHA) developed using the Internet technology development, and web management programs. (3) Procedure test: patients and medical staff evaluate WANHA's quality (UMARS), availability (SUS), and satisfaction, and conduct semi-structured interviews.

Results

In this study, 192 patients with malignant tumor surgery, 20 medical staff used WANHA. Patients with nutritional risks are supported by supporting treatment. The results show that patients who have not been treated during the perioperative period, the incidence of postoperative complications (22.4%) and the average hospitalization time after surgery decreased significantly. The incidence of nutritional risks is nearly more than the preoperative level. 45 patients and 20 medical staff participated in the survey of WANHA's SUS, UMARS, and satisfaction. In the interview, most patients and medical personnel believe that the procedure can improve the current medical services and nutritional health knowledge levels, promote the communication of medical staff and patients, and strengthen the nutritional health management of patients with malignant tumors under the concept of ERAS.

Conclusion

WeChat Applet of Nutrition and Health Assessment is a MHEALTH APP that enhances the nutrition and health management of patients with perioperative period. It can play a huge role in improving medical services, increasing patient satisfaction, and ERAS.

[Malnutrition in internal medicine : Screening, assessment and importance]

Disease-related malnutrition has a strong influence on the further course of the disease and mortality, especially in chronically ill patients. In recent years it could be shown in large randomized studies that an individual nutrition therapy could significantly and relevantly improve the clinical outcome of patients in internal medicine with a risk of malnutrition, both in hospital and in aftercare. Therefore, due to the increasing proportion of multimorbid patients the significance of malnutrition and its treatment is becoming increasingly more important in the practice and in research. Nutritional medicine should nowadays be considered as an effective and integral component of a holistic treatment in internal medicine; however, further research is necessary in order to investigate new nutritional biomarkers and for a better integration of an evidence-based personalized nutritional medicine into routine clinical practice.

Impact of nutritional and educational support on home enteral nutrition

BACKGROUND

Home Enteral Nutrition (HEN) is used to prevent or correct malnutrition in outpatients. Due to the complexity of this process, the indication, follow-up, and results of an educational program of HEN patients was evaluated.

METHODS

A prospective, observational, real-life, multicenter study was performed in 21 Spanish Hospital. Patients receiving HEN by nasogastric tube or ostomy were included. The following variables were collected: age, gender, HEN indication, type of formula, nutritional requirements, laboratory variables, complications, and quality standards of the educational program. To calculate the energy and protein requirements, the FAO/WHO/UNU formula was used considering the adjusted weight of the patients. All data were analyzed using SPSS.24.

RESULTS

414 patients were included. Most conditions diagnosed were neurodegenerative diseases (64.8%). 100 (25.3%) were diabetic. The mean weight was 59.3 ± 10.4 kg and BMI 22.6 ± 3.2. Moderate protein-calorie malnutrition was predominant at baseline (46.4%). Improvement in nutritional status at six months was recorded in more than 75% of patients (p < 0.05). Tolerance problems, diarrhea and abdominal distension fell between the 3- and 6-month visits (p < 0.05). Patients who received intermittent EN had fewer tolerance-related effects (OR 0.042; 95% CI 0.006-0.279) and less diarrhoea (OR 0.042; 95% CI 0.006-0.279). At the baseline and 6-month visits, compliance with the educational measures proposed by the prescriber was ≥ 99%.

CONCLUSION

The nutritional assessment to prescribe individualized HEN to each patient, together with educational measures and training in the proper use of this treatment for both patients and trainers, improves nutritional status and reduces the onset of adverse events.

Practical guideline on obesity care in patients with gastrointestinal and liver diseases - Joint ESPEN/UEG guideline

BACKGROUND

Patients with chronic gastrointestinal disease such as inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), celiac disease, gastroesophageal reflux disease (GERD), pancreatitis, and chronic liver disease (CLD) often suffer from obesity because of coincidence (IBD, IBS, celiac disease) or related pathophysiology (GERD, pancreatitis and CLD). It is unclear if such patients need a particular diagnostic and treatment that differs from the needs of lean gastrointestinal patients. The present guideline addresses this question according to current knowledge and evidence.

OBJECTIVE

The present practical guideline is intended for clinicians and practitioners in general medicine, gastroenterology, surgery and other obesity management, including dietitians and focuses on obesity care in patients with chronic gastrointestinal diseases.

METHODS

The present practical guideline is the shortened version of a previously published scientific guideline developed according to the standard operating procedure for ESPEN guidelines. The content has been re-structured and transformed into flow-charts that allow a quick navigation through the text.

RESULTS

In 100 recommendations (3× A, 33× B, 24 × 0, 40× GPP, all with a consensus grade of 90% or more) care of gastrointestinal patients with obesity - including sarcopenic obesity - is addressed in a multidisciplinary way. A particular emphasis is on CLD, especially metabolic associated liver disease, since such diseases are closely related to obesity, whereas liver cirrhosis is rather associated with sarcopenic obesity. A special chapter is dedicated to obesity care in patients undergoing bariatric surgery. The guideline focuses on adults, not on children, for whom data are scarce. Whether some of the recommendations apply to children must be left to the judgment of the experienced pediatrician.

CONCLUSION

The present practical guideline offers in a condensed way evidence-based advice how to care for patients with chronic gastrointestinal diseases and concomitant obesity, an increasingly frequent constellation in clinical practice.

A 1-year follow-up study in patients with idiopathic pulmonary fibrosis regarding adverse outcomes to unintended weight loss

OBJECTIVES

Malnutrition in pulmonary fibrosis may influence clinical outcomes negatively. This project aimed to investigate if weight, unintended weight loss (UWL) at baseline and weight development, and signs of sarcopenia measured by the strength, assistance with the walking, rising from a chair, climbing stairs, and falls questionnaire (SARC-F) are associated with hospital admissions and mortality for idiopathic pulmonary fibrosis outpatients in ≤1 y as well as referral to pulmonary rehabilitation.

METHODS

At baseline, prevalence of weight and UWL were sought in a cross-sectional questionnaire study, consecutively, including 100 patients in an outpatient clinic. Medical records were sought for time from diagnosis and comorbidities. One year after inclusion weight, UWL and SARC-F were collected by phone interviews, and medical records were revisited for clinical outcomes.

RESULTS

Of the 100 patients, two patients died and seven were lost to follow-up. The prevalence of UWL increased within the year (10-13%), and the amount of UWL increased (9.1-11.8 kg). Patients with a UWL at baseline had a significantly higher risk of mortality (odds ratio = 29.8; P = 0.037). UWL at baseline was associated with risk of hospital admissions (odds ratio = 14.7; P = 0.009). Based on the results from SARC-F, 20.9% have signs of sarcopenia. UWL at follow-up was associated with the risk of sarcopenia by SARC-F. Patients with risk of sarcopenia and those with body mass index ≥30 kg/m² were to a higher degree offered pulmonary rehabilitation; however, participation was low.

CONCLUSIONS

UWL at baseline was significantly associated with risk of hospital admissions and mortality in ≤1 y in idiopathic pulmonary fibrosis outpatients. Patients with signs of sarcopenia and body mass index ≥30 kg/m² were most often referred to pulmonary rehabilitation.

Are nutritional sufficiency of ≥75% energy and protein requirements relevant targets in patients at nutritional risk? - A one month follow-up study

BACKGROUND & AIM

Nutrient intake in patients at nutritional risk was recorded with the aim of reaching at least 75% of estimated requirements for energy and protein. However, the cutoff at 75% has only been sparsely investigated. The aim of this study was to re-evaluate the 75% cutoff of estimated energy and protein requirements among patients at or not at nutritional risk in relation to 30-day mortality and readmissions.

METHODS

A 30-day follow-up study was performed among hospitalized patients in 31 units at a Danish University Hospital. Data was collected using the nurses' quartile nutrition registration method and electronic patient journals. All patients were screened using the NRS-2002 and classified as either at nutritional risk (NRS-2002, score ≥3) or not at nutritional risk (NRS-2002, score <3). Energy and protein requirements were estimated using weighted Harris-Benedict equation and 1.3 g/kg/day, respectively.

RESULTS

In total, 318 patients were included in this study. Patients at nutritional risk were older, lower BMI, male, more comorbidities and a longer primary length of stay compared to patients not at nutritional risk (p < 0.05). After 30-day follow-up, mortality was higher among patients at risk (9.5% vs. 2.0%, p < 0.05). Patients at nutritional risk showed increased risk of mortality if they did not achieve 75% of estimated requirements (energy: OR = 8.08 [1.78; 36.79]; protein: OR = 3.40 [0.74; 15:53]). Furthermore, predicted probability of mortality decreased with increased energy and protein intakes. No significant associations were found for readmissions achieving 75% of estimated energy or protein requirements. A cutoff of 76-81% for energy and 58-62% for protein was equivalent with accepting a 6-8% mortality rate.

CONCLUSION

The results of this study indicate that an energy intake ≥75% of estimated requirement among patients at nutritional risk has a preventative effect regarding mortality within one month, but not for readmissions.

Association between prealbumin, all-cause mortality, and response to nutrition treatment in patients at nutrition risk: Secondary analysis of a randomized controlled trial

BACKGROUND

Because of the shorter half-life as compared with albumin, serum prealbumin concentrations have been proposed to be useful nutrition biomarkers for the assessment of patients at nutrition risk. In a post hoc analysis of patients at nutrition risk from a randomized controlled nutrition trial, we tested the hypothesis that (1) prealbumin is associated with higher all-cause 180-day mortality rates and that (2) individualized nutrition support compared with usual-care nutrition more effectively improves survival at 30 days in patients with low prealbumin levels compared with patients with normal prealbumin levels.

METHODS

We performed a prespecified cohort study in patients included in the pragmatic, Swiss, multicenter randomized controlled EFFORT trial comparing the effects of individualized nutrition support with usual care. We studied low prealbumin concentrations (<0.17 g/L) in a subgroup of 517 patients from one participating center.

RESULTS

A total of 306 (59.2%) patients (mean age 71.9 years, 53.6% men) had low admission prealbumin levels (<0.17 g/L). There was a significant association between low prealbumin levels and mortality at 180 days (115/306 [37.6%] vs 47/211 [22.3%], fully adjusted hazard ratio [HR]=1.59, 95% CI 1.11-2.28; P = 0.011). Prealbumin levels significantly improved the prognostic value of the Nutritional Risk Screening total score regarding mortality prediction at short- and long-term. The difference in mortality between patients receiving individualized nutrition support and usual-care nutrition was similar for patients with low prealbumin levels compared with patients with normal prealbumin levels (HR=0.90 [95% CI=0.51-1.59] vs HR=0.88 [95% CI=0.35-2.23]) with no evidence for interaction (P = 0.823).

CONCLUSION

Among medical inpatients at nutrition risk, low admission prealbumin levels correlated with different nutrition markers and higher mortality risk, but patients with low or high prealbumin levels had a similar benefit from nutrition support. Further studies should identify nutrition markers that help further personalize nutrition interventions.

Nutritional issues concerning general medical ward patients: feeding patients recovering from critical illness

PURPOSE OF REVIEW

ICU survivors often spend long periods of time in general wards following transfer from ICU in which they are still nutritionally compromised. This brief review will focus on the feeding of patients recovering from critical illness, as no formal recommendations or guidelines on nutrition management are available for this specific situation.

RECENT FINDINGS

While feeding should start in the ICU, it is important to continue and adapt nutritional plans on the ward to support individuals recovering from critical illness. This process is highly complex - suboptimal feeding may contribute significantly to higher morbidity and mortality, and seriously hinder recovery from illness. Recently, consensus diagnostic criteria for malnutrition have been defined and large-scale trials have advanced our understanding of the pathophysiological pathways underlying malnutrition. They have also helped further develop treatment algorithms. However, we must continue to identify specific clinical parameters and blood biomarkers to further personalize therapy for malnourished patients. Better understanding of such factors may help us adapt nutritional plans more efficiently.

SUMMARY

Adequate nutrition is a vigorous component of treatment in the post-ICU period and can enhance recovery and improve clinical outcome. To better personalize nutritional treatment because not every patient benefits from support in the same manner, it is important to further investigate biomarkers with a possible prognostic value.

MEDPass versus conventional administration of oral nutritional supplements - A randomized controlled trial comparing coverage of energy and protein requirements

BACKGROUND & AIMS

The use of oral nutritional supplements (ONS) in the hospital setting is important to reach individual protein and energy goals in patients at risk for malnutrition. Compliance with ONS can be challenging but may be improved by prescribing ONS in smaller portions with medication rounds (MEDPass). We compared the likelihood of meeting energy and protein requirements in patients receiving ONS with MEDPass versus conventional ONS administration.

METHODS

The MEDPass Trial is a randomized, controlled, open-label superiority trial conducted on medical and geriatric wards in a University Hospital in Switzerland. The MEDPass group was allocated to receive 50 ml of ONS four times per day with the medication rounds. The control group received ONS per conventional care between the meals. The primary outcome was the percentage of energy in relation to the individual requirement. Secondary outcomes included the coverage of protein intake in relation to the individual requirement, the amount of daily consumed ONS, the course of handgrip strength (HGS), body weight appetite and nausea. Furthermore, we compared 30-day mortality and hospital length of stay (LOS) was studied in medical patients.

RESULTS

From November 22nd, 2018 until November 30th, 2021, 204 patients were included in the trial (MEDPass group n = 100, control group n = 104). A total of 203 patients at nutritional risk were analyzed in the intention-to-treat analysis (ITT). Regarding the primary endpoint, there was no difference in the coverage of energy requirement between the MEDPass and control group (82 vs. 85% (Δ -3%, 95%CI -11 to 4%), p = 0.38). Similarly, no differences were found for the secondary outcomes including coverage of protein requirement (101 vs. 104% (Δ -3%, 95% CI -12 -7%), p = 0.57, average daily intake of ONS (170 vs 173 ml (Δ - 3 ml, 95% CI -14 to 8 ml), p = 0.58) and 30-day mortality (3 vs. 8 patients, OR 0.4 (95% CI 0.1-1.4), p = 0.15). The course of HGS, body weight, appetite and nausea did not differ between the groups (p = 0.29, p = 0.14, p = 0.65 and p = 0.94, respectively). The per protocol analysis including 178 patients showed similar results.

CONCLUSION

Within this controlled trial setting, we found a high compliance for ONS intake and high coverage of protein requirements but no further improvement when ONS was administered using MEDPass compared to conventional care. MEDPass administration may provide an alternative that is easy to integrate into nursing routines, which may lead to lower workload with cost benefits and reduction of food waste.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03761680.

Nutrition issues in the general medical ward patient: From general screening to specific diagnosis and individualized treatment

Disease-related malnutrition in patients in the general medical ward remains a complex syndrome, which contributes to high morbidity and mortality, and seriously interferes with recovery from acute illness. Recently, there have been important advances in the development of consensus diagnostic criteria for malnutrition, and through the recent completion of large-scale trials, the understanding of pathophysiological pathways and evidence-based treatment algorithms to provide nutrition care to patients at risk for malnutrition in the hospital setting has advanced. There is need to identify more specific clinical parameters and blood biomarkers, which allow a more personalized approach to the malnourished patients, because not all patients show the same response to nutrition interventions. Recent studies have suggested that some nutrition biomarkers of inflammation, kidney function and muscle health, among others, predict treatment response to nutrition interventions and may help to personalize treatments. In addition to advancing the science, there is need for more education of students and treating teams in the hospital to improve the screening of patients at hospital admission regarding nutrition risk with the start of individualized nutrition support interventions, thereby bringing optimal nutrition care to the bedside.

Association of CT-based diagnosis of sarcopenia with prognosis and treatment response in patients at risk of malnutrition - A secondary analysis of the Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) trial

BACKGROUND & AIM

CT-derived measures of muscle mass may help to identify patients with sarcopenia. We investigated the prognostic significance of CT-derived sarcopenia and muscle attenuation with nutritional markers, clinical outcomes and response to nutritional support in medical in-patients at nutritional risk.

METHOD

Within this secondary analysis of the randomized-controlled Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) comparing individualized nutritional support with usual care nutrition in medical inpatients, we investigated associations of CT-based sarcopenia and muscle attenuation at the level L3 with different nutritional and clinical outcomes, and the response to the nutritional intervention. The primary composite endpoint was adverse clinical outcome within 30 days of hospital admission.

RESULTS

We included 573 of 2028 EFFORT patients with available CT scans, of which 68.4% met the CT-based definition of sarcopenia and 72.9% had low muscle attenuation. In multivariate analysis, low skeletal muscle index was associated with higher nutritional risk (coefficient per NRS class -0.94 (95%CI -1.87 to -0.01) p = 0.049) and higher risk for adverse clinical outcomes (adjusted odds ratio 1.59 (95% CI 1.06 to 2.38), p = 0.024). Low muscle attenuation was also associated with adverse clinical outcome (adjusted odds ratio 1.67 (95%CI 1.08 to 2.58), p = 0.02). Nutritional support tended to be more effective in reducing mortality in non-sarcopenic patients compared to patients with CT-based sarcopenia (p for interaction 0.058).

CONCLUSIONS

Within a population of medical patients at nutritional risk, CT-based sarcopenia and muscle attenuation were associated with several nutritional parameters and predicted adverse clinical outcomes. Information from CT scans, thus may help to better characterize these patients, and may be helpful in guiding therapeutic interventions.

Nutritional Status as a Risk Factor for New-Onset Atrial Fibrillation in Acute Myocardial Infarction

Purpose

Our study aimed to identify new-onset atrial fibrillation (NOAF) risk factors in acute myocardial infarction (AMI) patients after treatment with percutaneous coronary intervention (PCI) and investigate whether their nutritional status can be a predicting factor of NOAF.

Patients and Methods

We analyzed 662 AMI patients after PCI for NOAF occurrence during follow-up hospitalization and divided them into an NOAF and non-NOAF group. The patients' nutritional status was assessed using the controlling nutritional status (CONUT) score and geriatric nutritional risk index (GNRI). The Kaplan‒Meier analysis was used to assess NOAF-free survival in varying degrees of malnutrition. Cox proportional hazards models were used to identify the risk factors for NOAF.

Results

Eighty-four (12.7%) patients developed NOAF during hospitalization. There was a statistically significant difference in the occurrence of NOAF among different categories of nutritional status. The CONUT score and GNRI classifications were independent predictors of NOAF. NOAF occurrence was associated with older age, higher uric acid levels, higher N-terminal pro-B-type natriuretic peptide levels, greater left atrial size, and worse Killip class upon admission.

Conclusion

The nutritional status can affect NOAF occurrence in AMI patients after PCI. The CONUT score and GNRI are ideal tools for evaluating the nutritional status of AMI patients, with an excellent predictive effect on NOAF.

Effects of individualized dietary counseling on nutritional status and quality of life in post-discharge patients after surgery for gastric cancer: A randomized clinical trial

Background

Currently, the supporting evidence for dietary counseling is insufficient. The aim of this study is to evaluate the impact of individualized dietary counseling on nutritional outcomes and quality of life (QOL) in patients undergoing surgery for gastric cancer.

Methods

This study was a prospective, single-center, randomized controlled trial. The patients after surgery for gastric cancer were randomly assigned (1:1) to the intervention group and the control group. In the intervention group, patients receive individualized dietary counseling based on individual calorie needs and symptom assessment at 24 h before discharge, 14, 21, 30, and 60 days postoperatively. Patients in the control group received routine dietary counseling. The primary endpoint was body mass index (BMI) loss at 30, 60, and 90 days after surgery; the secondary endpoints were calorie and protein intake at 30 and 60 days after surgery, blood parameters, the 90-day readmission rate, and QOL at 90 days after surgery.

Results

One hundred thirty patients were enrolled; 67 patients were assigned to the intervention group and 63 patients to the control group. Compared with the control group, patients in the intervention group were significantly less BMI loss at 30 days (-0.84 ± 0.65 vs. -1.29 ± 0.83), 60 days (-1.29 ± 0.92 vs. -1.77 ± 1.13), and 90 days (-1.37 ± 1.05 vs. -1.92 ± 1.66) after surgery (all P< 0.05). Subgroups analysis by surgery type showed that the intervention could significantly reduce BMI loss in patients undergoing total and proximal gastrectomy at 30 days (-0.75 ± 0.47 vs. -1.55 ± 1.10), 60 days (-1.59 ± 1.02 vs. -2.55 ± 1.16), and 90 days (-1.44 ± 1.19 vs. -3.26 ± 1.46) after surgery (all P< 0.05). At 60 days after surgery, calorie goals were reached in 35 patients (77.8%) in the intervention group and 14 patients (40.0%) in the control group (P = 0.001), and protein goals were reached in 40 patients (88.9%) in the intervention group and 17 patients (48.6%) in the control group (P< 0.001). Regarding the QOL at 90 days after surgery, the patients in the intervention group had a significantly lower level of fatigue, shortness of breath and stomach pain, better physical function, and cognitive function (P< 0.05).

Conclusions

Post-discharge individualized dietary counseling is an effective intervention to reduce post-gastrectomy patient weight loss and to elevate calorie intake, protein intake, and QOL.