Clinical malnutrition predictive model among gynecologic cancer patients prior to elective operation: A cross-sectional study

A nomogram for predicting the risk of malnutrition in hospitalized older adults: a retrospective study

BACKGROUND

Malnutrition is highly prevalent but under-recognized in hospitalized older adults, which is closely related to increased risk of adverse clinical outcomes and mortality. It is crucial to identify high-risk individuals at an early stage and manage them promptly. This study aimed to explore the predictive factors and develop a nomogram model for predicting the risk of malnutrition in hospitalized elderly patients.

METHODS

We conducted a retrospective study of data collected from 456 older individuals admitted to geriatric wards from four hospitals in China between August 2020 and December 2020 (136 in the malnutrition group and 320 in the non-malnutrition group). Least Absolute Selection and Shrinkage Operator (LASSO) regression and stepwise multivariate logistic regression were applied to screen predictors and create a nomogram. The predictive performance of the model was assessed by receiver operating characteristic (ROC) curve, concordance index (C-index) and calibration curve. The clinical utility was estimated by decision curve analysis (DCA). Youden's Index was used to identify the optimal cut-point of the nomogram.

RESULTS

Four independent predictive factors were utilized to construct the nomogram model after being selected by LASSO regression and multivariate logistic regression, namely body mass index (BMI), heart failure, frailty and hemoglobin. C-index of the model was 0.906 (95% CI: 0.872-0.939) and the area under the curve (AUC) was 0.906. The optimal cut-point of the nomogram was 82.74 with a sensitivity of 78.7% and specificity of 92.2% (Youden's index: 0.709). The calibration curve demonstrated a high degree of consistency between predicted probability and actual observation. The DCA indicated a favorable clinical benefit for the nomogram.

CONCLUSIONS

We have established a multi-dimensional nomogram model to predict the risk of malnutrition in Chinese hospitalized older adults. The model yields favorable predictive performance and clinical utility, which provides an effective approach for rapid identification of high-risk malnourished older individuals in clinical practice.

Gender-Specific Malnutrition and Muscle Depletion in Gastric and Colorectal Cancer: Role of Dietary Intake in a Jordanian Cohort

OBJECTIVES

This study aimed to assess malnutrition and muscle mass depletion risk in gastrointestinal cancer patients, exploring the differences between gastric and colorectal cancer, with a focus on gender0specific variations and dietary intake. It also examined whether muscle depletion mediates the relationship between dietary intake and malnutrition risk.

METHODS

A sample of 100 Jordanian pre-operative gastrointestinal cancer patients (60 male, 40 female) with gastric or colorectal cancer were assessed for malnutrition risk using the malnutrition universal screening tool (MUST) and for muscle depletion using fat-free mass index (FFMI) and mid-upper arm muscle area (MUAMA).

RESULTS

The study found that 80% (95% CI: 0.708-0.873) of patients were at high risk of malnutrition, with over 60% experiencing severe muscle loss. Gastric cancer patients showed higher, though not statistically significant, malnutrition risk (90.2% vs. 72.9%) and muscle depletion compared to colorectal cancer patients. Advanced cancer stages were associated with significantly higher risk of malnutrition and muscle depletion. Significant gender-specific differences in muscle depletion via FFMI (p = 0.012) and via MUAMA (p = 0.028) were also noted, especially in females with gastric cancer. Additionally, males exhibited a significantly higher malnutrition risk (p < 0.001) based on cancer stage. Patients' dietary intake was significantly (p < 0.001) below the recommended levels for energy, protein, carbohydrates, fiber, and essential fatty acids, which was associated with higher malnutrition risk, muscle depletion, low BMI (<18.5 kg/m2), and significant weight loss (>10%). Low dietary intake was strongly linked to increased malnutrition risk and muscle depletion, with muscle loss partially mediating (b = 0.4972, p < 0.0001) the relationship between poor dietary intake and malnutrition risk. Additionally, higher muscle mass was protective against malnutrition (OR = 16.0, 95% CI: 1.706-150.507), and cancer type was a significant predictor of malnutrition risk (OR = 14.4, 95% CI: 1.583-130.867).

CONCLUSIONS

Malnutrition risk and significant muscle loss are common in GI cancer patients, highlighting the urgent need for tailored nutrition care plans and lifestyle modifications.

Effect of perioperative immunonutrition intervention among gynecological cancer patients: A systematic review

BACKGROUND

Gynecologic cancer (GC) patients often experience systemic inflammation, malnutrition, and compromised postoperative outcomes. This systematic review aims to comprehensively synthesize existing data regarding the impact of perioperative immunonutrition (IMN) intervention on GC patients.

METHODS

The databases of CENTRAL, EMBASE, Web of Science, and the Cochrane Library were used to conduct a literature search, supplemented by internet search engines and manual searches. Publications released between January 2009 and October 2023 was identified, reviewed, and data extracted.

RESULTS

The review encompasses six studies involving 712 patients, comprising two randomized controlled trials (RCTs), two prospective studies, and two retrospective cohort studies. Three studies prescribed IMN perioperatively; two pre-operatively and one post-operatively. Four out of six studies reported less post-operative infection and complications. Two studies reported shorter hospitalization using the IMN formula. One study reported a longer hospitalization with IMN supplementation. Overall survival showed no significant difference in the two studies. Four studies reported positive modulation of inflammatory markers and lymphocytes as outcomes, with IMN formulas.

DISCUSSION AND CONCLUSION

Perioperative IMN emerge as a promising intervention, demonstrating notable benefits included shortened hospitalization as well and positive modulation of inflammatory markers.

Prognostic Nutritional Index as a Predictive Biomarker of Post-Operative Infectious Morbidity in Gynecological Cancer Patients: A Prospective Cohort Study

Malnutrition significantly impacts the post-operative process of gynecological cancer patients. A prominent variable for determining perioperative morbidity is the Prognostic Nutritional Index (PNI). To investigate PNI's predictive value on the risk of post-operative infections, we conducted a prospective cohort study involving women who underwent surgery for gynecological malignancies. Out of the 208 patients enrolled, 28 (13.5%) were malnourished and post-operative infections occurred in 43 patients. Notably, there was a significant difference in PNI between patients who developed infections and those who did not (p = 0.027), as well as between malnourished patients and those with normal nutritional status (p = 0.043). Univariate analysis showed that preoperative PNI predicts the risk of post-operative infections better than post-operative white blood cell count (AUC of 0.562 vs 0.375). However, the most accurate diagnostic results in the multivariate analysis were obtained from random forest and classification tree models (AUC of 0.987 and 0.977, respectively). Essentially, PNI and post-operative white blood cell count provided the best information gain according to rank probabilities. In conclusion, PNI appears to be a critical parameter that merits further investigation during the preoperative evaluation of gynecological malignancies.

Effectiveness of a Digital Decision Aid for Nutrition Support in Women with Gynaecological Cancer: A Comparative Study

This study aimed to examine the effects of an animated Patient Decision Aid (PtDA) about dietary choices on decisional conflict and decision regret. A prospective, observational, two-group comparative effectiveness study was conducted with patients (n = 90) from a southern Taiwan oncology inpatient unit. Data included the Malnutrition Universal Screening Tool (MUST), laboratory results, 16-item Decisional Conflict Scale (sf-DCS), and 5-item Decision Regret Scale (DRSc). Data were collected at admission (T0), after the first-cycle of chemotherapy but before discharge (T1), and after the six-cycle chemotherapy protocol (T2) (around 3 months). Group A received standardized nutrition education and a printed brochure, while Group B watched a 10-minute information video during a one-on-one inpatient consultation and engaged in a values clarification exercise between T0 and T1. The percentage of women with a MUST score ≧1 in Group A sharply increased over time, but not in Group B. Decision aid usage significantly increased patients' hemoglobin and lymphocyte values over time (p < 0.05). The digital PtDA contributed to less decisional conflict and decision regret in at-risk patients and improved their nutritional well-being. Decision-aids help patients make healthcare decisions in line with their values, and are sustainable for use by busy clinicians.

Demographic, clinical and psychological predictors of malnutrition among people with liver cancer

PURPOSE

This study aimed to explore the nutritional status and examine the demographic, clinical, nutritional, and psychosocial characteristics associated with malnutrition among people with liver cancer.

METHODS

A descriptive cross-sectional design was used. Data were collected from a convenience sample of 162 liver cancer outpatients at a tertiary university hospital. Nutritional status was evaluated using the Patient-Generated Subjective Global Assessment (PG-SGA). Self-administered structured questionnaires were administered, and medical records were reviewed for demographic, clinical, nutritional, and psychosocial characteristics.

RESULTS

Based on PG-SGA scores, 27 patients (16.7%) were classified into the malnutrition group. The stages of liver cancer, chemotherapy, physical and psychological symptom distress, global distress index, levels of alpha-fetoprotein and protein induced by vitamin K absence or antagonists, body mass index, appetite, hemoglobin and albumin levels, and depression were statistically significantly associated with malnutrition. Logistic regression model revealed that physical symptom distress, liver cancer stage, depression, and body mass index influenced statistically significantly malnutrition.

CONCLUSIONS

In this study, clinical, nutritional, and psychosocial characteristics predicted malnutrition among people with liver cancer. Nurses should consider these characteristics when evaluating the nutritional status of people with liver cancer.

Exercise and pre-habilitation with high whey-protein-based meal replacement therapy promote weight loss and preserve muscle mass before bariatric surgery

BACKGROUND

Bariatric surgery is considered as an effective therapy for those with morbid obesity. Preoperative weight loss with a very low-calorie diet is commonly used to ease the bariatric surgery. Pre-habilitation increases functional and physiological capacity. The study demonstrated the changes of body composition and functional status following short term pre-habilitation before bariatric surgery.

METHOD

This prospective study targeted those admitted for bariatric surgery. Participants underwent the biweekly pre-habilitation program included an individualized high whey-based protein very low-calorie (VLCHP) enteral regime (600-900 kcal/day) and moderate intensive exercise before bariatric surgery. Body composition and waist circumference were assessed after fortnight. Participants were segregated into morbid obese (MOG) (BMI <49 kg/m2) and super morbid obese group (SMOG) (BMI ≥50 kg/m2) for analysis.

RESULT

Majority of participants were female (71%) with median age 36.0 years old (MOG) and 34.3 years old (SMOG) respectively. SMOG achieved significant greater loss in weight (-7.4 kg vs -4.0 kg), fat percentage (-4.4% vs -1.7%) and fat mass (-9.9 kg vs -3.8 kg); but MOG had a significant increment in muscle mass (3.2 kg vs 2.8 kg) as compared to SOG (p < 0.001).

DISCUSSION

Body composition measurement and changes remain critical in nutritional assessment to achieve successful surgery and minimize nutritional complication. Whey-based VLCHP attenuates muscle loss and preserves myofibrillar protein synthesis; promotes a better muscle strength and mass growth during periods of negative energy balance combined with moderately intense aerobic activity.

CONCLUSION

Individualized whey-based VLCHP enteral regime and moderate intensive exercise encourage weight loss; increases muscle mass and strength; improve function status prior to bariatric surgery.

Development and validation of a radiomics-based nomogram for the prediction of postoperative malnutrition in stage IB1-IIA2 cervical carcinoma

Objective

In individuals with stage IB1-IIA2 cervical cancer (CC) who received postoperative radiotherapy ± chemotherapy (PORT/CRT), the interaction between sarcopenia and malnutrition remains elusive, let alone employing a nomogram model based on radiomic features of psoas extracted at the level of the third lumbar vertebra (L3). This study was set to develop a radiomics-based nomogram model to predict malnutrition as per the Patient-Generated Subjective Global Assessment (PG-SGA) for individuals with CC.

Methods

In total, 120 individuals with CC underwent computed tomography (CT) scans before PORT/CRT. The radiomic features of psoas at L3 were obtained from non-enhanced CT images. Identification of the optimal features and construction of the rad-score formula were conducted utilizing the least absolute shrinkage and selection operator (LASSO) logistic regression to predict malnutrition in the training dataset (radiomic model). Identification of the major clinical factors in the clinical model was performed by means of binary logistic regression analysis. The radiomics-based nomogram was further developed by integrating radiomic signatures and clinical risk factors (combined model). The receiver operating characteristic (ROC) curves and decision curves analysis (DCA) were employed for the evaluation and comparison of the three models in terms of their predictive performance.

Results

Twelve radiomic features in total were chosen, and the rad-score was determined with the help of the non-zero coefficient from LASSO regression. Multivariate analysis revealed that besides rad-score, age and Eastern Cooperative Oncology Group performance status could independently predict malnutrition. As per the data of this analysis, a nomogram prediction model was constructed. The area under the ROC curves (AUC) values of the radiomic and clinical models were 0.778 and 0.847 for the training and 0.776 and 0.776 for the validation sets, respectively. An increase in the AUC was observed up to 0.972 and 0.805 in the training and validation sets, respectively, in the combined model. DCA also confirmed the clinical benefit of the combined model.

Conclusion

This radiomics-based nomogram model depicted potential for use as a marker for predicting malnutrition in stage IB1-IIA2 CC patients who underwent PORT/CRT and required further investigation with a large sample size.

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

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

Progressive Skeletal Muscle Loss After Surgery and Adjuvant Radiotherapy Impact Survival Outcomes in Patients With Early Stage Cervical Cancer

The effect of skeletal muscle loss associated with surgery and adjuvant radiotherapy on survival outcomes in patients with early-stage cervical cancer remains unclear. We analyzed the data of 133 patients with early-stage cervical cancer who underwent surgery and adjuvant radiotherapy between 2013 and 2018 at two tertiary centers. Skeletal muscle changes were measured using computed tomography scans at baseline, at simulation for radiotherapy, and at 3 months post-treatment. A decrease of ≥5% in the skeletal muscle was defined as “muscle loss.” The Patient-Reported Outcome version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) was used to assess gastrointestinal toxicity. The Patient-Generated Subjective Global Assessment (PG-SGA) was used for nutritional assessment. Predictors of overall survival were identified using the Cox regression models. The median follow-up period was 3.7 years. After treatment, 32 patients (24.1%) experienced muscle loss. The rate of muscle loss was higher in patients with PRO-CTCAE score ≥3 or PG-SGA score ≥4 at the end of radiotherapy than in patients with PRO-CTCAE score ≤2 or PG-SGA score 0–3 (75.0 vs. 10.5%, p < 0.001; 71.4 vs. 2.2%, p < 0.001). The 3-year overall survival was significantly lower in patients with muscle loss than in those with muscle preserved (65.6 vs. 93.9%, p < 0.001). Multivariate analysis showed that muscle loss was independently associated with poor overall survival (hazard ratio, 4.55; 95% confidence interval: 1.63–12.72; p < 0.001). Muscle loss after surgery and adjuvant radiotherapy was associated with poor overall survival in patients with early-stage cervical cancer. Muscle loss is associated with patient-reported gastrointestinal toxicity and deterioration in nutritional status.

Postoperative Dietary Intake Achievement: A Secondary Analysis of a Randomized Controlled Trial

Sufficient postoperative dietary intake is crucial for ensuring a better surgical outcome. This study aimed to investigate the postoperative dietary intake achievement and predictors of postoperative dietary intake among gynecologic cancer patients. A total of 118 participants were included in this secondary analysis. Postoperative dietary data was pooled and re-classified into early postoperative dietary intake achievement (EDIA) (daily energy intake (DEI) ≥ 75% from the estimated energy requirement (EER)) and delay dietary intake achievement (DDIA) (DEI < 75% EER) There was a significant difference in postoperative changes in weight (p = 0.002), muscle mass (p = 0.018), and handgrip strength (p = 0.010) between the groups. Postoperative daily energy and protein intake in the EDIA was significantly greater than DDIA from operation day to discharged (p = 0.000 and p = 0.036). Four significant independent postoperative dietary intake predictors were found: preoperative whey protein-infused carbohydrate loading (p = 0.000), postoperative nausea vomiting (p = 0.001), age (p = 0.010), and time to tolerate clear fluid (p = 0.016). The multilinear regression model significantly predicted postoperative dietary intake, F (4, 116) = 68.013, p = 0.000, adj. R² = 0.698. With the four predictors’ recognition, the integration of a more specific and comprehensive dietitian-led supportive care with individualized nutrition intervention ought to be considered to promote functional recovery.