Diagnostic test accuracy of preoperative nutritional screening tools in adults for malnutrition: a systematic review and network meta-analysis

Drivers of bias in diagnostic test accuracy estimates when using expert panels as a reference standard: a simulation study

BACKGROUND

Expert panels are often used as a reference standard when no gold standard is available in diagnostic test accuracy research. It is often unclear what study and expert panel characteristics produce the best estimates of diagnostic test accuracy. We simulated a large range of scenarios to assess the impact of study and expert panel characteristics on index test diagnostic accuracy estimates.

METHODS

Simulations were performed in which an expert panel was the reference standard to estimate the sensitivity and specificity of an index diagnostic test. Diagnostic accuracy was determined by combining probability estimates of target condition presence, provided by experts using four component reference tests, through a predefined threshold. Study and panel characteristics were varied in several scenarios: target condition prevalence, accuracy of component reference tests, expert panel size, study population size, and random or systematic differences between expert's probability estimates. The total bias in each scenario was quantified using mean squared error.

RESULTS

When estimating an index test with 80% sensitivity and 70% specificity, bias in estimates was hardly affected by the study population size or the number of experts. Prevalence had a large effect on bias, scenarios with a prevalence of 0.5 estimated sensitivity between 63.3% and 76.7% and specificity between 56.1% and 68.7%, whereas scenarios with a prevalence of 0.2 estimated sensitivity between 48.5% and 73.3% and specificity between 65.5% and 68.7%. Improved reference tests also reduced bias. Scenarios with four component tests of 80% sensitivity and specificity estimated index test sensitivity between 60.1% and 77.4% and specificity between 62.9% and 69.1%, whereas scenarios with four component tests of 70% sensitivity and specificity estimated index test sensitivity between 48.5% and 73.4% and specificity between 56.1% and 67.0%.

CONCLUSIONS

Bias in accuracy estimates when using an expert panel will increase if the component reference tests are less accurate. Prevalence, the true value of the index test accuracy, and random or systematic differences between experts can also impact the amount of bias, but the amount and even direction will vary between scenarios.

Association of malnutrition with cognitive frailty in China: a systematic review and meta-analysis

Background

With an aging population, China faces a growing burden of age-related health conditions, including cognitive frailty and malnutrition. This study aimed to investigate the current status of malnutrition in individuals with cognitive frailty in China and to assess the association between the two conditions.

Methods

We conducted a comprehensive search of databases including PubMed, Web of Science, Scopus, Embase, Cochrane Library, CNKI, Wanfang, and Weipu up to April 26, 2024. Meta-analysis was performed using Stata/MP 16, with sensitivity and subgroup analyses to explore heterogeneity, and Begg's and Egger's tests to assess publication bias, applying the trim-and-fill method for correction.

Results

Of 2,077 records, 19 were included. The pooled prevalence of cognitive frailty was 26% (95% confidence interval [CI]: 0.17-0.36, p < 0.01), and the prevalence of malnutrition was 45% (95% CI, 0.30-0.58, p < 0.01). A significant association was identified between cognitive frailty and malnutrition (odds ratio [OR] = 4.23, 95% CI: 2.56-6.99, p < 0.001), adjusted to OR = 3.00 (95% CI, 1.87-4.80) post-correction.

Conclusion

Malnutrition is prevalent among individuals with cognitive frailty in China. Given its higher prevalence in community settings than in hospitals, early screening and specific interventions are crucial to address this issue.

Can invasive interventions be avoided with a holistic swallowing therapy program in older patients in intensive care units: percutaneous endoscopic gastrostomy tubes or oral intake?

Introduction

The use of percutaneous endoscopic gastrostomy (PEG) tubes in older patients did not show any benefits in terms of survival, improvement in quality of life, or reduction in aspiration pneumonia. Significant gaps exist regarding the evidence for the evaluation and management of dysphagia in older patients. This study aimed to diagnose swallowing disorders and highlight the importance of swallowing therapy in older patients in intensive care units (ICUs).

Materials and methods

Twenty-five older patients (12 men, 13 women, mean age 67.22 ± 24.03 years) hospitalized in the ICUs with complaints of dysphagia were analyzed prospectively. The 12 weeks (14-16 sessions) of swallowing therapy were administered to patients with dysphagia who signed the (voluntary) consent form. The bedside water swallowing test (BWSS), Functional Oral Intake Scale (FOIS) Score, Clinical Swallowing Evaluation, Mini Nutritional Assessment Test (MNAT), Eating Assessment Tool (EAT-10), the Turkish version of the World Health Organisation Quality of Life Scale Elderly Module, and the Swallowing Therapy Programme Protocol were applied. Pretherapy stage (T1) and post-therapy stage (T2) results were compared with videofluoroscopy swallowing study (VFSS) recordings with thin liquids, moderately thick liquids, extremely thick liquids, and crackers (International Dysphagia Diet Standardization Initiative [IDDSI] Levels 0, 3, 4, and 7, respectively).

Results

The World Health Organisation Quality of Life Scale Elderly Module (WHOQOL-OLD) raw scores significantly improved from T1 (38.63 ± 7.05) to T2 (73.07 ± 4.82). The bedside water swallowing test results demonstrated statistically significant differences in therapy timings among older patients (p < 0.001). There were significant improvements in swallowing physiology, as represented by the improved oral and pharyngeal composite scores of the Modified Barium Swallow Impairment Profile (MBSImP) and Penetration-Aspiration Scala (PAS) levels. Before therapy, all patients exhibited high rates of oropharyngeal residue with thin liquids and spoon-thick pudding viscosities (MNA ≤ 17). The results reported in the present study show that malnutrition risk is linked to a poorer QoL in older patients on admission to ICUs. Statistical analyses revealed the dominant effects of functional status and eating-related factors on QoL in this group.

Discussion

Early dysphagia diagnosis of older patients and subsequent application of exercise-based swallowing therapy increase the quality of life of patients. In this study, exercise-based swallowing therapy was developed in Turkey and can be used in older patients as part of a holistic cognitive-communication-swallowing intervention program. Results prove the effectiveness of the developed exercise-based swallowing therapy on the cognitive-communication-swallowing skills of older patients. The present findings reinforce the role of nutrition as a priority for improving patients' perceptions of QoL. Further studies are required to investigate and identify the interventions that improve QoL in older patients. More studies with better research designs are required to establish whether nutritional intervention is effective in enhancing QoL in this vulnerable group.

Joint association of physical activity and the geriatric nutritional risk index with survival outcomes among cancer survivors in the United States: a population-based cohort study

Introduction

The relationship between physical activity (PA) and nutritional status on the prognosis of cancer survivors remains underexplored. We aimed to investigate the combined effects of PA and Geriatric Nutritional Risk Index (GNRI) on prognostic assessment of survival outcomes in US cancer survivors.

Methods

2,619 subjects were screened from the National Health and Nutrition Examination Survey (NHANES) database from 1999 to 2018. The self-reported Global Physical Activity Questionnaire (GPAQ) for PA assessment, and the GNRI for nutritional status assessment. Kaplan-Meier (K-M) curves and Cox proportional risk models were used to evaluate the effect of PA combined with GNRI on the prognostic outcomes of death in cancer survivors.

Results

The sufficient PA (≥600 MET min/week) combined with High-GNRI (>98) subgroups significantly reduced the risk of all-cause mortality (HR: 0.56; 95% CI, 0.35-0.90) and cancer-related mortality (HR: 0.24; 95% CI, 0.12-0.50) compared to other subgroups. Subgroup analyses indicated that the combination of sufficient PA and High-GNRI was associated with a significantly reduced all-cause and cancer-related mortality among specific groups-including individuals of female, patients with non-obesity-related cancers, and those with higher educational attainment. After excluding participants who died within the first 12 months of follow-up, sensitivity analyses confirmed the robustness of the association between PA and GNRI in predicting prognostic outcomes among cancer survivors.

Conclusion

Our study shows that among U.S. cancer survivors, sufficient PA combined with High-GNRI is linked to reduced mortality. These findings emphasize the benefits of PA and nutritional status in improving prognosis and support the need for further studies to develop targeted interventions.

A nomogram for predicting nutritional risk before gastric cancer surgery

BACKGROUND AND OBJECTIVES

Gastric cancer (GC) is the fourth leading cause of cancer death worldwide. Patients with GC have higher nutritional risk. This study aimed to construct a nomogram model for predicting preoperative nutritional risk in patients with GC in order to assess preoperative nutritional risk in patients more precisely.

METHODS AND STUDY DESIGN

Patients diagnosed with GC and undergoing surgical treatment were included in this study. Data was collected through clinical information, laboratory testing, and radiomics-derived characteristics. Least absolute shrinkage selection operator (LASSO) regression analysis and multi-variable logistic regression were employed to construct a clinical prediction model, which takes the form of a logistic nomogram. The effectiveness of the nomogram model was evaluated using receiver operat-ing characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA).

RESULTS

A total of three predictors, namely body mass index (BMI), hemoglobin (Hb) and radiomics characteristic score (Radscore) were identified by LASSO regression analysis from a total of 21 variables studied. The model constructed using these three predictors displayed medium prediction ability. The area under the ROC curve was 0.895 (95% CI 0.844-0.945) in the training set, with a cutoff value of 0.651, precision of 0.957, and sensitivity of 0.718. In the validation set, it was 0.880 (95% CI 0.806-0.954), with a cutoff value of 0.655, precision of 0.930, and sensitivity of 0.698. DCA also confirmed the clinical benefit of the combined model.

CONCLUSIONS

This simple and dependable nomogram model for clinical prediction can assist physicians in assessing preoperative nutritional risk in GC patients in a time-efficient and accurate manner to facilitate early identification and diagnosis.

Can CONUT and PNI Scores Predict Necrotizing Pancreatitis in Acute Pancreatitis Patients Presenting to the Emergency Department?

Background and Objectives: Acute pancreatitis, characterized by pancreatic inflammation, poses significant morbidity and mortality worldwide, with varied etiologies including gallstones, alcohol, and certain medications. Necrotizing pancreatitis represents a severe form of parenchymal damage with considerable impact on patient quality of life. Early identification of necrotizing pancreatitis is crucial for timely intervention and improved outcomes. The aim of this study was to investigate the usability of CONUT and PNI scores as prognostic indicators. Materials and Methods: We conducted a retrospective observational study involving patients presenting to the emergency department with acute pancreatitis between January 2020 and October 2023. The Controlling Nutritional Status (CONUT) score and Prognostic Nutrition Index (PNI) were calculated from serum biomarkers to assess nutritional status. Patients were categorized into necrotizing and nonnecrotizing pancreatitis groups, and the utility of CONUT and PNI scores in predicting necrotizing pancreatitis was evaluated. Results: A total of 339 patients were included, with 8.26% diagnosed with necrotizing pancreatitis. CONUT and PNI scores significantly differed between necrotizing and nonnecrotizing groups, with higher CONUT scores and lower PNI scores observed in the necrotizing group. Receiver operating characteristic (ROC) curve analysis revealed significant predictive value of CONUT and PNI scores for necrotizing pancreatitis, with cutoff values of >5 and ≤34, respectively. Conclusions: CONUT and PNI scores demonstrate promise in predicting necrotizing pancreatitis in patients admitted to the emergency department with acute pancreatitis. Additionally, these scores may serve as prognostic indicators for mortality in acute pancreatitis patients. Early identification using CONUT and PNI scores could facilitate timely intervention, potentially reducing mortality and morbidity in this patient population.

Enteral Nutrition in Operated-On Gastric Cancer Patients: An Update

It is well established that the preoperative nutritional status of gastric cancer (GC) patients significantly affects the prognosis of the operated patients, their overall survival, as well as the disease-specific survival. Existing data support that preoperative assessment of nutritional status and early correction of nutritional deficiencies exert a favorable effect on early postoperative outcomes. A variety of relevant indices are used to assess the nutritional status of GC patients who are candidates for surgery. The guidelines of almost all international organizations recommend the use of oral enteral nutrition (EN). Oncologically acceptable types of gastrectomy and methods of patient rehabilitation should take into account the expected postoperative nutritional status. The majority of data support that perioperative EN reduces complications and hospital stay, but not mortality. Oral EN in the postoperative period, albeit in small amounts, helps to reduce the weight loss that is a consequence of gastrectomy. Iron deficiency with or without anemia and low serum levels of vitamin B12 are common metabolic sequelae after gastrectomy and should be restored. EN also significantly helps patients undergoing neoadjuvant or adjuvant antineoplastic therapy. The occurrence of the so-called "postgastrectomy syndromes" requires dietary modifications and drug support. This review attempts to highlight the benefits of EN in GC patients undergoing gastrectomy and to emphasize the type of necessary nutritional management, based on current literature data.

Validity of nutrition screening tools for risk of malnutrition among hospitalized adult patients: A systematic review and meta-analysis

BACKGROUNDS & AIMS

Malnutrition is prevalent among hospitalized patients in developed countries, contributing to negative health outcomes and increased healthcare costs. Timely identification and management of malnutrition are crucial. The lack of a universally accepted definition and standardized diagnostic criteria for malnutrition has led to the development of various screening tools, each with varying validity. This complicates early identification of malnutrition, hindering effective intervention strategies. This systematic review and meta-analysis aimed to identify the most valid and reliable nutritional screening tool for assessing the risk of malnutrition in hospitalized adults.

METHODS

A systematic literature search was conducted to identify validation studies published from inception to November 2023, in the Pubmed/MEDLINE, Embase, and CINAHL databases. This systematic review was registered in INPLASY (INPLASY202090028). The risk of bias and quality of included studies were assessed using the Quality Assessment of Diagnostic Accuracy Studies version 2 (QUADAS-2). Meta-analyses were performed for screening tools accuracy using the symmetric hierarchical summary receiver operative characteristics models.

RESULTS

Of the 1646 articles retrieved, 60 met the inclusion criteria and were included in the systematic review, and 21 were included in the meta-analysis. A total of 51 malnutrition risk screening tools and 9 reference standards were identified. The meta-analyses assessed four common malnutrition risk screening tools against two reference standards (Subjective Global Assessment [SGA] and European Society for Clinical Nutrition and Metabolism [ESPEN] criteria). The Malnutrition Universal Screening Tool (MUST) vs SGA had a sensitivity (95% Confidence Interval) of 0.84 (0.73-0.91), and specificity of 0.85 (0.75-0.91). The MUST vs ESPEN had a sensitivity of 0.97 (0.53-0.99) and specificity of 0.80 (0.50-0.94). The Malnutrition Screening Tool (MST) vs SGA had a sensitivity of 0.81 (0.67-0.90) and specificity of 0.79 (0.72-0.74). The Mini Nutritional Assessment-Short Form (MNA-SF) vs ESPEN had a sensitivity of 0.99 (0.41-0.99) and specificity of 0.60 (0.45-0.73). The Nutrition Universal Screening Tool-2002 (NRS-2002) vs SGA had a sensitivity of 0.76 (0.58-0.87) and specificity of 0.86 (0.76-0.93).

CONCLUSIONS

The MUST demonstrated high accuracy in detecting malnutrition risk in hospitalized adults. However, the quality of the studies included varied greatly, possibly introducing bias in the results. Future research should compare tools within a specific patient population using a valid and universal gold standard to ensure improved patient care and outcomes.