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Schuetz P. Response to JPEN Journal Club 80. Prespecified outcomes. JPEN J Parenter Enteral Nutr 2024; 48:254-255. [PMID: 37884344 DOI: 10.1002/jpen.2571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 10/25/2023] [Indexed: 10/28/2023]
Affiliation(s)
- Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
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Koretz RL. Response to the letter to the editor regarding JPEN Journal Club 80. Prespecified outcomes. JPEN J Parenter Enteral Nutr 2024; 48:256-257. [PMID: 38155327 DOI: 10.1002/jpen.2591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 12/12/2023] [Indexed: 12/30/2023]
Affiliation(s)
- Ronald L Koretz
- Department of Medicine, UCLA Medical Center Olive View, Sylmar, California, USA
- Clinical Medicine, University of California David Geffen School of Medicine, Los Angeles, California, USA
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Koretz RL. JPEN Journal Club 80. Prespecified outcomes. JPEN J Parenter Enteral Nutr 2024; 48:360-362. [PMID: 37850565 DOI: 10.1002/jpen.2567] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 10/16/2023] [Indexed: 10/19/2023]
Affiliation(s)
- Ronald L Koretz
- Department of Medicine, Olive View-UCLA Medical Center, Sylmar, California, USA
- University of California David Geffen School of Medicine, Los Angeles, California, USA
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Stumpf F, Wunderle C, Ritz J, Bernasconi L, Neyer P, Tribolet P, Stanga Z, Mueller B, Bischoff SC, Schuetz P. Prognostic implications of the arginine metabolism in patients at nutritional risk: A secondary analysis of the randomized EFFORT trial. Clin Nutr 2024; 43:660-673. [PMID: 38309228 DOI: 10.1016/j.clnu.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/26/2023] [Accepted: 01/14/2024] [Indexed: 02/05/2024]
Abstract
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).
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Affiliation(s)
- Franziska Stumpf
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland; Institute of Nutritional Medicine, University of Hohenheim, Garbenstraße 30, 70599 Stuttgart, Germany
| | - Carla Wunderle
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland
| | - Jacqueline Ritz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland
| | - Luca Bernasconi
- Institute of Laboratory Medicine, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland
| | - Peter Neyer
- Institute of Laboratory Medicine, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland
| | - Pascal Tribolet
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland; Department of Health Professions, Bern University of Applied Sciences, Falkenplatz 24, 3012 Bern, Switzerland; Faculty of Life Sciences University of Vienna, Djerassiplatz 1, 1030 Vienna, Austria
| | - Zeno Stanga
- Division of Diabetes, Endocrinology, Nutritional Medicine, and Metabolism, Bern University Hospital and University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland
| | - Beat Mueller
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland; Medical Faculty of the University of Basel, Klingelbergstrasse 61, 4056 Basel, Switzerland
| | - Stephan C Bischoff
- Institute of Nutritional Medicine, University of Hohenheim, Garbenstraße 30, 70599 Stuttgart, Germany
| | - Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland; Medical Faculty of the University of Basel, Klingelbergstrasse 61, 4056 Basel, Switzerland.
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Wunderle C, Siegenthaler J, Seres D, Owen-Michaane M, Tribolet P, Stanga Z, Mueller B, Schuetz P. 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). Am J Clin Nutr 2024; 119:800-808. [PMID: 38290574 DOI: 10.1016/j.ajcnut.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/18/2024] [Accepted: 01/22/2024] [Indexed: 02/01/2024] Open
Abstract
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.
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Affiliation(s)
- Carla Wunderle
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland
| | - Jolanda Siegenthaler
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland
| | - David Seres
- Institute of Human Nutrition, Columbia University Irving Medical Center, 622 West 168(th) Street, New York, NY 10032, United States
| | - Michael Owen-Michaane
- Institute of Human Nutrition, Columbia University Irving Medical Center, 622 West 168(th) Street, New York, NY 10032, United States
| | - Pascal Tribolet
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland; Department of Health Professions, Bern University of Applied Sciences, Murtenstrasse 10, 3008 Bern, Switzerland; Faculty of Life Sciences University of Vienna, Djerassiplatz 1, 1030 Vienna, Austria
| | - Zeno Stanga
- Division of Diabetes, Endocrinology, Nutritional Medicine, and Metabolism, Inselspital Bern, Bern University Hospital, University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland
| | - Beat Mueller
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland; Medical Faculty of the University of Basel, Klingelbergstrasse 61, 4056 Basel, Switzerland
| | - Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland; Medical Faculty of the University of Basel, Klingelbergstrasse 61, 4056 Basel, Switzerland.
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Boesiger F, Poggioli A, Netzhammer C, Bretscher C, Kaegi-Braun N, Tribolet P, Wunderle C, Kutz A, Lobo DN, Stanga Z, Mueller B, Schuetz P. Changes in serum albumin concentrations over 7 days in medical inpatients with and without nutritional support. A secondary post-hoc analysis of a randomized clinical trial. Eur J Clin Nutr 2023; 77:989-997. [PMID: 37419969 PMCID: PMC10564620 DOI: 10.1038/s41430-023-01303-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Serum albumin concentrations are frequently used to monitor nutritional therapy in the hospital setting but supporting studies are largely lacking. Within this secondary analysis of a randomized nutritional trial (EFFORT), we assessed whether nutritional support affects short-term changes in serum albumin concentrations and whether an increase in albumin concentration has prognostic implications regarding clinical outcome and response to treatment. METHODS We analyzed patients with available serum albumin concentrations at baseline and day 7 included in EFFORT, a Swiss-wide multicenter randomized clinical trial that compared individualized nutritional therapy with usual hospital food (control group). RESULTS Albumin concentrations increased in 320 of 763 (41.9%) included patients (mean age 73.3 years (SD ± 12.9), 53.6% males) with no difference between patients receiving nutritional support and controls. Compared with patients that showed a decrease in albumin concentrations over 7 days, those with an increase had a lower 180-day mortality [74/320 (23.1%) vs. 158/443 (35.7%); adjusted odds ratio 0.63, 95% CI 0.44 to 0.90; p = 0.012] and a shorter length of hospital stay [11.2 ± 7.3 vs. 8.8 ± 5.6 days, adjusted difference -2.2 days (95%CI -3.1 to -1.2)]. Patients with and without a decrease over 7 days had a similar response to nutritional support. CONCLUSION Results from this secondary analysis indicate that nutritional support did not increase short-term concentrations of albumin over 7 days, and changes in albumin did not correlate with response to nutritional interventions. However, an increase in albumin concentrations possibly mirroring resolution of inflammation was associated with better clinical outcomes. Repeated in-hospital albumin measurements in the short-term is, thus, not indicated for monitoring of patients receiving nutritional support but provides prognostic information. TRAIL REGISTRATION ClinicalTrials.gov Identifier: NCT02517476.
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Affiliation(s)
- Fabienne Boesiger
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Alessia Poggioli
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Claudine Netzhammer
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Céline Bretscher
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Nina Kaegi-Braun
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Pascal Tribolet
- Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland
- Faculty of Life Sciences, University of Vienna, Vienna, Austria
| | - Carla Wunderle
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Alexander Kutz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Zeno Stanga
- Division of Diabetes, Endocrinology, Nutritional Medicine, and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Beat Mueller
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland.
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland.
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Bretscher C, Buergin M, Gurzeler G, Kägi-Braun N, Gressies C, Tribolet P, Lobo DN, Evans DC, Stanga Z, Mueller B, Schuetz P. Association between prealbumin, all-cause mortality, and response to nutrition treatment in patients at nutrition risk: Secondary analysis of a randomized controlled trial. JPEN J Parenter Enteral Nutr 2023; 47:408-419. [PMID: 36587281 DOI: 10.1002/jpen.2470] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 12/27/2022] [Accepted: 12/29/2022] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- Céline Bretscher
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Michelle Buergin
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Gianna Gurzeler
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nina Kägi-Braun
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Carla Gressies
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Pascal Tribolet
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - David C Evans
- Trauma/Critical Care Surgery, Ohio Health Grant Medical Center, Columbus, Ohio, USA
| | - Zeno Stanga
- Division of Diabetology, Endocrinology, Nutritional Medicine, and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Beat Mueller
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
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Baumgartner A, Olpe T, Griot S, Mentil N, Staub N, Burn F, Schindera S, Kaegi-Braun N, Tribolet P, Hoess C, Pavlicek V, Bilz S, Sigrist S, Brändle M, Henzen C, Thomann R, Rutishauser J, Aujesky D, Rodondi N, Donzé J, Stanga Z, Mueller B, Schuetz P. 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. Clin Nutr 2023; 42:199-207. [PMID: 36603460 DOI: 10.1016/j.clnu.2022.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 12/07/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Annic Baumgartner
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Tobias Olpe
- Medical Faculty of the University of Basel, Switzerland
| | | | - Nicole Mentil
- Medical Faculty of the University of Basel, Switzerland
| | | | - Felice Burn
- Department of Radiology Kantonsspital Aarau, Aarau, Switzerland
| | | | - Nina Kaegi-Braun
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Pascal Tribolet
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland
| | - Claus Hoess
- Internal Medicine, Kantonsspital Muensterlingen, Switzerland
| | | | - Stefan Bilz
- Internal Medicine & Endocrinology/Diabetes, Kantonsspital St.Gallen, Switzerland
| | - Sarah Sigrist
- Internal Medicine & Endocrinology/Diabetes, Kantonsspital St.Gallen, Switzerland
| | - Michael Brändle
- Internal Medicine & Endocrinology/Diabetes, Kantonsspital St.Gallen, Switzerland
| | | | | | | | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Institute of Primary Health Care (BIHAM), University of Bern, Switzerland
| | - Jacques Donzé
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Zeno Stanga
- Division of Diabetology, Endocrinology, Nutritional Medicine & Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Beat Mueller
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Switzerland
| | - Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Switzerland.
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Müller NA, Kaegi-Braun N, Durmisi M, Gressies C, Tribolet P, Stanga Z, Mueller B, Schuetz P. Low T3 syndrome upon admission and response to nutritional support in malnourished medical inpatients. J Clin Endocrinol Metab 2022; 108:e240-e248. [PMID: 36546619 DOI: 10.1210/clinem/dgac743] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/17/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION During illness, deiodination of thyroxine (T4) to triiodothyronine (T3) is down regulated. This is called "low T3 syndrome", an adaptive metabolic mechanism to reduce energy expenditure and prevent catabolism. We investigated the prognostic role of low T3 syndrome in patients at nutritional risk regarding mortality, clinical outcomes and response to nutritional support. METHODS This is 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 Swiss multicenter trial comparing effects of individualized nutritional support with usual care in adult medical inpatients at nutritional risk. The primary endpoint was all-cause mortality over 30-,180-days and 5-years. RESULTS We had complete data including fT3 concentration of 801/2028 (39.5%) patients from the initial trial. Of these 492 (61.4%) had low T3 syndrome (fT3 < 3.2 pmol/l). Low T3 syndrome was associated with higher mortality over 30 days (adjusted hazard ratio 1.97 [95%CI 1.17 to 3.31], p 0.011) and other adverse clinical outcomes. Nutritional support only lowered mortality in the group of patients with but not in those without low T3 syndrome (adjusted odds ratio of nutritional support of 0.82 [95%CI 0.47 to 1.41] vs. 1.47 [95%CI 0.55 to 3.94]). This finding, however, was not significant in interaction analysis (p for interaction = 0.401). CONCLUSIONS Our secondary analysis of a randomized trial suggests that medical inpatients at nutritional risk with low T3 syndrome have a substantial increase in mortality and may show a more pronounced beneficial response to nutritional support interventions.
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Affiliation(s)
- Natasha Anouschka Müller
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse 25, CH-5001, Switzerland
- Medical Faculty of the University Basel, Switzerland
| | - Nina Kaegi-Braun
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse 25, CH-5001, Switzerland
| | - Mirsada Durmisi
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse 25, CH-5001, Switzerland
- Medical Faculty of the University Basel, Switzerland
| | - Carla Gressies
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse 25, CH-5001, Switzerland
| | - Pascal Tribolet
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse 25, CH-5001, Switzerland
- Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland
- Faculty of Life Sciences University of Vienna, Vienna, Austria
| | - Zeno Stanga
- Division of Diabetology, Endocrinology, Nutritional Medicine, and Metabolism, Inselspital Bern, Bern University Hospital, University of Bern, Switzerland
| | - Beat Mueller
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse 25, CH-5001, Switzerland
- Medical Faculty of the University Basel, Switzerland
| | - Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse 25, CH-5001, Switzerland
- Medical Faculty of the University Basel, Switzerland
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Schuetz P, Sulo S, Walzer S, Krenberger S, Brunton C. Nutritional support during the hospital stay is cost-effective for preventing adverse outcomes in patients with cancer. Front Oncol 2022; 12:916073. [PMID: 36016618 PMCID: PMC9396738 DOI: 10.3389/fonc.2022.916073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/15/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveAmong patients with cancer, malnutrition remains common and is a key challenge in oncology practice today. A prior study from our group revealed that malnourished cancer inpatients who got nutritional treatment (intervention group) had lower mortality and improved functional and quality of life outcomes compared to inpatients without nutritional support (control group). Our present analysis aimed to determine whether the improved patient recovery by nutritional support was paralleled by cost-effectiveness of this nutritional care.MethodsWe analyzed hospital costs and health outcomes in patients with cancer, using a Markov simulation model with daily cycles to analyze the economic impact of nutritional support in malnourished inpatients with malignancies. We compared results for a nutritional intervention group and a control group across a 30-day timeframe. Five health states were designated (malnourished but stable, complications, intensive care unit (ICU) admission, discharge, death). Costs for the different health states were based on publicly available data for the Swiss medical system. Total patient cost categories included in-hospital nutrition, days spent in the normal ward, days in the ICU, and medical complications.ResultsTotal per-patient costs for in-hospital supportive nutrition was Swiss francs (CHF) 129. Across a 30-day post-admission interval, our model determined average overall costs of care of CHF 46,420 per-patient in the intervention group versus CHF 43,711 in the control group—a difference of CHF 2,709 per patient. Modeled results showed a cost of CHF 1,788 to prevent one major complication, CHF 4,464 to prevent one day in the ICU, and CHF 3,345 to prevent one death. Recovery benefits of nutritional care were thus paralleled by cost-effectiveness of this care.ConclusionIn-hospital nutritional support for oncology patients at nutritional risk is a low-cost intervention that has both clinical and financial benefits.
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Affiliation(s)
- Philipp Schuetz
- Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
- *Correspondence: Philipp Schuetz,
| | - Suela Sulo
- Abbott Nutrition, Global Health Economics & Outcomes Research, Chicago, IL, United States
| | - Stefan Walzer
- MArS Market Access & Pricing Strategy GmbH, Weil am Rhein, Germany
- State University Baden-Wuerttemberg, Loerrach, Germany
- Social Work & Health Care, University of Applied Sciences Ravensburg-Weingarten, Weingarten, Germany
| | | | - Cory Brunton
- Abbott Nutrition, Global Health Economics & Outcomes Research, Chicago, IL, United States
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Handgrip Strength Values Depend on Tumor Entity and Predict 180-Day Mortality in Malnourished Cancer Patients. Nutrients 2022; 14:nu14102173. [PMID: 35631314 PMCID: PMC9146854 DOI: 10.3390/nu14102173] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 12/10/2022] Open
Abstract
BACKGROUND Cancer-related malnutrition is a prevalent condition associated with a loss of muscle mass and impaired functional status, leading to immunodeficiency, impaired quality of life and adverse clinical outcomes. Handgrip strength (HGS) is a practical measure to assess muscle strength in individual patients during clinical practice. However, HGS reference values refer to populations of healthy people, and population-specific values, such as those in the population of cancer patients, still need to be defined. METHODS Within a secondary analysis of a previous randomized controlled nutritional trial focusing on hospitalized cancer patients at risk for malnutrition, we investigated sex-specific HGS values stratified by age and tumor entity. Additionally, we examined the association between HGS and 180-day all-cause mortality. RESULTS We included data from 628 cancer patients, which were collected from eight hospitals in Switzerland. Depending on the age of patients, HGS varied among female patients from 7 kg to 26 kg and among male patients from 20.5 kg to 44 kg. An incremental decrease in handgrip strength by 10 kg resulted in a 50% increase in 180-day all-cause mortality (odds ratio 1.52 (95%CI 1.19 to 1.94), p = 0.001). CONCLUSION Our data provide evidence of the prognostic implications of HGS measurement in cancer patients and validate the prognostic value of handgrip strength in regard to long-term mortality. In addition, our results provide expected HGS values in the population of hospitalized malnourished cancer patients, which may allow better interpretation of values in individual patients.
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12
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Schuetz P, Sulo S, Walzer S, Krenberger S, Stagna Z, Gomes F, Mueller B, Brunton C. Economic Evaluation of Individualized Nutritional Support for Hospitalized Patients with Chronic Heart Failure. Nutrients 2022; 14:nu14091703. [PMID: 35565669 PMCID: PMC9099480 DOI: 10.3390/nu14091703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/13/2022] [Accepted: 04/18/2022] [Indexed: 02/01/2023] Open
Abstract
Background Malnutrition is a highly prevalent risk factor in hospitalized patients with chronic heart failure (CHF). A recent randomized trial found lower mortality and improved health outcomes when CHF patients with nutritional risk received individualized nutritional treatment. Objective To estimate the cost-effectiveness of individualized nutritional support in hospitalized patients with CHF. Methods This analysis used data from CHF patients at risk of malnutrition (N = 645) who were part of the Effect of Early Nutritional Therapy on Frailty, Functional Outcomes and Recovery of Undernourished Medical Inpatients Trial (EFFORT). Study patients with CHF were randomized into (i) an intervention group (individualized nutritional support to reach energy, protein, and micronutrient goals) or (ii) a control group (receiving standard hospital food). We used a Markov model with daily cycles (over a 6-month interval) to estimate hospital costs and health outcomes in the comparator groups, thus modeling cost-effectiveness ratios of nutritional interventions. Results With nutritional support, the modeled total additional cost over the 6-month interval was 15,159 Swiss Francs (SF). With an additional 5.77 life days, the overall incremental cost-effectiveness ratio for nutritional support vs. no nutritional support was 2625 SF per life day gained. In terms of complications, patients receiving nutritional support had a cost savings of 6214 SF and an additional 4.11 life days without complications, yielding an incremental cost-effectiveness ratio for avoided complications of 1513 SF per life day gained. Conclusions On the basis of a Markov model, this economic analysis found that in-hospital nutritional support for CHF patients increased life expectancy at an acceptable incremental cost-effectiveness ratio.
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Affiliation(s)
- Philipp Schuetz
- Medical University Department, Kantonsspital Aarau, 5001 Aarau, Switzerland;
- Medical Faculty, University of Basel, 4001 Basel, Switzerland
- Correspondence: ; Fax: +41-62-838-4100
| | - Suela Sulo
- Abbott Nutrition, Chicago, IL 60045, USA; (S.S.); (C.B.)
| | - Stefan Walzer
- MArS Market Access & Pricing Strategy GmbH, 79576 Weil am Rhein, Germany; (S.W.); (S.K.)
- Health Care Management, State University Baden-Wuerttemberg, 70174 Loerrach, Germany
- Social Work & Health Care, University of Applied Sciences Ravensburg-Weingarten, 88250 Weingarten, Germany
| | - Sebastian Krenberger
- MArS Market Access & Pricing Strategy GmbH, 79576 Weil am Rhein, Germany; (S.W.); (S.K.)
| | - Zeno Stagna
- Division of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, 4001 Bern, Switzerland;
| | - Filomena Gomes
- NOVA Medical School, Universidade NOVA de Lisboa, 1169-056 Lisboa, Portugal;
| | - Beat Mueller
- Medical University Department, Kantonsspital Aarau, 5001 Aarau, Switzerland;
- Medical Faculty, University of Basel, 4001 Basel, Switzerland
| | - Cory Brunton
- Abbott Nutrition, Chicago, IL 60045, USA; (S.S.); (C.B.)
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13
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Kaegi-Braun N, Boesiger F, Tribolet P, Gomes F, Kutz A, Hoess C, Pavlicek V, Bilz S, Sigrist S, Brändle M, Henzen C, Thomann R, Rutishauser J, Aujesky D, Rodondi N, Donzé J, Stanga Z, Lobo DN, Cederholm T, Mueller B, Schuetz P. Validation of modified GLIM criteria to predict adverse clinical outcome and response to nutritional treatment: A secondary analysis of a randomized clinical trial. Clin Nutr 2022; 41:795-804. [PMID: 35263688 DOI: 10.1016/j.clnu.2022.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/12/2022] [Accepted: 02/14/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND & AIMS The Global Leadership Initiative on Malnutrition (GLIM) recently suggested specific criteria to standardize the diagnosis of malnutrition. There is need for validation of these criteria regarding response to nutrition treatment. Our aim was to validate modified GLIM (mGLIM) criteria among medical inpatients at risk of disease related malnutrition for prediction of outcome and response to nutritional therapy. METHODS This is a secondary analysis of the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), a multicenter randomized controlled trial conducted between April 2014 and February 2018. Adult medical inpatients at nutritional risk (Nutrition Risk Score 2002 ≥ 3 points) were randomly assigned to receive nutritional therapy according to an algorithm based on individualized nutritional requirements (intervention group) or standard hospital food (control group). We included all participants with available information regarding mGLIM criteria. The primary outcome was adverse clinical outcome, which was a composite of 30-day all-cause mortality, ICU-admission, rehospitalization rate, major complications and decline in functional status. RESULTS Of 1917 eligible participants at nutritional risk, 1181 (61.6%) met the diagnosis of malnutrition based on mGLIM criteria. The incidence of adverse clinical outcome was significantly higher in mGLIM-positive participants compared with mGLIM-negative participants [330/1181 (27.9%) versus 140/736 (19.0%); multivariable adjusted odds ratio [OR] 1.53; 95% CI 1.22-1.93; p < 0.001]. Regarding the effect of nutritional therapy, the reduction in adverse clinical outcomes was higher in mGLIM-positive participants [180/581 (31.0%) vs. 150/600 (25.0%), OR 0.69; 95% CI 0.53-0.9, p = 0.007], compared with mGLIM-negative participants [75/379 (19.8%) versus 65/357 (18.2%), OR 0.95; 95% CI 0.65-1.40, p = 0.797], a finding that was, however, not significant in interaction analysis (p for interaction = 0.217). CONCLUSION Data from this secondary analysis of a multicenter randomized trial involving medical inpatients at nutritional risk validate the strong prognostic value of mGLIM criteria regarding adverse clinical outcomes and other long-term outcomes. However, further research is needed to improve the ability of GLIM criteria to predict therapeutic response to nutritional interventions. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02517476.
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Affiliation(s)
- Nina Kaegi-Braun
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Fabienne Boesiger
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Pascal Tribolet
- Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland; Faculty of Life Sciences, University of Vienna, Vienna, Austria
| | - Filomena Gomes
- The New York Academy of Sciences, New York, NY, USA; NOVA Medical School, Universidade NOVA de Lisboa, Lisboa, Portugal
| | - Alexander Kutz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Claus Hoess
- Internal Medicine, Kantonsspital Münsterlingen, Münsterlingen, Switzerland
| | - Vojtech Pavlicek
- Internal Medicine, Kantonsspital Münsterlingen, Münsterlingen, Switzerland
| | - Stefan Bilz
- Internal Medicine and Endocrinology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Sarah Sigrist
- Internal Medicine and Endocrinology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Michael Brändle
- Internal Medicine and Endocrinology, Kantonsspital St Gallen, St Gallen, Switzerland
| | | | - Robert Thomann
- Internal Medicine, Bürgerspital Solothurn, Solothurn, Switzerland
| | - Jonas Rutishauser
- Internal Medicine, Kantonsspital Baselland, Standort Bruderholz, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Jacques Donzé
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Zeno Stanga
- Division of Diabetes, Endocrinology, Nutritional Medicine, and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dileep N Lobo
- Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Tommy Cederholm
- Clinical Nutrition and Metabolism, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden; Theme Inflammation and Aging, Karolinska University Hospital, Stockholm, Sweden
| | - Beat Mueller
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Basel, Switzerland
| | - Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Basel, Switzerland.
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14
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Prospective validation of five malnutrition screening and assessment instruments among medical inpatients: Secondary analysis of a randomized clinical trial. Clin Nutr 2022; 41:1307-1315. [DOI: 10.1016/j.clnu.2022.04.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/19/2022] [Accepted: 04/19/2022] [Indexed: 01/04/2023]
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15
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Bretschera C, Boesiger F, Kaegi-Braun N, Hersberger L, Lobo DN, Evans DC, Tribolet P, Gomes F, Hoess C, Pavlicek V, Bilz S, Sigrist S, Brändle M, Henzen C, Thomann R, Rutishauser J, Aujesky D, Rodondi N, Donzé J, Stanga Z, Mueller B, Schuetz P. Admission serum albumin concentrations and response to nutritional therapy in hospitalised patients at malnutrition risk: Secondary analysis of a randomised clinical trial. EClinicalMedicine 2022; 45:101301. [PMID: 35198927 PMCID: PMC8844847 DOI: 10.1016/j.eclinm.2022.101301] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Historically, admission serum albumin concentrations have been considered useful biochemical markers for nutrition assessment. However, there is a lack of randomised trial data investigating whether low albumin concentrations are helpful for identifying patients benefitting from nutritional support. METHODS This study was a secondary analysis of the EFFORT trial, a Swiss-wide multicentre, randomised controlled trial comparing individualised nutritional support with usual care nutrition in medical inpatients from April 1, 2014, to February 1, 2018. 1389 of 2028 patients at nutritional risk with available albumin concentrations on admission were included. The primary endpoint was all-cause mortality within 30 and 180 days. Patients were stratified into groups of low or normal albumin based on the albumin cut-off of 30 g/L. ClinicalTrials.gov number, NCT02517476. FINDINGS 1389 patients (mean age, 73.1 (SD 3.5) years; 747 (53.8%) men) were included and 676 (48.7%) had low serum albumin concentrations at admission (<30 g/L). Mortality at 180 days was significantly increased in the low albumin group compared with patients with normal albumin concentrations (219/676 (32.4%) vs. 162/713 (22.7%), fully adjusted HR 1.4, 95%CI 1.11 to 1.77, p = 0.005]. Effects of nutritional support on 30-day mortality were similar for patients with low compared to patients with normal albumin concentrations (HR 0.68, 95%CI 0.44 to 1.05 vs. HR 0.70, 95%CI 0.41 to 1.20), with no evidence for a subgroup effect (p for interaction=0.97). INTERPRETATION Based on this secondary analysis of a randomised trial, low admission serum albumin concentrations in hospitalised, non-critically ill, medical patients at nutritional risk had prognostic implications and indicated higher mortality risk but were not helpful in selecting patients for nutritional interventions. FUNDING The Swiss National Science Foundation (SNSF) (PP00P3_150531) and the Research Council of the Kantonsspital Aarau (1410.000.058 and 1410.000.044) provided funding for the EFFORT trial.
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Affiliation(s)
- Céline Bretschera
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse, Aarau CH-5001, Switzerland
| | - Fabienne Boesiger
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse, Aarau CH-5001, Switzerland
| | - Nina Kaegi-Braun
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse, Aarau CH-5001, Switzerland
| | - Lara Hersberger
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse, Aarau CH-5001, Switzerland
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, Queen's Medical Centre, Nottingham Biomedical Research Centre, National Institute for Health Research (NIHR), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - David C. Evans
- Trauma / Critical Care Surgery, Ohio Health Grant Medical Center, Columbus, OH, USA
| | - Pascal Tribolet
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse, Aarau CH-5001, Switzerland
- Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland
| | - Filomena Gomes
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse, Aarau CH-5001, Switzerland
- The New York Academy of Sciences, New York, NY, USA
| | - Claus Hoess
- Internal Medicine, Kantonsspital Münsterlingen, Münsterlingen, Switzerland
| | - Vojtech Pavlicek
- Internal Medicine, Kantonsspital Münsterlingen, Münsterlingen, Switzerland
| | - Stefan Bilz
- Internal Medicine and Endocrinology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Sarah Sigrist
- Internal Medicine and Endocrinology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Michael Brändle
- Internal Medicine and Endocrinology, Kantonsspital St Gallen, St Gallen, Switzerland
| | | | - Robert Thomann
- Internal Medicine, Bürgerspital Solothurn, Solothurn, Switzerland
| | - Jonas Rutishauser
- Internal Medicine, Kantonsspital Baselland Standort Bruderholz, Switzerland
| | | | - Nicolas Rodondi
- Department of General Internal Medicine, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Jacques Donzé
- Medical Faculty of the University of Basel, Basel, Switzerland
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Zeno Stanga
- Division of Diabetology, Endocrinology, Nutritional Medicine, and Metabolism, Switzerland
| | - Beat Mueller
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse, Aarau CH-5001, Switzerland
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse, Aarau CH-5001, Switzerland
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Corresponding author at: Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse, Aarau CH-5001, Switzerland.
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Association of proteomic markers with nutritional risk and response to nutritional support: a secondary pilot study of the EFFORT trial using an untargeted proteomics approach. Clin Nutr ESPEN 2022; 48:282-290. [DOI: 10.1016/j.clnesp.2022.01.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/05/2022] [Accepted: 01/27/2022] [Indexed: 11/23/2022]
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Papathanail I, Brühlmann J, Vasiloglou MF, Stathopoulou T, Exadaktylos AK, Stanga Z, Münzer T, Mougiakakou S. Evaluation of a Novel Artificial Intelligence System to Monitor and Assess Energy and Macronutrient Intake in Hospitalised Older Patients. Nutrients 2021; 13:4539. [PMID: 34960091 PMCID: PMC8706142 DOI: 10.3390/nu13124539] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/09/2021] [Accepted: 12/14/2021] [Indexed: 01/07/2023] Open
Abstract
Malnutrition is common, especially among older, hospitalised patients, and is associated with higher mortality, longer hospitalisation stays, infections, and loss of muscle mass. It is therefore of utmost importance to employ a proper method for dietary assessment that can be used for the identification and management of malnourished hospitalised patients. In this study, we propose an automated Artificial Intelligence (AI)-based system that receives input images of the meals before and after their consumption and is able to estimate the patient's energy, carbohydrate, protein, fat, and fatty acids intake. The system jointly segments the images into the different food components and plate types, estimates the volume of each component before and after consumption, and calculates the energy and macronutrient intake for every meal, based on the kitchen's menu database. Data acquired from an acute geriatric hospital as well as from our previous study were used for the fine-tuning and evaluation of the system. The results from both our system and the hospital's standard procedure were compared to the estimations of experts. Agreement was better with the system, suggesting that it has the potential to replace standard clinical procedures with a positive impact on time spent directly with the patients.
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Affiliation(s)
- Ioannis Papathanail
- ARTORG Center for Biomedical Engineering Research, University of Bern, Murtenstrasse 50, 3008 Bern, Switzerland; (I.P.); (M.F.V.); (T.S.)
| | - Jana Brühlmann
- Geriatrische Klinik St. Gallen AG, Rorschacherstrasse 94, 9000 St. Gallen, Switzerland; (J.B.); (T.M.)
| | - Maria F. Vasiloglou
- ARTORG Center for Biomedical Engineering Research, University of Bern, Murtenstrasse 50, 3008 Bern, Switzerland; (I.P.); (M.F.V.); (T.S.)
| | - Thomai Stathopoulou
- ARTORG Center for Biomedical Engineering Research, University of Bern, Murtenstrasse 50, 3008 Bern, Switzerland; (I.P.); (M.F.V.); (T.S.)
| | | | - Zeno Stanga
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
| | - Thomas Münzer
- Geriatrische Klinik St. Gallen AG, Rorschacherstrasse 94, 9000 St. Gallen, Switzerland; (J.B.); (T.M.)
| | - Stavroula Mougiakakou
- ARTORG Center for Biomedical Engineering Research, University of Bern, Murtenstrasse 50, 3008 Bern, Switzerland; (I.P.); (M.F.V.); (T.S.)
- Department of Emergency Medicine, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
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18
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Struja T, Wolski W, Schapbach R, Mueller B, Laczko E, Schuetz P. Association of metabolomic markers and response to nutritional support: A secondary analysis of the EFFORT trial using an untargeted metabolomics approach. Clin Nutr 2021; 40:5062-5070. [PMID: 34455264 DOI: 10.1016/j.clnu.2021.07.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/19/2021] [Accepted: 07/26/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS The EFFORT trial reported a substantial risk reduction for adverse events and mortality in medical in-patients receiving a nutritional support intervention. With the use of an untargeted metabolomics approach, we investigated the prognostic and therapeutic potential of metabolomic markers to understand, whether there are distinct metabolic patterns associated with malnutrition risk as assessed by the Nutritional Risk screening (NRS 2002) score, the risk of 30-day mortality and the response to nutritional support, respectively. METHODS Out of the 2088 samples we randomly selected 120 blood samples drawn on day 1 after hospital admission and before treatment initiation. Samples were stratified by NRS 2002, treatment allocation (intervention vs. control), and mortality at 30 days, but not on the type of medical illness. We performed untargeted analysis by liquid chromatography mass spectrometry (LC-MS/MS). RESULTS We measured 1389 metabolites in 120 patients of which 81 (67.5%) survived until day 30. After filtering, 371 metabolites remained, and 200 were matched to one or more Human Metabolome Data Base (HMDB) entries. Between group analysis showed a slight distinction between the treatment groups for patients with a NRS 3, but not for those with NRS 4 and ≥ 5. C-statistic between those who died and survived at day 30 ranged from 0.49 (95% confidence interval 0.35-0.68) for a combination of 5 metabolites/predictors to 0.66 (95% confidence interval 0.53-0.79) for a combination of 100 metabolites. Pathway analysis found significant enrichment in the pathways for nitrogen, vitamin B3 (nicotinate and nicotinamide), leukotriene, and arachidonic acid metabolisms in nutritional support responders compared to non-responders. CONCLUSION In our heterogenous population of medical inpatients with different illnesses and comorbidities, metabolomic markers showed little prognostic and therapeutic potential for better phenotyping malnutrition and response to nutritional therapy. Future studies should focus on more selected patient populations to understand whether a metabolomic approach can advance the nutritional care of patients.
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Affiliation(s)
- Tristan Struja
- Medical University Clinic, Division of Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Aarau, Switzerland.
| | - Witold Wolski
- Functional Genomics Center Zurich, ETH and University of Zurich, Zurich, Switzerland.
| | - Ralph Schapbach
- Functional Genomics Center Zurich, ETH and University of Zurich, Zurich, Switzerland.
| | - Beat Mueller
- Medical University Clinic, Division of Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Switzerland.
| | - Endre Laczko
- Functional Genomics Center Zurich, ETH and University of Zurich, Zurich, Switzerland.
| | - Philipp Schuetz
- Medical University Clinic, Division of Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Switzerland.
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Schuetz P, Sulo S, Walzer S, Vollmer L, Brunton C, Kaegi-Braun N, Stanga Z, Mueller B, Gomes F. Cost savings associated with nutritional support in medical inpatients: an economic model based on data from a systematic review of randomised trials. BMJ Open 2021; 11:e046402. [PMID: 34244264 PMCID: PMC8273448 DOI: 10.1136/bmjopen-2020-046402] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND AIMS Nutritional support improves clinical outcomes during hospitalisation as well as after discharge. Recently, a systematic review of 27 randomised, controlled trials showed that nutritional support was associated with lower rates of hospital readmissions and improved survival. In the present economic modelling study, we sought to determine whether in-hospital nutritional support would also return economic benefits. METHODS The current economic model applied cost estimates to the outcome results from our recent systematic review of hospitalised patients. In the underlying meta-analysis, a total of 27 trials (n=6803 patients) were included. To calculate the economic impact of nutritional support, a Markov model was developed using transitions between relevant health states. Costs were estimated accounting for length of stay in a general hospital ward, hospital-acquired infections, readmissions and nutritional support. Six-month mortality was also considered. The estimated daily per-patient cost for in-hospital nutrition was US$6.23. RESULTS Overall costs of care within the model timeframe of 6 months averaged US$63 227 per patient in the intervention group versus US$66 045 in the control group, which corresponds to per patient cost savings of US$2818. These cost savings were mainly due to reduced infection rate and shorter lengths of stay. We also calculated the costs to prevent a hospital-acquired infection and a non-elective readmission, that is, US$820 and US$733, respectively. The incremental cost per life-day gained was -US$1149 with 2.53 additional days. The sensitivity analyses for cost per quality-adjusted life day provided support for the original findings. CONCLUSIONS For medical inpatients who are malnourished or at nutritional risk, our findings showed that in-hospital nutritional support is a cost-effective way to reduce risk for readmissions, lower the frequency of hospital-associated infections, and improve survival rates.
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Affiliation(s)
- Philipp Schuetz
- Internal Medicine, Kantonsspital Aarau AG, Aarau, Switzerland
- University of Basel, Basel, Swizerland
| | - Suela Sulo
- Abbott Nutrition, Abbott Park, Illinois, USA
| | - Stefan Walzer
- MArS Market Access & Pricing Strategy GmbH, Weil am Rhein, Germany
- State University Baden-Weurttemberg, Lörrarch, germany
- Weingarten University of Applied Sciences, Weingarten, Germany
| | - Lutz Vollmer
- MArS Market Access & Pricing Strategy GmbH, Weil am Rhein, Germany
| | | | | | - Zeno Stanga
- Inselspital Universitatsspital Bern, Bern, BE, Switzerland
| | - Beat Mueller
- Internal Medicine, Kantonsspital Aarau AG, Aarau, Switzerland
| | - Filomena Gomes
- Internal Medicine, Kantonsspital Aarau AG, Aarau, Switzerland
- The New York Academy of Sciences, New York city, New York, USA
- NOVA Medical School, Universidade NOVA de Lisboa, Lisboa, Portugal
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20
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Bargetzi L, Brack C, Herrmann J, Bargetzi A, Hersberger L, Bargetzi M, Kaegi-Braun N, Tribolet P, Gomes F, Hoess C, Pavlicek V, Bilz S, Sigrist S, Brändle M, Henzen C, Thomann R, Rutishauser J, Aujesky D, Rodondi N, Donzé J, Laviano A, Stanga Z, Mueller B, Schuetz P. Nutritional support during the hospital stay reduces mortality in patients with different types of cancers: secondary analysis of a prospective randomized trial. Ann Oncol 2021; 32:1025-1033. [PMID: 34022376 DOI: 10.1016/j.annonc.2021.05.793] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/29/2021] [Accepted: 05/14/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Nutritional support in patients with cancer aims at improving quality of life. Whether use of nutritional support is also effective in improving clinical outcomes requires further study. PATIENTS AND METHODS In this preplanned secondary analysis of patients with cancer included in a prospective, randomized-controlled, Swiss, multicenter trial (EFFORT), we compared protocol-guided individualized nutritional support (intervention group) to standard hospital food (control group) regarding mortality at 30-day (primary endpoint) and other clinical outcomes. RESULTS We analyzed 506 patients with a main admission diagnosis of cancer, including lung cancer (n = 113), gastrointestinal tumors (n = 84), hematological malignancies (n = 108) and other types of cancer (n = 201). Nutritional risk based on Nutritional Risk Screening (NRS 2002) was an independent predictor for mortality over 180 days with an (age-, sex-, center-, type of cancer-, tumor activity- and treatment-) adjusted hazard ratio of 1.29 (95% CI 1.09-1.54; P = 0.004) per point increase in NRS. In the 30-day follow-up period, 50 patients (19.9%) died in the control group compared to 36 (14.1%) in the intervention group resulting in an adjusted odds ratio of 0.57 (95% CI 0.35-0.94; P = 0.027). Interaction tests did not show significant differences in mortality across the cancer type subgroups. Nutritional support also significantly improved functional outcomes and quality of life measures. CONCLUSIONS Compared to usual hospital nutrition without nutrition support, individualized nutritional support reduced the risk of mortality and improved functional and quality of life outcomes in cancer patients with increased nutritional risk. These data further support the inclusion of nutritional care in cancer management guidelines.
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Affiliation(s)
- L Bargetzi
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Basel, Switzerland
| | - C Brack
- Medical Faculty of the University of Basel, Basel, Switzerland
| | - J Herrmann
- Medical Faculty of the University of Basel, Basel, Switzerland
| | - A Bargetzi
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Basel, Switzerland
| | - L Hersberger
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Basel, Switzerland
| | - M Bargetzi
- Medical Faculty of the University of Basel, Basel, Switzerland; Division of Oncology, Hematology and Transfusion Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - N Kaegi-Braun
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - P Tribolet
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland
| | - F Gomes
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; The New York Academy of Sciences, New York, USA
| | - C Hoess
- Internal Medicine, Kantonsspital Muensterlingen, Muensterlingen, Switzerland
| | - V Pavlicek
- Internal Medicine, Kantonsspital Muensterlingen, Muensterlingen, Switzerland
| | - S Bilz
- Internal Medicine & Endocrinology/Diabetes, Kantonsspital St.Gallen, St.Gallen, Switzerland
| | - S Sigrist
- Internal Medicine & Endocrinology/Diabetes, Kantonsspital St.Gallen, St.Gallen, Switzerland
| | - M Brändle
- Internal Medicine & Endocrinology/Diabetes, Kantonsspital St.Gallen, St.Gallen, Switzerland
| | - C Henzen
- Internal Medicine, Kantonsspital Luzern, Luzern, Switzerland
| | - R Thomann
- Internal Medicine, Buergerspital Solothurn, Solothurn, Switzerland
| | - J Rutishauser
- Internal Medicine, Kantonsspital Baselland, Liestal, Switzerland
| | - D Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - N Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - J Donzé
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, USA
| | - A Laviano
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Z Stanga
- Division of Diabetes, Endocrinology, Nutritional Medicine & Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - B Mueller
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Basel, Switzerland
| | - P Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Basel, Switzerland.
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21
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Individualized Nutritional Support for Hospitalized Patients With Chronic Heart Failure. J Am Coll Cardiol 2021; 77:2307-2319. [PMID: 33958128 DOI: 10.1016/j.jacc.2021.03.232] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/10/2021] [Accepted: 03/15/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Deterioration of nutritional status during hospitalization in patients with chronic heart failure increases mortality. Whether nutritional support during hospitalization reduces these risks, or on the contrary, may be harmful due to an increase in salt and fluid intake, remains unclear. OBJECTIVES The purpose of this trial was to study the effect of nutritional support on mortality in patients hospitalized with chronic heart failure who are at nutritional risk. METHODS A total of 645 patients with chronic heart failure (36% [n = 234] with acute decompensation) participated in the investigator-initiated, open-label EFFORT (Effect of early nutritional support on Frailty, Functional Outcomes and Recovery of malnourished medical inpatients) trial. Patients were randomized to protocol-guided individualized nutritional support to reach energy, protein, and micronutrient goals (intervention group) or standard hospital food (control group). The primary endpoint was all-cause mortality at 30 days. RESULTS Mortality over 180 days increased with higher severity of malnutrition (odds ratio per 1-point increase in Nutritional Risk Screening 2002 score: 1.65; 95% confidence interval [CI]: 1.21 to 2.24; p = 0.001). By 30 days, 27 of 321 intervention group patients (8.4%) died, compared with 48 of 324 (14.8%) control group patients (odds ratio: 0.44; 95% CI: 0.26 to 0.75; p = 0.002). Patients at high nutritional risk showed the most benefit from nutritional support. Mortality effects remained significant at 180-day follow-up. Intervention group patients also had a lower risk for major cardiovascular events at 30 days (17.4% vs. 26.9%; odds ratio: 0.50; 95% CI: 0.34 to 0.75; p = 0.001). CONCLUSIONS Among hospitalized patients with chronic heart failure at high nutritional risk, individualized nutritional support reduced the risk for mortality and major cardiovascular events compared with standard hospital food. These data support malnutrition screening upon hospital admission followed by an individualized nutritional support strategy in this vulnerable patient population. (Effect of Early Nutritional Therapy on Frailty, Functional Outcomes and Recovery of Undernourished Medical Inpatients Trial [EFFORT]; NCT02517476).
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22
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The impact of nutritional support on malnourished inpatients with aging-related vulnerability. Nutrition 2021; 89:111279. [PMID: 34090212 DOI: 10.1016/j.nut.2021.111279] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/04/2021] [Accepted: 04/01/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Malnutrition is highly prevalent in patients with aging-related vulnerability defined by very old age (≥80 y), physical frailty or cognitive impairment, and increases the risks for morbidity and mortality. The effects of individualized nutritional support for patients with aging-related vulnerability in the acute hospital setting on mortality and other clinical outcomes remains understudied. METHODS For 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 analyzed data of patients at a nutritional risk (Nutritional Risk Screening 2002 score ≥3 points) with aging-related vulnerability, randomized to receive protocol-guided individualized nutritional support to reach specific protein and energy goals (intervention group) or routine hospital food (control group). The primary endpoint was all-cause 30-d mortality. RESULTS Of the 881 patients with aging-related vulnerability, 23.4% presented with a frailty syndrome, 81.8% were age ≥80 y and 15.3% showed cognitive impairment. Patients with aging-related vulnerability receiving individualized nutritional support compared with routine hospital food showed a >50% reduction in the risk of 30-day mortality (60 of 442 [13.6%] versus 31 of 439 [7.1%]; odds ratio: 0.48; 95% confidence interval, 0.31-0.76; P = 0.002). Significant improvements were also found for long-term mortality at 180 days, as well as functional outcomes and quality of life measures. CONCLUSIONS Malnourished patients with aging-related vulnerability show a significant and clinically relevant reduction in the risk of mortality and other adverse clinical outcomes after individualized in-hospital nutritional support compared to routine hospital nutrition. These data support the early screening of patients with aging-related vulnerability for nutritional risk, followed by a nutritional assessment and implementation of individualized nutritional interventions.
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23
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Efthymiou A, Hersberger L, Reber E, Schönenberger KA, Kägi-Braun N, Tribolet P, Mueller B, Schuetz P, Stanga Z. Nutritional risk is a predictor for long-term mortality: 5-Year follow-up of the EFFORT trial. Clin Nutr 2021; 40:1546-1554. [PMID: 33743290 DOI: 10.1016/j.clnu.2021.02.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/28/2021] [Accepted: 02/18/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND AIMS The nutritional risk screening (NRS 2002) is a validated screening tool for malnutrition. This study aims to investigate the prognostic value of the NRS 2002 and its individual components regarding long-term mortality and adverse outcomes in a well-characterized cohort of medical inpatients. METHODS We performed a 5-year follow-up investigation of patients included in the investigator-initiated, prospective, randomized controlled multicenter EFFORT trial that evaluated the effects of individualized nutritional intervention vs. standard hospital food. We used multivariable cox regression analyses adjusted for randomisation arm, study centre, comorbidities and main admission diagnosis to investigate associations between NRS 2002 total scores at time of hospital admission and several long-term outcomes. RESULTS We had confirmed mortality data over the mean follow-up time of 3.2 years in 1874 from the initial cohort of 2028 EFFORT patients. Mortality showed a step-wise increase in patients with NRS 3 (289/565 [51.2%]) and NRS 4 (355/717 [49.6%]) to 59.5% (353/593) in patient with NRS≥5 corresponding to an adjusted Hazard Ratio (HR) of 1.28 (95%CI 1.15 to 1.42, p ≤ 0.001) for mortality after one year and 1.13 (95%CI 1.05 to 1.23, p = 0.002) for the overall time period. All individual components of NRS including disease severity, food intake, weight loss and BMI provided prognostic information regarding long-term mortality risk. CONCLUSION Nutritional risk mirrored by a NRS 2002 total score is a strong and independent predictor of long-term mortality and morbidity in polymorbid medical inpatients particularly in patients with high nutritional risk with an NRS ≥5 points.
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Affiliation(s)
- Andriana Efthymiou
- Division of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Lara Hersberger
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Emilie Reber
- Division of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | | | | | | | | | - Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland.
| | - Zeno Stanga
- Division of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
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24
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Bargetzi A, Emmenegger N, Wildisen S, Nickler M, Bargetzi L, Hersberger L, Segerer S, Kaegi-Braun N, Tribolet P, Gomes F, Hoess C, Pavlicek V, Bilz S, Sigrist S, Brändle M, Henzen C, Thomann R, Rutishauser J, Aujesky D, Rodondi N, Donzé J, Stanga Z, Mueller B, Schuetz P. Admission kidney function is a strong predictor for the response to nutritional support in patients at nutritional risk. Clin Nutr 2021; 40:2762-2771. [PMID: 33933742 DOI: 10.1016/j.clnu.2021.03.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/26/2021] [Accepted: 03/08/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) are at substantial risk of malnutrition, which negatively affects clinical outcomes. We investigated the association of kidney function assessed at hospital admission and effectiveness of nutritional support in hospitalized medical patients at risk of malnutrition. METHODS This is a secondary analysis of an investigator-initiated, randomized-controlled, Swiss multicenter trial (EFFORT) that compared individualised nutritional support with usual hospital food on clinical outcomes. We compared effects of nutritional support on mortality in subgroups of patients stratified according to kidney function at the time of hospital admission (estimated glomerular filtration rates [eGFR] <15, 15-29, 30-59, 60-89 and ≥ 90 ml/min/1.73 m2). RESULTS We included 1943 of 2028 patients (96%) from the original trial with known admission creatinine levels. Admission eGFR was a strong predictor for the beneficial effects of nutritional support in regard to lowering of 30-day mortality. Patients with an eGFR <15, 15-29 and 30-59 had the strongest mortality benefit (odds ratios [95%CI] of 0.24 [0.05 to 1.25], 0.37 [0.14 to 0.95] and 0.39 [0.21 to 0.75], respectively), while patients with less severe impairment in kidney function had a less pronounced mortality benefits (p for interaction 0.001). A similar stepwise association of kidney function and response to nutritional support was found also for other secondary outcomes. CONCLUSION In medical inpatients at nutritional risk, admission kidney function was a strong predictor for the response to nutritional therapy. Initial kidney function may help to individualize nutritional support in the future by identification of patients with most clinical benefit. CLINICAL TRIAL REGISTRATION Registered under ClinicalTrials.gov Identifier no. NCT02517476.
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Affiliation(s)
- Annika Bargetzi
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Switzerland
| | | | | | - Manuela Nickler
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Division of Nephrology, Kantonsspital Aarau, Aarau, Switzerland
| | - Laura Bargetzi
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Switzerland
| | - Lara Hersberger
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Switzerland
| | - Stephan Segerer
- Division of Nephrology, Kantonsspital Aarau, Aarau, Switzerland
| | - Nina Kaegi-Braun
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Pascal Tribolet
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland
| | - Filomena Gomes
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; The New York Academy of Sciences, New York City, NY, USA
| | - Claus Hoess
- Internal Medicine, Kantonsspital Muensterlingen, Switzerland
| | | | - Stefan Bilz
- Internal Medicine & Endocrinology/Diabetes, Kantonsspital St.Gallen, Switzerland
| | - Sarah Sigrist
- Internal Medicine & Endocrinology/Diabetes, Kantonsspital St.Gallen, Switzerland
| | - Michael Brändle
- Internal Medicine & Endocrinology/Diabetes, Kantonsspital St.Gallen, Switzerland
| | | | | | | | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; Institute of Primary Health Care (BIHAM), University of Bern, Switzerland
| | - Jacques Donzé
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Zeno Stanga
- Division of Diabetes, Endocrinology, Nutritional Medicine & Metabolism, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Beat Mueller
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Switzerland
| | - Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Switzerland.
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Schuetz P, Sulo S, Walzer S, Vollmer L, Stanga Z, Gomes F, Rueda R, Mueller B, Partridge J. Economic evaluation of individualized nutritional support in medical inpatients: Secondary analysis of the EFFORT trial. Clin Nutr 2020; 39:3361-3368. [DOI: 10.1016/j.clnu.2020.02.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 02/12/2020] [Accepted: 02/16/2020] [Indexed: 12/24/2022]
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Effect of nutritional support in patients with lower respiratory tract infection: Secondary analysis of a randomized clinical trial. Clin Nutr 2020; 40:1843-1850. [PMID: 33081983 PMCID: PMC7547398 DOI: 10.1016/j.clnu.2020.10.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/03/2020] [Accepted: 10/06/2020] [Indexed: 02/05/2023]
Abstract
Background In polymorbid patients with bronchopulmonary infection, malnutrition is an independent risk factor for mortality. There is a lack of interventional data investigating whether providing nutritional support during the hospital stay in patients at risk for malnutrition presenting with lower respiratory tract infection lowers mortality. Methods For this secondary analysis of a randomized clinical trial (EFFORT), we analyzed data of a subgroup of patients with confirmed lower respiratory tract infection from an initial cohort of 2028 patients. Patients at nutritional risk (Nutritional Risk Screening [NRS] score ≥3 points) were randomized to receive protocol-guided individualized nutritional support to reach protein and energy goals (intervention group) or standard hospital food (control group). The primary endpoint of this analysis was all-cause 30-day mortality. Results We included 378 of 2028 EFFORT patients (mean age 74.4 years, 24% with COPD) into this analysis. Compared to usual care hospital nutrition, individualized nutritional support to reach caloric and protein goals showed a similar beneficial effect of on the risk of mortality in the subgroup of respiratory tract infection patients as compared to the main EFFORT trial (odds ratio 0.47 [95%CI 0.17 to 1.27, p = 0.136] vs 0.65 [95%CI 0.47 to 0.91, p = 0.011]) with no evidence of a subgroup effect (p for interaction 0.859). Effects were also similar among different subgroups based on etiology and type of respiratory tract infection and for other secondary endpoints. Conclusion This subgroup analysis from a large nutrition support trial suggests that patients at nutritional risk as assessed by NRS 2002 presenting with bronchopulmonary infection to the hospital likely have a mortality benefit from individualized inhospital nutritional support. The small sample size and limited statistical power calls for larger nutritional studies focusing on this highly vulnerable patient population. Clinical trial registration Registered under ClinicalTrials.gov Identifier no. NCT02517476.
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27
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Merker M, Felder M, Gueissaz L, Bolliger R, Tribolet P, Kägi-Braun N, Gomes F, Hoess C, Pavlicek V, Bilz S, Sigrist S, Brändle M, Henzen C, Thomann R, Rutishauser J, Aujesky D, Rodondi N, Donzé J, Stanga Z, Mueller B, Schuetz P. Association of Baseline Inflammation With Effectiveness of Nutritional Support Among Patients With Disease-Related Malnutrition: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2020; 3:e200663. [PMID: 32154887 PMCID: PMC7064875 DOI: 10.1001/jamanetworkopen.2020.0663] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Inflammation is a key driver of malnutrition during illness and is often accompanied by metabolic effects, including insulin resistance and reduction of appetite. However, it still remains unclear if inflammation influences the response to nutritional support among patients with disease-related malnutrition. OBJECTIVE To examine whether patients' baseline inflammatory status is associated with the effect of nutritional support on 30-day mortality. DESIGN, SETTING, AND PARTICIPANTS This is a secondary analysis of the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), a randomized clinical trial conducted in 8 Swiss hospitals from April 2014 to February 2018. A total of 1950 participants who had C-reactive protein measurements at the time of admission were included in this secondary analysis. Data analysis was conducted between June and July 2019. INTERVENTIONS Hospitalized patients at risk for malnutrition were randomly assigned to receive protocol-guided individualized nutritional support to reach protein and energy goals (intervention group) or standard hospital food (control group). MAIN OUTCOMES AND MEASURES The primary end point was 30-day mortality. Based on C-reactive protein levels at admission, patients were stratified into groups with low, moderate, or high inflammation (<10 mg/L, 10-100 mg/L, and >100 mg/L, respectively). RESULTS A total of 1950 patients (median [interquartile range] age, 75 [65-83] years; 1025 [52.6%] men) were included; 533 (27.3%) had low levels of inflammation, 894 (45.9%) had moderate levels of inflammation, and 523 (26.8%) had high levels of inflammation. Compared with the control group, patients receiving nutritional support showed a significant reduction in 30-day mortality, regardless of C-reactive protein level (adjusted odds ratio, 0.61; 95% CI, 0.43-0.86; P = .005). In the subgroup of patients with high inflammation, there was no beneficial effect of nutritional support (adjusted odds ratio, 1.32; 95% CI, 0.70-2.50; P = .39), providing evidence that inflammation has a significant modifying association (P for interaction = .005). CONCLUSIONS AND RELEVANCE Based on this secondary analysis of a multicenter randomized trial, a patient's admission inflammatory status was associated with their response to nutritional support. If validated in future clinical trials, nutritional support may need to be individualized based on a patient's initial presentation and markers of inflammation. These results may also help to explain some of the heterogeneity in treatment effects of nutrition seen in previous critical care trials. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02517476.
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Affiliation(s)
- Meret Merker
- Medical University Department, University of Basel, Kantonsspital Aarau, Aarau, Switzerland
| | | | | | - Rebekka Bolliger
- Medical University Department, University of Basel, Kantonsspital Aarau, Aarau, Switzerland
| | - Pascal Tribolet
- Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland
| | - Nina Kägi-Braun
- Internal Medicine, Kantonsspital Muensterlingen, Muensterlingen, Switzerland
| | | | - Claus Hoess
- Internal Medicine, Kantonsspital Muensterlingen, Muensterlingen, Switzerland
| | - Vojtech Pavlicek
- Internal Medicine, Kantonsspital Muensterlingen, Muensterlingen, Switzerland
| | - Stefan Bilz
- Internal Medicine and Endocrinology/Diabetes, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Sarah Sigrist
- Internal Medicine and Endocrinology/Diabetes, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Michael Brändle
- Internal Medicine and Endocrinology/Diabetes, Kantonsspital St Gallen, St Gallen, Switzerland
| | | | - Robert Thomann
- Internal Medicine, Kantonsspital Solothurn, Solothurn, Switzerland
| | | | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Jaques Donzé
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Zeno Stanga
- Division of Diabetology, Endocrinology, Nutritional Medicine, and Metabolism, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Beat Mueller
- Medical University Department, University of Basel, Kantonsspital Aarau, Aarau, Switzerland
| | - Philipp Schuetz
- Medical University Department, University of Basel, Kantonsspital Aarau, Aarau, Switzerland
- University of Basel, Basel, Switzerland
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Friedli N, Baumann J, Hummel R, Kloter M, Odermatt J, Fehr R, Felder S, Baechli V, Geiser M, Deiss M, Tribolet P, Gomes F, Mueller B, Stanga Z, Schuetz P. Refeeding syndrome is associated with increased mortality in malnourished medical inpatients: Secondary analysis of a randomized trial. Medicine (Baltimore) 2020; 99:e18506. [PMID: 31895785 PMCID: PMC6946353 DOI: 10.1097/md.0000000000018506] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 11/18/2019] [Accepted: 11/26/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Whether the occurrence of refeeding syndrome (RFS), a metabolic condition characterized by electrolyte shifts after initiation of nutritional therapy, has a negative impact on clinical outcomes remains ill-defined. We prospectively investigated a subgroup of patients included in a multicentre, nutritional trial (EFFORT) for the occurrence of RFS. METHODS In this secondary analysis of a randomized-controlled trial investigating the effects of nutritional support in malnourished medical inpatients, we prospectively screened patients for RFS and classified them as "RFS confirmed" and "RFS not confirmed" based on predefined criteria (i.e. electrolyte shifts, clinical symptoms, clinical context, and patient history). We assessed associations of RFS and mortality within 180 days (primary endpoint) and other secondary endpoints using multivariable regression analysis. RESULTS Among 967 included patients, RFS was confirmed in 141 (14.6%) patients. Compared to patients with no evidence for RFS, patients with confirmed RFS had significantly increased 180-days mortality rates (42/141 (29.8%) vs 181/826 (21.9%), adjusted odds ratio (OR) 1.53 (95% CI 1.02 to 2.29), P < .05). Patients with RFS also had an increased risk for ICU admission (6/141 (4.3%) vs 13/826 (1.6%), adjusted OR 2.71 (95% CI 1.01 to 7.27), P < .05) and longer mean length of hospital stays (10.5 ± 6.9 vs 9.0 ± 6.6 days, adjusted difference 1.57 days (95% CI 0.38-2.75), P = .01). CONCLUSION A relevant proportion of medical inpatients with malnutrition develop features of RFS upon hospital admission, which is associated with long-term mortality and other adverse clinical outcomes. Further studies are needed to develop preventive strategies for RFS in this patient population.
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Affiliation(s)
- Natalie Friedli
- Medical University Department, Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau
| | | | | | | | - Jonas Odermatt
- Medical University Department, Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau
| | - Rebecca Fehr
- Medical University Department, Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau
| | - Susan Felder
- Medical University Department, Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau
| | - Valerie Baechli
- Medical University Department, Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau
| | - Martina Geiser
- Medical University Department, Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau
| | - Manuela Deiss
- Medical University Department, Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau
| | - Pascal Tribolet
- Medical University Department, Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau
- Department of Health Professions Bern, University of Applied Sciences, Bern, Switzerland
| | - Filomena Gomes
- Medical University Department, Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau
- The New York Academy of Sciences, NY, USA
| | - Beat Mueller
- Medical University Department, Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau
- Medical Faculty of the University of Basel, Basel
| | - Zeno Stanga
- Department of Endocrinology, Diabetes, Nutritional Medicine and Metabolism, Bern University Hospital, and University of Bern, Switzerland
| | - Philipp Schuetz
- Medical University Department, Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau
- Medical Faculty of the University of Basel, Basel
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29
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Nutritional Management and Outcomes in Malnourished Medical Inpatients in 2020: The Evidence Is Growing! J Clin Med 2019; 9:jcm9010027. [PMID: 31877661 PMCID: PMC7019932 DOI: 10.3390/jcm9010027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 12/18/2019] [Indexed: 12/14/2022] Open
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30
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Hersberger L, Bargetzi L, Bargetzi A, Tribolet P, Fehr R, Baechli V, Geiser M, Deiss M, Gomes F, Kutz A, Kägi-Braun N, Hoess C, Pavlicek V, Schmid S, Bilz S, Sigrist S, Brändle M, Benz C, Henzen C, Nigg M, Thomann R, Brand C, Rutishauser J, Aujesky D, Rodondi N, Donzé J, Stanga Z, Mueller B, Schuetz P. Nutritional risk screening (NRS 2002) is a strong and modifiable predictor risk score for short-term and long-term clinical outcomes: secondary analysis of a prospective randomised trial. Clin Nutr 2019; 39:2720-2729. [PMID: 31882232 DOI: 10.1016/j.clnu.2019.11.041] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/27/2019] [Accepted: 11/30/2019] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The Nutritional Risk Screening 2002 (NRS 2002) identifies patients at risk of malnutrition. We studied the prognostic implications of this score with regard to short-term and long-term clinical outcomes in a well-characterised cohort of medical inpatients from a previous trial. METHODS This is a secondary analysis of an investigator-initiated, prospective randomised controlled multicenter trial in Switzerland (EFFORT) that compared the effects of an individualised nutritional support intervention with standard of care. We investigated associations between admission NRS and several short-term and long-term outcomes using multivariable regression analyses. RESULTS Of the 2028 patients, 31% had an NRS of 3, 38% of 4 and 31% of ≥5 points, and 477 (24%) died during the 180 days of follow-up. For each point increase in NRS, we found a stepwise increase in risk of 30-day mortality (adjusted Hazard Ratio (HR) 1.22 (95% CI 1.00 to 1.48), p = 0.048) and 180-day mortality (adjusted HR 1.37 (95% CI 1.22 to 1.55), p < 0.001). NRS was associated with length of hospital stay (adjusted difference of 0.60 days per NRS point increase, 95%CI 0.23 to 0.97, p = 0.002) and functional outcomes at 180 days (adjusted decrease in Barthel index of -4.49 points per NRS point increase, 95%CI -6.54 to -2.45, p < 0.001). In a subgroup analysis, associations of NRS and short-term adverse outcomes were less pronounced in patients receiving nutritional support (intervention group) compared to control group patients (adjusted HR for 30-day mortality 1.12 [95%CI 0.83 to 1.52, p = 0.454] vs. 1.33 [95%CI 1.02 to 1.72, p = 0.032]). CONCLUSION The NRS is a strong and independent risk score for malnutrition-associated mortality and adverse outcomes over 180 days. Our data provide strong evidence that the nutritional risk, however, is modifiable and can be reduced by the provision of adequate nutritional support.
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Affiliation(s)
- Lara Hersberger
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Switzerland
| | - Laura Bargetzi
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Switzerland
| | - Annika Bargetzi
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Switzerland
| | | | - Rebecca Fehr
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Valerie Baechli
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Martina Geiser
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Manuela Deiss
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Filomena Gomes
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; The New York Academy of Sciences, New York City, NY, USA
| | - Alexander Kutz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Switzerland
| | - Nina Kägi-Braun
- Internal Medicine, Kantonsspital Muensterlingen, Switzerland
| | - Claus Hoess
- Internal Medicine, Kantonsspital Muensterlingen, Switzerland
| | | | - Sarah Schmid
- Internal Medicine, Kantonsspital Muensterlingen, Switzerland
| | - Stefan Bilz
- Internal Medicine & Endocrinology/Diabetes, Kantonsspital St.Gallen, Switzerland
| | - Sarah Sigrist
- Internal Medicine & Endocrinology/Diabetes, Kantonsspital St.Gallen, Switzerland
| | - Michael Brändle
- Internal Medicine & Endocrinology/Diabetes, Kantonsspital St.Gallen, Switzerland
| | - Carmen Benz
- Internal Medicine & Endocrinology/Diabetes, Kantonsspital St.Gallen, Switzerland
| | | | - Melina Nigg
- Internal Medicine, Kantonsspital Luzern, Switzerland
| | | | - Claudia Brand
- Internal Medicine, Buergerspital Solothurn, Switzerland
| | | | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; Institute of Primary Health Care (BIHAM), University of Bern, Switzerland
| | - Jacques Donzé
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Zeno Stanga
- Division of Diabetology, Endocrinology, Nutritional Medicine & Metabolism, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Beat Mueller
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Switzerland
| | - Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Switzerland.
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31
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Li X, He N, Zhai S, Shi L. Optimising early nutritional support for medical inpatients. Lancet 2019; 394:2069-2070. [PMID: 31818404 DOI: 10.1016/s0140-6736(19)32469-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/28/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Xiaoxiao Li
- Department of Pharmacy, Peking University Third Hospital, Beijing, China; Department of Pharmacy Administration and Clinical Pharmacy School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Na He
- Department of Pharmacy, Peking University Third Hospital, Beijing, China; Department of Pharmacy Administration and Clinical Pharmacy School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China; Department of Pharmacy Administration and Clinical Pharmacy School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Luwen Shi
- Department of Pharmacy Administration and Clinical Pharmacy School of Pharmaceutical Sciences, Peking University, Beijing 100191, China.
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32
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Schuetz P, Stanga Z, Mueller B. Optimising early nutritional support for medical inpatients - Authors' reply. Lancet 2019; 394:2070-2071. [PMID: 31818406 DOI: 10.1016/s0140-6736(19)32617-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 08/28/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Philipp Schuetz
- Medical University Department, Department of General Internal and Emergency Medicine and Department of Endocrinology, Diabetes and Metabolism, Kantonsspital, Aarau 5000, Switzerland; University of Basel, Basel, Switzerland.
| | - Zeno Stanga
- Department of Diabetes, Endocrinology, Nutritional Medicine, and Metabolism, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Beat Mueller
- Medical University Department, Department of General Internal and Emergency Medicine and Department of Endocrinology, Diabetes and Metabolism, Kantonsspital, Aarau 5000, Switzerland; University of Basel, Basel, Switzerland
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33
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Merker M, Amsler A, Pereira R, Bolliger R, Tribolet P, Braun N, Hoess C, Pavlicek V, Bilz S, Sigrist S, Brändle M, Henzen C, Thomann R, Rutishauser J, Aujesky D, Rodondi N, Donzé J, Stanga Z, Mueller B, Schuetz P. Vitamin D deficiency is highly prevalent in malnourished inpatients and associated with higher mortality: A prospective cohort study. Medicine (Baltimore) 2019; 98:e18113. [PMID: 31770235 PMCID: PMC6890327 DOI: 10.1097/md.0000000000018113] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The impact of vitamin D deficiency on the recovery of patients with malnutrition remains undefined. Our aim was to study the prevalence of vitamin D deficiency in a well-characterized cohort of patients with malnutrition and its association with outcomes.Within this secondary analysis of a randomized controlled trial, we examined the association of vitamin D deficiency and adverse clinical outcomes over a follow-up of 180 days in hospitalized patients at risk for malnutrition. We measured 25-hydroxyvitamin D levels upon admission and defined Vitamin D deficiency when levels were <50nmol/l. The primary endpoint was 180-day mortality.The prevalence of vitamin D deficiency in our cohort of 828 patients was 58.2% (n = 482). Patients with vitamin D deficiency had increased 180-day mortality rates from 23.1% to 29.9% (odds ratio 1.42, 95% confidence interval [CI] 1.03-1.94, P = .03). When adjusting the analysis for demographics, comorbidities, and randomization, this association remained significant for the subgroup of patients not receiving vitamin D treatment (adjusted odds ratio 1.63, 95% CI 1.01-2.62, P = .04). There was no significantly lower risk for mortality in the subgroup of vitamin D deficient patients receiving vitamin D treatment compared to not receiving treatment (adjusted odds ratio 0.74, 95% CI 0.48-1.13, P = .15).Vitamin D deficiency is highly prevalent in the population of malnourished inpatients and is negatively associated with long-term mortality particularly when patients are not receiving vitamin D treatment. Our findings suggest that malnourished patients might benefit from vitamin D screening and treatment in case of deficiency.
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Affiliation(s)
- Meret Merker
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau
| | | | | | - Rebekka Bolliger
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau
| | - Pascal Tribolet
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau
- Department of Health Professions, Bern University of Applied Sciences, Bern
| | - Nina Braun
- Internal Medicine, Kantonsspital Münsterlingen, Münsterlingen
| | - Claus Hoess
- Internal Medicine, Kantonsspital Münsterlingen, Münsterlingen
| | | | - Stefan Bilz
- Internal Medicine & Endocrinology, Kantonsspital St. Gallen, St. Gallen
| | - Sarah Sigrist
- Internal Medicine & Endocrinology, Kantonsspital St. Gallen, St. Gallen
| | - Michael Brändle
- Internal Medicine & Endocrinology, Kantonsspital St. Gallen, St. Gallen
| | | | | | | | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Jaques Donzé
- Department of General Internal Medicine, Inselspital, Bern University Hospital
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Zeno Stanga
- Division of Diabetology, Endocrinology, Nutritional Medicine & Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Beat Mueller
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau
| | - Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau
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34
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Koretz RL. JPEN Journal Club 49. Pilot Trials. JPEN J Parenter Enteral Nutr 2019; 44:554-556. [PMID: 31549417 DOI: 10.1002/jpen.1716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 09/04/2019] [Indexed: 11/08/2022]
Affiliation(s)
- Ronald L Koretz
- Olive View-UCLA Medical Center, Sylmar, California, USA.,David Geffen-UCLA School of Medicine, Los Angeles, California, USA
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35
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Hoskin K, Müller B, Schütz P. [Nutritional Therapy in the Elderly - What Do We Know Today?]. PRAXIS 2019; 108:863-868. [PMID: 31571539 DOI: 10.1024/1661-8157/a003307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Nutritional Therapy in the Elderly - What Do We Know Today? Abstract. Malnutrition in the elderly has a high prevalence and is a strong and independent risk factor for complications and high mortality. Early diagnosis and therapeutic intervention have demonstrated positive effects on the risk for complications and morbidity/mortality. The nutritional therapy should be individually tailored to meet patients' needs and nutritional goals. Associated factors and diseases need to be taken into account while deciding on the nutritional therapy and nutritional targets. A big interprofessional effort is needed to address this specific problem. However, the latest EFFORT study showed: The expenditure is worthwhile!
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Affiliation(s)
- Katja Hoskin
- Abteilung für Endokrinologie, Diabetologie und Metabolismus, Medizinische Universitätsklinik, Kantonsspital Aarau
| | - Beat Müller
- Abteilung für Endokrinologie, Diabetologie und Metabolismus, Medizinische Universitätsklinik, Kantonsspital Aarau
| | - Philipp Schütz
- Abteilung für Endokrinologie, Diabetologie und Metabolismus, Medizinische Universitätsklinik, Kantonsspital Aarau
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36
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Schuetz P, Fehr R, Baechli V, Geiser M, Deiss M, Gomes F, Kutz A, Tribolet P, Bregenzer T, Braun N, Hoess C, Pavlicek V, Schmid S, Bilz S, Sigrist S, Brändle M, Benz C, Henzen C, Mattmann S, Thomann R, Brand C, Rutishauser J, Aujesky D, Rodondi N, Donzé J, Stanga Z, Mueller B. Individualised nutritional support in medical inpatients at nutritional risk: a randomised clinical trial. Lancet 2019; 393:2312-2321. [PMID: 31030981 DOI: 10.1016/s0140-6736(18)32776-4] [Citation(s) in RCA: 425] [Impact Index Per Article: 85.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 10/20/2018] [Accepted: 10/23/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Guidelines recommend the use of nutritional support during hospital stays for medical patients (patients not critically ill and not undergoing surgical procedures) at risk of malnutrition. However, the supporting evidence for this recommendation is insufficient, and there is growing concern about the possible negative effects of nutritional therapy during acute illness on recovery and clinical outcomes. Our aim was thus to test the hypothesis that protocol-guided individualised nutritional support to reach protein and caloric goals reduces the risk of adverse clinical outcomes in medical inpatients at nutritional risk. METHODS The Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) is a pragmatic, investigator-initiated, open-label, multicentre study. We recruited medical patients at nutritional risk (nutritional risk screening 2002 [NRS 2002] score ≥3 points) and with an expected length of hospital stay of more than 4 days from eight Swiss hospitals. These participants were randomly assigned (1:1) to receive either protocol-guided individualised nutritional support to reach protein and caloric goals (intervention group) or standard hospital food (control group). Randomisation was done with variable block sizes and stratification according to study site and severity of malnutrition using an interactive web-response system. In the intervention group, individualised nutritional support goals were defined by specialist dietitians and nutritional support was initiated no later than 48 h after admission. Patients in the control group received no dietary consultation. The composite primary endpoint was any adverse clinical outcome defined as all-cause mortality, admission to intensive care, non-elective hospital readmission, major complications, and decline in functional status at 30 days, and it was measured in all randomised patients who completed the trial. This trial is registered with ClinicalTrials.gov, number NCT02517476. FINDINGS 5015 patients were screened, and 2088 were recruited and monitored between April 1, 2014, and Feb 28, 2018. 1050 patients were assigned to the intervention group and 1038 to the control group. 60 patients withdrew consent during the course of the trial (35 in the intervention group and 25 in the control group). During the hospital stay, caloric goals were reached in 800 (79%) and protein goals in 770 (76%) of 1015 patients in the intervention group. By 30 days, 232 (23%) patients in the intervention group experienced an adverse clinical outcome, compared with 272 (27%) of 1013 patients in the control group (adjusted odds ratio [OR] 0·79 [95% CI 0·64-0·97], p=0·023). By day 30, 73 [7%] patients had died in the intervention group compared with 100 [10%] patients in the control group (adjusted OR 0·65 [0·47-0·91], p=0·011). There was no difference in the proportion of patients who experienced side-effects from nutritional support between the intervention and the control group (162 [16%] vs 145 [14%], adjusted OR 1·16 [0·90-1·51], p=0·26). INTERPRETATION In medical inpatients at nutritional risk, the use of individualised nutritional support during the hospital stay improved important clinical outcomes, including survival, compared with standard hospital food. These findings strongly support the concept of systematically screening medical inpatients on hospital admission regarding nutritional risk, independent of their medical condition, followed by a nutritional assessment and introduction of individualised nutritional support in patients at risk. FUNDING The Swiss National Science Foundation and the Research Council of the Kantonsspital Aarau, Switzerland.
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Affiliation(s)
- Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Basel, Switzerland.
| | - Rebecca Fehr
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Valerie Baechli
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Martina Geiser
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Manuela Deiss
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Filomena Gomes
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; The New York Academy of Sciences, New York, NY, USA
| | - Alexander Kutz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Pascal Tribolet
- Internal Medicine, Spital Lachen, Lachen, Switzerland; Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland
| | | | - Nina Braun
- Internal Medicine, Kantonsspital Münsterlingen, Münsterlingen, Switzerland
| | - Claus Hoess
- Internal Medicine, Kantonsspital Münsterlingen, Münsterlingen, Switzerland
| | - Vojtech Pavlicek
- Internal Medicine, Kantonsspital Münsterlingen, Münsterlingen, Switzerland
| | - Sarah Schmid
- Internal Medicine, Kantonsspital Münsterlingen, Münsterlingen, Switzerland
| | - Stefan Bilz
- Internal Medicine and Endocrinology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Sarah Sigrist
- Internal Medicine and Endocrinology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Michael Brändle
- Internal Medicine and Endocrinology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Carmen Benz
- Internal Medicine and Endocrinology, Kantonsspital St Gallen, St Gallen, Switzerland
| | | | - Silvia Mattmann
- Internal Medicine, Kantonsspital Luzern, Luzern, Switzerland
| | - Robert Thomann
- Internal Medicine, Bürgerspital Solothurn, Solothurn, Switzerland
| | - Claudia Brand
- Internal Medicine, Bürgerspital Solothurn, Solothurn, Switzerland
| | - Jonas Rutishauser
- Internal Medicine, Kantonsspital Baselland, Standort Bruderholz Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Jacques Donzé
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Zeno Stanga
- Division of Diabetology, Endocrinology, Nutritional Medicine, and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Beat Mueller
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Basel, Switzerland
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