Evaluation of Nutritional Support and In-Hospital Mortality in Patients With Malnutrition

Functional Assessment of >18 Years Old Patients at Internal Medicine Ward-Relationship with In-Hospital and 30-Day Mortality

Objective

To evaluate the connection between the items included in the AVD-DezIs score (a questionnaire about basic and instrumental activities of daily living and other topics related to social and personal life) and in-hospital and 30-day mortality after discharge.

Methods

Prospective cohort study of hospitalizations in the Internal Medicine ward from 2014 to 2020, including >18 years old patients with a fully completed AVD-DezIs. To identify in-hospital and 30 days mortality, univariate and multivariate logistic models were applied, including random effects if justified.

Results

A total of 19,771 episodes of hospitalization were included. In the univariate analysis, except for the presence of isolation and financial insufficiency, all the items were predictors of mortality in-hospital or within 30 days after discharge. In multivariate analysis, older age, male sex, longer hospital stay, higher Charlson score, deficiency in all four activities of daily living, deficiency in meal preparation and housekeeping, presence of pain/depression, immobility, and malnutrition are associated with a higher probability of in-hospital death whereas older age, male gender, higher Charlson score, longer length of hospital stay, deficiency in personal hygiene, ambulation, and eating habits, as well as the presence of incontinence and malnutrition, are associated with a higher probability of 30 days after discharge death.

Discussion/Conclusion

Except for isolation and financial insufficiency, all items were individually associated with the outcomes. When they are considered in conjunction and taking into account sex, age, comorbidities and length of stay, the predictive ability of in-hospital and 30 days mortality differed.

Perceptions, barriers and facilitators regarding nutritional care for patients with chronic limb threatening ischemia: a focus group study among healthcare professionals

BACKGROUND

Nutrition and nutritional care are essential for optimal outcomes, and, therefore of importance for patients with chronic limb threatening ischemia (CLTI) given their high risk of complications. However, insight is lacking in how healthcare professionals directly involved in the care of patients with CLTI perceive nutritional care, as well as in the perceived barriers and facilitators regarding optimal nutritional care.

METHODS

In this qualitative study with a phenomenological approach, three online focus groups were conducted with various healthcare professionals directly involved in the care of patients with CLTI. Sample size was guided by information power. Focus group recordings were transcribed verbatim, and reflexive thematic analysis was performed.

RESULTS

Seventeen healthcare professionals participated, including vascular surgeons, fellows in vascular surgery, a medical doctor and researcher, nurse specialized in wound care, general nurse, physical therapists, dietitians, and nutrition assistants. Four themes were generated: (1) nutritional care is crucial for optimal clinical outcomes and a healthy life, (2) insufficient attention to undernutrition and nutritional care by healthcare professionals, (3) patient-related factors challenge healthcare professionals in providing nutritional care, and (4) need for optimizing the organizational process related to nutritional care. Perceived barriers regarding nutritional care included knowledge deficits, nutritional care not being part of the healthcare professionals' routine, missing tools to identify undernutrition, patient-related factors, and time constraints. Facilitators regarding nutritional care included more scientific evidence regarding the effect of nutritional care on clinical outcomes and optimization of organizational processes related to nutritional care.

CONCLUSION

Healthcare professionals perceive nutritional care as important for optimal outcomes, but nutritional care is not routinely implemented in the care of patients with CLTI. This lack of implementation of nutritional care may be due to the barriers perceived in various domains. The findings of this study stress the need to optimize nutritional care, with the aim of improving outcomes in the CLTI population.

Nutritional screening on hospital admission and one-year clinical outcomes in a prospective cohort of older patients

BACKGROUND & AIMS

Malnutrition negatively affects the prognosis and quality of life of hospitalized patients. However, there are several gaps between evidence-based knowledge and current clinical practice. Our primary aim was to describe the prevalence of malnutrition risk in a cohort of in a cohort of older inpatients; secondly, we explored its predictors and its independent impact on 12-month survival.

METHODS

Prospective study focused on patients aged 65 years and older consecutively admitted for any reason to the acute geriatric and general medical units of an Italian university hospital. Comprehensive geriatric assessment data, including the short form of the Mini Nutritional Assessment (MNA-SF), were collected within 48 hours of admission. The prevalence of malnutrition and risk of malnutrition according to the MNA-SF represented the main outcome. Correlations among clinical variables, nutritional status, and one-year survival were analyzed using multivariable and Cox models.

RESULTS

Among 594 patients (median age: 84 years, 49.5 % female), mostly living at home with moderate functional autonomy, 82.3 % were identified as probably malnourished or at risk of malnutrition according to MNA-SF (39.9 % and 42.4 %, respectively). Malnutrition and the risk of malnutrition were positively associated with living alone at home (OR 2.803, 95%CI 1.567-5.177, p < 0.001), and negatively associated with autonomy in IADL (OR 0.765, 95%CI 0.688-0.846, p < 0.001) and the best performance at HST (OR 0.901, 95%CI 0.865-0.936; p < 0.001). After 12 months, 31.8 % of patients was dead and mortality was positively correlated with malnutrition according to MNA-SF (OR 2.493, 95%CI 1.345-4.751, p = 0.004), institutionalization (OR 2.815, 95%CI 1.423-5.693, p = 0.003) and severe cognitive impairment (OR 1.701, 95%CI 1.031-2.803, p = 0.036).

CONCLUSION

Malnutrition is common among older inpatients upon admission, primarily influenced by their functional and cognitive status, and it is linked to a worse prognosis. Early incorporation of thorough nutritional and functional assessments into clinical practice is crucial to improve prognosis prediction and enable timely, focused interventions targeting modifiable causal factors in a patient-centered approach.

Development and validation of a nomogram of all-cause mortality in adult Americans with diabetes

This study aimed to develop and validate a predictive model of all-cause mortality risk in American adults aged ≥ 18 years with diabetes. 7918 participants with diabetes were enrolled from the National Health and Nutrition Examination Survey (NHANES) 1999-2016 and followed for a median of 96 months. The primary study endpoint was the all-cause mortality. Predictors of all-cause mortality included age, Monocytes, Erythrocyte, creatinine, Nutrition Risk Index (NRI), neutrophils/lymphocytes (NLR), smoking habits, alcohol consumption, cardiovascular disease (CVD), urinary albumin excretion rate (UAE), and insulin use. The c-index was 0.790 (95% CI 0.779-0.801, P < 0.001) and 0.792 (95% CI: 0.776-0.808, P < 0.001) for the training and validation sets, respectively. The area under the ROC curve was 0.815, 0.814, 0.827 and 0.812, 0.818 and 0.829 for the training and validation sets at 3, 5, and 10 years of follow-up, respectively. Both calibration plots and DCA curves performed well. The model provides accurate predictions of the risk of death for American persons with diabetes and its scores can effectively determine the risk of death in outpatients, providing guidance for clinical decision-making and predicting prognosis for patients.

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

OBJECTIVES

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

DESIGN

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

PARTICIPANTS

Patients with diabetes and risk for malnutrition.

INTERVENTIONS

Individualised nutritional support versus usual care.

PRIMARY OUTCOME MEASURE

30-day all-cause mortality.

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION NUMBER

NCT02517476.

The Association of the Essential Amino Acids Lysine, Methionine, and Threonine with Clinical Outcomes in Patients at Nutritional Risk: Secondary Analysis of a Randomized Clinical Trial

Lysine, methionine, and threonine are essential amino acids with vital functions for muscle and connective tissue health, metabolic balance, and the immune system. During illness, the demand for these amino acids typically increases, which puts patients at risk for deficiencies with harmful clinical consequences. In a secondary analysis of the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), which compared individualized nutritional support to usual care nutrition in patients at nutritional risk, we investigated the prognostic impact of the lysine, methionine, and threonine metabolism. We had complete clinical and amino acid data in 237 patients, 58 of whom reached the primary endpoint of death at 30 days. In a model adjusted for comorbidities, sex, nutritional risk, and trial intervention, low plasma methionine levels were associated with 30-day mortality (adjusted HR 1.98 [95% CI 1.16 to 3.36], p = 0.01) and with a decline in functional status (adjusted OR 2.06 [95% CI 1.06 to 4.01], p = 0.03). The results for lysine and threonine did not show statistically significant differences regarding clinical outcomes. These findings suggest that low levels of methionine may be critical during hospitalization among patients at nutritional risk. Further studies should investigate the effect of supplementation of methionine in this patient group to improve outcomes.

Enteral nutrition: An underappreciated source of patient safety events

Enteral nutrition (EN) therapies are prescribed for patients not able to maintain adequate nutrition through the oral route. Medical errors and close calls associated with the provision of EN therapy leading to actual and potential patient harm have been reported. The purpose of this study was to determine the number, type, and severity of safety events related to the provision of EN therapies reported to a national database and provide workable recommendations from the literature to improve safety. An interdisciplinary team queried the National Center for Patient Safety (NCPS) Joint Patient Safety Reporting (JPSR) system using keywords related to EN therapy use. The team reviewed the number, type, and severity of reported events and safety codes as categorized by the NCPS and then thematically classified the narratives using the Medication Use Process (MUP). Our query revealed 1227 safety events related to the EN keywords. Thematic analysis of the top five event subtypes (n = 1030) revealed that there were 691 EN safety reports directly related to an MUP step, and the majority fell into the steps of administering (31%), followed by monitoring (28%), dispensing (26%), prescribing (11%), and transcription (4%), with many events involving more than one MUP step. Safety events associated with the provision of EN therapies leading to patient harm have been reported to the JPSR system. To improve safety related to EN use, modifications to prescribing, transcribing/documenting, dispensing, administering, and monitoring of prescribed EN therapies are needed.

Geriatric nutritional risk index has a prognostic value for recovery outcomes in elderly patients with brain abscess

Background

The Geriatric Nutritional Risk Index (GNRI) is a straightforward and objective tool for nutritional screening in older patients and has been demonstrated to possess prognostic predictive value in several diseases. Nonetheless, there is a lack of research on the nutritional risk associated with brain abscess in the older. This study aimed to evaluate the prevalence of nutritional risk among these patients by GNRI and to investigate its potential prognostic value for clinical outcomes.

Materials and methods

From August 2019 to April 2023, 100 older patients diagnosed with brain abscess were enrolled in this single-center prospective cohort study, which evaluated the prognostic value of the Geriatric Nutritional Risk Index (GNRI) in elderly brain abscess patients. Data collected included demographic, and clinical characteristics at admission and calculated the GNRI, and the Glasgow Outcome Scale (GOS) score 6 months post-discharge. A GOS score of 5 was considered indicative of a good recovery, whereas scores ranging from 1 to 4 were classified as poor recovery.

Results

The results revealed that 48% of older brain abscess patients were at risk of malnutrition according to the GNRI. These patients had significantly higher post-admission C-reactive protein (CRP) levels (p = 0.017), more comorbidities (p < 0.001), and higher age-adjusted Charlson Comorbidity Index (aCCI) scores (p < 0.001) compared to those without nutritional risk. Spearman correlation analysis showed that GNRI scores were negatively correlated with CRP levels, comorbidities, and aCCI scores, and positively correlated with Glasgow Outcome Scale (GOS) scores (Spearman's ρ = 0.624, p < 0.001). Multivariate logistic regression revealed that lower GNRI values were linked to reduced GOS levels (OR = 0.826, 95% CI: 0.775-0.880). ROC analysis determined a GNRI threshold of 97.50 for predicting poor recovery, with 90.57% sensitivity and 87.23% specificity.

Conclusion

The older brain abscess patients exhibited a high malnutrition risk. GNRI showed an important predictive value for recovery in older patients, which could be helpful in clinical intervention and rehabilitation.

Malnutrition and Its Determinants among Older Adults Living in French Caribbean Nursing Homes: A Cross-Sectional Study

BACKGROUND

This study aimed to assess the prevalence of malnutrition and its determinants in older adults living in French Caribbean nursing homes.

METHODS

This cross-sectional study was taken from the KASEHAD (Karukera Study of Ageing in EHPAD) study. Nutritional status was assessed with the Mini Nutritional Assessment Short-Form (MNA-SF). Clinical characteristics and scores on geriatric scales (Mini-Mental State Examination (MMSE), Activities of Daily Living (ADL), Short Physical Performance Battery (SPPB), Center for Epidemiologic Studies-Depression (CESD) and Questionnaire Quality of Life Alzheimer's Disease (QoL-AD)) were extracted. Bivariate analysis and logistic models adjusted were performed to test the association between nutritional status and both socio-demographic variables and geriatric scales.

RESULTS

A total of 332 older adults from six nursing homes were included in the KASEHPAD study. Among the participants, 319 had an MNA-SF score. The mean age was 81.3 ± 10.6 years, and half of the participants were men. The frequency of malnutrition (MNA-SF ≤ 7) was 27.6% (95% confidence interval (CI): 22.0-32.5) (n = 88). Based on the multivariable analysis, a low MMSE was associated with malnutrition (OR: 0.81 (0.68-0.92); p = 0.015) and there was a borderline significant link between a higher CESD score and malnutrition (OR: 1.05 (1.00-1.12); p = 0.07).

CONCLUSIONS

Cognitive decline and a tendency toward depression were associated with malnutrition in nursing homes in the French West Indies. Although this study cannot establish causal relationships, the identification of these three geriatric syndromes in nursing homes is crucial for preventing adverse health events.

Prevention and Treatment of Malnutrition in Older Adults Living in Long-Term Care or the Community: An Evidence-Based Nutrition Practice Guideline

Malnutrition in older adults can decrease quality of life and increase risk of morbidities and mortality. Accurate and timely identification of malnutrition, as well as subsequent implementation of effective interventions, are essential to decrease poor outcomes associated with malnutrition in older adults. The Academy of Nutrition and Dietetics Evidence Analysis Center conducted a systematic review of the literature to develop an evidence-based nutrition practice guideline for the prevention and treatment of malnutrition in older adults. The objective of this guideline was to provide evidence-based recommendations to identify, prevent, or treat protein-energy malnutrition in older adults (mean age ≥65 years) living in long-term care and community settings. This guideline provides 11 nutrition recommendations to inform shared decision making among dietitians, members of the health care team, family members or caregivers, and older adults living in long-term care or the community to prevent or treat malnutrition. Topics include dietitian effectiveness, nutrition assessment tools, oral nutrition supplements, food fortification, and home-delivered and congregate meals. Guideline implementation should include consideration of the importance of comprehensive individualized nutrition care for older adults. Future research is needed to address gaps that were identified related to the validity, reliability, and feasibility of nutrition assessment tools, as well as the effectiveness of dietitian interventions on outcomes of interest in older adults living in long-term care and the community.

Exploring the intersections of frailty, sarcopenia, and cachexia with malnutrition

This review examines our current understanding of consensus definitions for frailty, sarcopenia, and cachexia and their perceived overlap with malnutrition. Patients with these syndromes will often meet the criteria for malnutrition. It is common for these overlap syndromes to be misapplied by practitioners, and confusion has been further exacerbated by the lack of a common malnutrition language. To address the latter concern, we recommend using either the standalone Global Leadership Initiative in Malnutrition (GLIM) framework or the GLIM consensus criteria integrated with other accepted approaches as dictated by preference and available resources. Established care standards should guide the recognition and treatment of malnutrition to promote optimal clinical outcomes and quality of life. The effectiveness of nutrition interventions may be reduced in settings of severe acute inflammation and in end-stage disease that is associated with cachexia. However, such interventions may still assist patients to tolerate treatments that target the underlying etiology for an overlap syndrome, and they may help to improve select clinical outcomes and quality of life. Recent, large, well-designed randomized controlled trials have demonstrated the compelling positive clinical effects of medical nutrition therapy. The application of concurrent malnutrition risk screening and assessment is therefore a high priority. The necessity to deliver specific interventions that target the underlying mechanisms of these overlap syndromes and also diagnose and address malnutrition is paramount. It must be highlighted that securing beneficial outcomes for frailty, sarcopenia, and cachexia will also require nonnutrition interventions, like comprehensive care plans, pharmacologic agents, and prescribed exercise.

Differences in risk of serious infections between patients with secondary versus primary nephropathy following rituximab treatment: a retrospective cohort study

Background

The incidence of severe infections (SIs) in patients with autoimmune nephropathy after rituximab (RTX) treatment varies significantly. Our study aims to identify high-risk populations, specifically by comparing the differences in the risk of SIs between patients with primary nephropathy and those with nephropathy in the context of systemic autoimmune diseases (referred to as secondary nephropathy).

Methods

This retrospective cohort study investigated the occurrence of SIs in adult patients with immune-related kidney disease who received RTX treatment at our institution from 2017 to 2022. Multivariable COX regression models were used to analyze the association between the type of nephropathy (primary or secondary) and SIs. Propensity score analyses, subgroup analyses, and E-value calculations were performed to ensure the reliability of the results.

Results

Out of 123 patients, 32 (26%) developed 39 cases of SIs during a mean follow-up period of 19.7 ± 14.6 months post-RTX treatment, resulting in an incidence rate of 18.9/100 patient-years. The multivariable COX regression analysis indicated that patients with secondary nephropathy had a significantly higher risk of SIs compared to those with primary nephropathy (HR = 5.86, 95% CI: 1.05-32.63, P = 0.044), even after accounting for confounding variables including gender, age, BMI, history of prior SIs, baseline eGFR, lymphocyte counts, IgG levels, and the utilization of other immunosuppressive therapies. Various sensitivity analyses consistently supported these findings, with an E-value of 5.99. Furthermore, advanced age (HR: 1.03; 95% CI: 1.01-1.06; P = 0.023), low baseline IgG levels (HR: 0.75; 95% CI: 0.64-0.89; P < 0.001), and recent history of SIs (HR: 5.68; 95% CI: 2.2-14.66; P < 0.001) were identified as independent risk factors.

Conclusion

The incidence of SIs following RTX administration in patients with autoimmune nephropathy is significant. It is crucial to note that there are distinct differences between the subgroups of primary and secondary nephropathy. Patients with secondary nephropathy, particularly those who are elderly, have low baseline IgG levels, and have a recent history of SI, are more susceptible to SIs.

Increasing the Volume of Delivered Enteral Feeds Using a Volume-Based Feeding Protocol in a Neuroscience Intensive Care Unit

BACKGROUND

Iatrogenic malnutrition is a significant burden to patients, clinicians, and health care systems. Compared with well-nourished patients, underfed patients (those who receive less than 80% of their daily energy requirement) have more adverse outcomes related to nutritional status. Volume-based protocols allow for catch-up titrations, are consistently superior to rate-based protocols, and can be implemented in most settings.

LOCAL PROBLEM

This project was conducted in an 8-bed neuroscience intensive care unit in which up to 41% of patients who required enteral feeding were underfed.

METHODS

This quality improvement clinical practice change project used a before-and-after design to evaluate (1) the effect of implementing a volume-based feeding protocol on the delivery of enteral feeds and (2) the effect of a nutrition-based project on staff members' attitudes regarding nutrition in critical care. The effectiveness of a volume-based feeding titration protocol was compared with that of a rate-based feeding protocol for achieving delivery of at least 80% of prescribed nutrition per 24-hour period. Staff members' attitudes were assessed using a survey before and after the project.

RESULTS

During 241 enteral feeding days (n = 40 patients), the percentage of delivered enteral feeding volume and the percentage of days patients received at least 80% of the prescribed volume increased after volume-based feeding was implemented. After project implementation, 74 staff members reported increased emphasis on nutrition delivery in their practice and a higher level of agreement that nutrition is a priority when caring for critically ill patients.

CONCLUSIONS

Using a volume-based feeding protocol with supplemental staff education resulted in improved delivery of prescribed enteral feeding.

Comparison of the Value of Four Objective Nutritional Indices in Assessing the Long-Term Prognosis of Elderly Patients with Heart Failure with Preserved Ejection Fraction

Background

The long-term prognosis of heart failure with preserved ejection fraction (HFpEF) is influenced by malnutrition. Currently, there's a deficit in objective and comprehensive nutritional assessment methods to evaluate the nutritional status and predicting the long-term outcomes of HFpEF patients.

Methods

Our retrospective study included two hundred and eighteen elderly HFpEF patients admitted to the cardiovascular ward at the Air Force Medical Centre from January 2016 to December 2021. Based on follow-up outcomes, patients were categorized into all-cause death (99 cases) and Survival (119 cases) groups. We compared general data, laboratory results, and nutritional indexes between groups. Differences in subgroups based on Triglyceride-Total Cholesterol-Body Weight Index (TCBI), Geriatric Nutritional Risk Index (GNRI), Prognostic Nutritional Index (PNI), and Controlled Nutrition Score (CONUT) were analyzed using Kaplan-Meier survival curves and log-rank test. COX regression was used to identify all-cause mortality risk factors, and the predictive accuracy of the four nutritional indices was assessed using receiver operating characteristic (ROC) curves and Delong test analysis.

Results

A total of 101 (45.41%) HFpEF patients experienced all-cause mortality during 59.02 ± 1.79 months of follow-up. The all-cause mortality group exhibited lower GNRI and PNI levels, and higher CONUT levels than the Survival group (p < 0.05). Kaplan-Meier analysis revealed lower cumulative survival in the low GNRI ( ≤ 96.50) and low PNI ( ≤ 43.75) groups, but higher in the low CONUT ( ≤ 2) group, compared to their respective medium and high-value groups. Multifactorial COX regression identified low PNI ( ≤ 43.75) as an independent all-cause mortality risk factor in elderly HFpEF patients. ROC and Delong's test indicated PNI (area under the curve [AUC] = 0.698, 95% confidence interval [CI] 0.629-0.768) as a more effective predictor of all-cause mortality than TCBI (AUC = 0.533, 95% CI 0.456-0.610) and CONUT (AUC = 0.621, 95% CI 0.547-0.695; p < 0.05). However, there was no significant difference compared to GNRI (AUC = 0.663, 95% CI 0.590-0.735; p > 0.05).

Conclusions

In elderly HFpEF patients a PNI ≤ 43.75 was identified as an independent risk factor for all-cause mortality. Moreover, PNI demonstrates superior prognostic performance in predicting all-cause mortality in elderly patients with HFpEF when compared to TCBI, GNRI, and COUNT.

Is self-screening for 'at risk of malnutrition' feasible in a home setting?

INTRODUCTION

Despite malnutrition being established as a well-known risk for postoperative complications, the lack of screening for nutritional risk remains a challenge. The aim of this study was to investigate whether self-screening for nutritional risk prior to surgery is feasible in a home setting and if it will increase number of patients screened for nutritional risk, and secondly, to compare their screening results with the "in-hospital assessments" conducted by healthcare professionals.

MATERIALS AND METHODS

This was a prospective study involving patients from six randomly selected surgical wards at two Norwegian hospitals as a part of the "Feasibility study of implementing the surgical Patient Safety Checklist the (PASC)". This checklist included a self-reported screening tool based on the Nutritional Risk Screening tool (NRS 2002) to identify "at risk of malnutrition" in patients that will undergo surgery the next 3 months or less. The original screening tool (NRS 2002) was used as a standard routine to identify "at risk of malnutrition" by healthcare professionals at hospital. The interrater reliability between these results was investigated using Fleiss multi rater Kappa with overall agreement and reported with Landis and Koch's grading system (poor, slight, fair, moderate, substantial, and almost perfect).

RESULTS

Out of 215 surgical patients in the home setting, 164 (76.7%) patients completed the self-reported screening tool. A total of 123 (57.2%) patients were screened in-hospital, of whom 96 (44.7%) prior to surgery and 96 (44.7%) were screened both at hospital (pre- and post-surgery) and at home. Self-screening at home improved malnutrition screening participation by 71.9% compared to hospital screening prior to surgery (165 (76.7%) and 96 (44.7%), respectively) and by 34.1% compared to pre- and postoperative in-hospital screening, 165 (76.7%) and 123 (57.2%), respectively). The degree of agreement between patients identified to be "at risk of malnutrition" by the self-reported screening tool and healthcare professionals was poor (κ = - 0.04 (95% CI: -0.24, 0.16), however, the degrees of agreement between the patients and healthcare professionals answers to the initial NRS 2002 questions "low BMI", "weight loss", and "reduced food intake" were almost perfect (κ = 1.00 (95% CI: 0,82, 1.18)), moderate (κ = 0.55 (95% CI: 0.34, 0.75)), and slight (κ = 0.08 (95% CI: - 0.10, 0.25) respectively.

CONCLUSIONS

Three out of four patients completed the self-screening form and the preoperative screening rate improved with 70%. Preoperatively self-screening in a home setting may be a feasible method to increase the number of elective surgical patients screened for risk of malnutrition.

TRIAL REGISTRATION

The trial is registered in ClinicalTrials.gov ID NCT03105713. https://classic.clinicaltrials.gov/ct2/show/NCT03105713.

ESPEN practical guideline: Nutritional support for polymorbid medical inpatients

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

AIM

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

DESIGN

Retrospective cohort study.

METHODS

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

RESULTS

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

CONCLUSION

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

RELEVANCE IN CLINICAL PRACTICE

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

IMPACT

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

REPORTING METHOD

We adhered to the STROBE Checklist for cohort studies.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Dietary Provision, GLIM-Defined Malnutrition and Their Association with Clinical Outcome: Results from the First Decade of nutritionDay in China

Malnutrition is a common and serious issue that worsens patient outcomes. The effects of dietary provision on the clinical outcomes of patients of different nutritional status needs to be verified. This study aimed to identify dietary provision in patients with eaten quantities of meal consumption and investigate the effects of dietary provision and different nutritional statuses defined by the GLIM criteria on clinical outcomes based on data from the nutritionDay surveys in China. A total of 5821 adult in-patients from 2010 to 2020 were included in this study's descriptive and Cox regression analyses. Rehabilitation and home discharge of 30-day outcomes were considered a good outcome. The prevalence of malnutrition defined by the GLIM criteria was 22.8%. On nutritionDay, 51.8% of all patients received dietary provisions, including hospital food and a special diet. In multivariable models adjusting for other variables, the patients receiving dietary provision had a nearly 1.5 higher chance of a good 30-day outcome than those who did not. Malnourished patients receiving dietary provision had a 1.58 (95% CI [1.36-1.83], p < 0.001) higher chance of having a good 30-day outcome and had a shortened length of hospital stay after nutritionDay (median: 7 days, 95% CI [6-8]) compared to those not receiving dietary provision (median: 11 days, 95% CI [10-13]). These results highlight the potential impacts of the dietary provision and nutritional status of in-patients on follow-up outcomes and provide knowledge on implementing targeted nutrition care.

Adequate calorie and protein administration via enteral nutrition may contribute to improved 30-day survival in patients with solid tumors at nutritional risk

BACKGROUND

Patients with cancer receiving adequate enteral nutrition (EN) have improved clinical outcomes. Unfortunately, discrepancies may exist between the amounts prescribed and received. This study aimed to investigate: (1) the receiving exclusive EN, (2) the relationship between inadequacy and unfavorable outcomes, and (3) the impact of inadequate EN administration on the survival of patients with cancer.

METHODS

This study included hospitalized patients with solid tumors who exclusively received EN and were evaluated using data extracted from electronic medical records. Nutritional risk was evaluated using Nutritional Risk Screening (NRS - 2002). EN adequacy was assessed from days 3-7 of hospitalization. Calorie and protein delivery by EN was classified as adequate (≥80 % of EN administration) or inadequate (<80 % of EN administration). Data were analyzed using dispersion and Bland-Altman plots, Pearson's chi-square and Fisher's exact tests, and Kaplan-Meier survival curves.

RESULTS

A total of 114 patients were evaluated (63.9 ± 13.1 years of age, 67.5 % male, 32.5 % with head and neck cancer, and 86.8 % at nutritional risk). During the 5-day evaluation period, only 14 % of the patients received the mean volume, proteins, and calories according to the EN prescription. A relationship was observed between inadequate EN (<80 %) and 30-day in-hospital mortality. This result was confirmed by Kaplan-Meier survival analysis (p = 0.020), which showed a survival benefit in patients at nutritional risk who received adequate calories and protein.

CONCLUSION

This study demonstrated significant caloric and protein deficits related with EN. Furthermore, adequate calorie and protein administration could contribute to improved survival in patients with cancer who are at a risk of malnutrition, however, randomized controlled trials are required to confirm whether adequate calorie administration could contribute to improved survival.

Long-term association between malnutrition and all-cause mortality among older adults: A 10-years follow-up study

BACKGROUND & AIMS

Prior studies have shown an association between malnutrition and mortality. However, it is uncertain whether malnutrition assessed with the Mini Nutritional Assessment (MNA) instrument is suitable for providing long-term prognostic information regarding older adults admitted to hospital. The aim of the present study was to examine if MNA-assessed malnutrition was associated with long-term mortality in older adults admitted to hospital and for how long the association persisted.

METHODS

1768 older adults (≥65 years old) admitted to a Swedish hospital were assessed with the 18-item MNA during 2008-2009 and followed-up after 10 years. All-cause mortality (ACM) was analyzed separately for the five follow-up periods 0 to ≤2 years, >2 to ≤4 years, >4 to ≤6 years, >6 to ≤8 years, and >8 to ≤10 years using Cox regression models adjusted for important demographic, nutritional, and clinical confounders.

RESULTS

The participants were on average 78.1 years old at baseline, with 56.0% being females. At 10 years follow-up, 174 (94.1%) malnourished patients, 757 (75.9%) patients at risk of malnutrition, and 297 (50.7%) well-nourished patients had died. For all follow-up periods, malnourished patients and patients at risk of malnutrition had significantly higher risks of early death in the adjusted regression analyses when compared with well-nourished patients (all P < 0.05), with the highest risk observed for malnourished patients. For patients still alive at 8 years, the risk of death during the following two years was 2.7 times higher for patients being malnourished at baseline (P = 0.013) and 1.9 times higher for patients being at risk of malnutrition at baseline (P = 0.001), compared with patients being well-nourished at baseline.

CONCLUSIONS

MNA-assessed malnutrition is an important independent predictor of long-term mortality in older adults admitted to hospital and the association is consistent over 10 years of follow-up. In clinical practice, MNA may provide long-term prognostic information to rule out those at low risk of mortality and therefore in less need of further assessment and intervention, such that the resources can focus on those in actual need of nutritional support.

National Trends in Mortality and Urgent Dialysis after Acute Hypertension in Japan From 2010 Through 2019

BACKGROUND

Despite increasing incidences of hypertension, recent trends in mortality and urgent dialysis following acute hypertension (AHT) remain undetermined.

METHODS

This retrospective observational cohort study evaluated 50 316 hospitalized AHT patients from 2010 to 2019, using an administrative claims database in Japan. We examined trends in incidence, urgent dialysis, mortality, and its risk factors using Poisson regression models. Using International Classification of Disease and Related Health Problems, 10th Revision codes, AHT was categorized into 5 spectrums: malignant hypertension (n=1792), hypertensive emergency (n=17 907), hypertensive urgency (n=1562), hypertensive encephalopathy (n=6593), and hypertensive heart failure (HHF; n=22 462).

RESULTS

The median age of the patients was 76 years, and 54.9% were women. The total AHT incidence was 70 cases per 100 000 admission year. The absolute death rate increased from 1.83% (95% CI, 1.40-2.40) to 2.88% ([95% CI, 2.42-3.41]; Cochran-Armitage trend test, P<0.0001). Upward trends were observed in patients aged ≥80, with lean body mass index ≤18.4, and with HHF. Urgent dialysis rates increased from 1.52% (95% CI, 1.12-2.06) to 2.60% (2.17-3.1; Cochran-Armitage trend test; P=0.0071) in 48 235 patients, excluding maintenance dialysis patients. Older age, men, lean body mass, malignant hypertension, HHF, and underlying chronic kidney disease correlated with higher mortality risk; greater hospital volume correlated with lower mortality risk; and malignant hypertension, HHF, diabetes, chronic kidney disease, and scleroderma correlated with a higher risk of urgent dialysis.

CONCLUSIONS

Mortality and urgent dialysis rates following AHT have increased. Aging, complex comorbidities, and HHF-type AHT contributed to the rising trend of mortality.

Review of Diet Protocols Following Orthognathic Surgery and Analysis of Postoperative Weight Loss

INTRODUCTION

Orthognathic surgery is routinely practiced, yet little comparative data exists to evaluate post-orthognathic surgery diet protocols.

OBJECTIVE

To evaluate which postoperative diet protocols are recommended and to quantify post-orthognathic surgery weight changes in our institutional cohort.

METHODS

An internet search was carried out on Google for "orthognathic surgery diet" and the postoperative diet recommendations from centers worldwide were quantified. Additionally, a retrospective analysis of patients that underwent orthognathic surgery at our institution was performed, and their preoperative and postoperative weights were recorded.

RESULTS

The internet search yielded 58 centers that met our inclusion criteria. Most centers were in the United States (n = 37, 63.8%) and were oral and maxillofacial surgeon (OMFS)-led centers (n = 39, 67.2%). Postoperative diets were categorized into 7 distinct protocols, ranging from most to least restrictive-the most popular was liquid diet for 2 to 4 weeks followed by soft diet for 2 to 6 weeks. There were no significant patterns observed across different geographical regions or specialties.In our institution, 135 patients were identified. Overall, there was an average maximum weight loss of 4.1 kg by week 4, followed by a gradual increase in weight. Linear regression analysis showed that patients with greater preoperative body mass index (BMI) lost more weight postoperatively than patients with lower BMI (R2 = 0.25, P < .001).

CONCLUSION

There is a significant variability in recommended postoperative diets following orthognathic surgery. Following a moderately restrictive diet at our institution, patients returned to their preoperative weight after approximately 4 months.

Effects of malnutrition on outcomes of patients with femoral head osteonecrosis undergoing total hip arthroplasty: A population-based study

BACKGROUND

This study aimed to evaluate the impact of malnutrition on in-hospital outcomes in patients undergoing total hip arthroplasty (THA) for osteonecrosis of the femoral head (ONFH).

METHODS

This population-based retrospective study extracted data of patients undergoing THA for ONFH in the US National Inpatient Sample between 2005 and 2018. Factors associated with in-hospital mortality, medical and surgical complications, unfavorable discharge, and prolonged hospital stay were determined by logistic regression analysis.

RESULTS

A total of 72,304 adults ≥18 years old with nontraumatic ONFH admitted for primary THA were included. Malnutrition was detected in 7152 (9.9%) patients using validated discharge codes. In-hospital mortality was 0.8% vs 0.1% for patients who were malnourished vs nonmalnourished. After adjusting for confounders, malnutrition was significantly associated with an increased risk of in-hospital death (adjusted odds ratio [aOR], 4.67; 95% CI, 2.43-8.97), medical complications (aOR, 1.49; 95% CI, 1.32-1.68), surgical complications (aOR, 1.78; 95% CI, 1.61-1.96), unfavorable discharge (aOR, 1.24; 95% CI, 1.11-1.39), and prolonged hospital stay (aOR, 1.90; 95% CI, 1.67-2.16) compared with adequate nutrition. Malnutrition was also associated with higher total hospital costs (adjusted β = $9620; 95% CI, 7.87-11.36). Furthermore, the association between malnutrition, any medical or surgical complications, and unfavorable discharge was stronger in patients younger than 50 years than those ≥50 years old.

CONCLUSIONS

In US patients undergoing primary THA for ONFH, malnutrition increases the risk of unfavorable in-hospital outcomes. This patient subgroup may require special attention and better strategies to improve perioperative care.

ESPEN guideline on nutritional support for polymorbid medical inpatients

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Geriatric Nutritional Risk Index and Risk of Mortality in Critically Ill Patients With Acute Kidney Injury: A Multicenter Cohort Study

OBJECTIVES

Malnutrition is associated with adverse outcomes in acute or chronic diseases. However, the prediction value of the Geriatric Nutritional Risk Index (GNRI) in critically ill patients with acute kidney injury (AKI) has not been well studied.

METHODS

Data was extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) and the electronic intensive care unit database. We used two nutritional indicators, the GNRI and the modified Nutrition Risk in Critically ill (NUTRIC) score, to evaluate the relationship between the nutritional status of patients with AKI and prognosis. The outcome is in-hospital mortality and 90-day mortality. The prediction accuracy of GNRI was compared with the NUTRIC score.

RESULTS

A total of 4,575 participants with AKI were enrolled in this study. The median age of 68 (interquartile range, 56-79) years, and 1,142 (25.0%) patients experienced in-hospital mortality, and 1,238 (27.1%) patients experienced 90-day mortality. Kaplan-Meier survival analysis indicated that lower GNRI levels and high NUTRIC score are associated with lower in-hospital and 90-day survival of patients with AKI (P < .001 by log-rank test). After multivariate adjustment, Cox regression analysis demonstrated a 2-fold increased risk of in-hospital (hazard ratio = 2.019, 95% confidence interval: 1.699-2.400, P < .001) and 90-day (hazard ratio = 2.023, 95% confidence interval: 1.715-2.387, P < .001) mortality in the low GNRI group. Moreover, the multivariate-adjusted Cox model containing GNRI had higher prediction accuracy for the prognosis of patients with AKI than that with NUTRIC score (AUCGNRI model vs. AUCNUTRIC model for in-hospital mortality = 0.738 vs. 0.726, AUCGNRI model vs. AUCNUTRIC model for 90-day mortality = 0.748 vs. 0.726). In addition, the prediction value of GNRI was validated by the electronic intensive care unit database (7,881 patients with AKI) with satisfying performance (AUCGNRI model = 0.680).

CONCLUSIONS

Our results demonstrated that GNRI is strongly associated with survival in patients in the intensive care unit coexisting with AKI, and the GNRI has a superior predictive value than the NUTRIC score.

Malnutrition risk prevalence in hospitalised patients in Castilla-La Mancha: Ten years after the PREDyCES® study

INTRODUCTION

The PREDyCESR study showed ten years ago that malnutrition is a highly prevalent problem at the hospital level. In the present study we investigate the prevalence of malnutrition in hospitals of Castilla La Mancha and its relationship with complications, mortality and length of hospital stay.

METHODS

433 patients (236 men and 197 women), from 4 hospitals were included and randomised within the first 48 h of admission. Nutritional risk was assessed using the NRS-2002 screening test.

RESULTS

The mean age of the patients was 71.3 ± 0.9 years (alpha-trimmed mean ± insorized standard deviation). Their mean weight was 72.3 ± 0.8 kg and BMI 26.8 ± 0.3 kg/m2. The mean length of hospital stay was 7.2 ± 0.3 days. Of the 433 study patients, 19.4% were defined as 'at-risk' by NRS-2002 > 3. Of the patients at risk, 39.3% received nutritional support. Patients at nutritional risk had an increased length of hospital stay (9.6 vs 6.8 days; p = 0.012) and had more complications and/or higher mortality (40.5% of complications and/or mortality vs 16.4%; p < 0.005). The OR of having a complication and/or death was 3.93 (95% CI: 2.36-6.5); p < 0.005. Regarding the results obtained in the PREDyCES® study, no significant differences were found in the prevalence of nutritional risk at patients' admission (19.4% vs 23%; p = 0.12).

CONCLUSIONS

The nutritional risk at hospital admission continues to be high. Patients at nutritional risk have more complications, higher mortality and an increased length of hospital stay.

Prevalence and Impact of Malnutrition in Hospitalizations Among Celiac Diseases: A Nationwide Analysis

BACKGROUND/AIMS

Celiac disease (CD) is a T-cell-mediated gluten sensitivity that results in villous atrophy in the small intestine, leading to chronic malabsorption. Patients with celiac disease are prone to malnutrition. We assessed the impact of malnutrition on in-hospital outcomes in patients with CD.

MATERIALS AND METHODS

Patients with a primary discharge diagnosis of CD between January 2016 and December 2019 were included in the National Inpatient Sample Database. Data were collected on patient demographics, hospital characteristics, the Charlson Comorbidity Index (CCI), and concomitant comorbidities. The association between malnutrition and outcomes, including mortality, deep vein thrombosis (DVT), pulmonary embolism (PE), sepsis, acute kidney injury (AKI), length of stay (LOS), and total hospitalization charges (THC), was analyzed using the multivariate regression model.

RESULTS

A total of 187310 patients with CD were included in the analysis. Patients with CD and malnutrition had a higher risk of mortality (adjusted odds ratio [aOR], 2.08; p<0.001), AKI (aOR=1.18, p=0.003), and DVT (aOR=1.53; p<0.001) compared to patients with CD without malnutrition. No significant difference was noted in the rates of sepsis and PE. Patients with malnutrition also had a prolonged LOS (2.89 days; p<0.001) and higher THC ($22252.18; p<0.001) compared to patients without malnutrition.

DISCUSSION

Patients with CD and malnutrition are at high risk of worse outcomes. Early identification of malnutrition in CD can help prevent morbidity and mortality. Even strict adherence to a gluten-free diet has been associated with malnutrition. Further studies identifying factors associated with malnutrition in CD and the impact of interventions to prevent and treat malnutrition are encouraged.

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

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

Physical Performance and Falling Risk Are Associated with Five-Year Mortality in Older Adults: An Observational Cohort Study

Background: Falls in older people have a significant impact on public health. The scientific literature has provided evidence about the necessity for older adults to be physically active, since it reduces the incidence of falls, several diseases, and deaths, and can even slow down some effects of aging. The primary aim of our study is to identify if physical performances and risk of falling are related to 1-, 2-, 3-, 4-, and 5-year mortality. Its secondary aim is to establish if people with both severely impaired physical performance and a high risk of falling also present impairment in other geriatric domains. Methods: In this prospective study, we enrolled subjects aged 65 years or more, subjected them to comprehensive assessment (including assessment of risk of falling, physical capacities, comorbidities, autonomies in daily living, cognitive abilities, mood, and nutritional status), and followed them for 5 years. Results: We included 384 subjects, 280 of whom were women (72.7%), with a median age of 81 years. Our results showed that physical performances and risk of falling are highly correlated to each other (rho = 0.828). After divided the sample into three groups (people without augmented risk of falling and able to perform adequate physical activity; people with moderate risk of falling and/or disability; people with severe risk of falling and/or disability), we found that the more severe the disability and risk of falling were, the more compromised the other geriatric domains were. Moreover, the survival probability progressively increased following the same trend, amounting to only 41% in severely compromised people, 51.1% in moderately compromised people, and 62.8% in people without physical compromise nor an augmented falling risk (p = 0.0124). Conclusions: Poor physical performance combined with a high risk of falling, correlated with each other, are associated with higher mortality and impairment in multiple domains in older adults.

Impact of malnutrition and nutrition support in hospitalised patients with inflammatory bowel disease

BACKGROUND

Malnutrition is prevalent in patients with inflammatory bowel disease (IBD) and has been associated with worse clinical outcomes.

AIMS

This observational study examines trends in protein-calorie malnutrition (PCM) amongst hospitalised IBD and non-IBD patients, and the association between (1) malnutrition and (2) nutrition support and hospitalisation outcomes.

METHODS

We queried the Nationwide Readmissions Database from 2010 to 2018 for hospitalisations with and without IBD. Amongst patients with IBD and concurrent PCM, we identified those who received nutrition support. Multivariable Cox proportional hazards and Kaplan-Meier analyses evaluated the associations between PCM and nutrition support and readmission and mortality. Multiple linear regression described the association between compared variables and length of stay (LOS) and total hospitalisation costs.

RESULTS

This study included 1,216,033 patients (1,820,023 hospitalisations) with Crohn's disease (CD), 832,931 patients (1,089,853 hospitalizations) with ulcerative colitis (UC) and 240,488,656 patients (321,220,427 hospitalisations) without IBD. Admitted IBD patients were 2.9-3.1 times more likely to have PCM than non-IBD patients. IBD patients with PCM had a higher risk of readmission and mortality, as well as longer LOS and higher hospitalisation costs. Nutrition support (parenteral and enteral) was associated with a reduced risk of readmission, but higher mortality increased LOS and higher total hospitalisation costs.

CONCLUSIONS

Malnutrition in hospitalised IBD patients remains an important contributor to readmission, mortality, LOS and healthcare costs. Providing nutrition support to IBD patients may reduce the risk of readmission. Further studies are needed to evaluate the role of nutrition support amongst hospitalised IBD patients to optimise disease and healthcare outcomes.

Development and evaluation of a Massive Open Online Course (MOOC) for healthcare professionals on malnutrition in older adults

BACKGROUND

Education about malnutrition in older adults is often lacking in the curricula of healthcare professionals. Massive open online courses (MOOCs) are an innovative form of education that can potentially improve the knowledge of healthcare professionals.

OBJECTIVES

(1) to describe the development of a MOOC on malnutrition in older adults and (2) to evaluate the MOOC on the basis of knowledge gained.

DESIGN

The MOOC was developed by following a structured approach. For the evaluation of the MOOC, a cross-sectional descriptive study was conducted.

PARTICIPANTS

Overall, 1288 nurses, dietitians, medical doctors and other healthcare professionals participated in the evaluation study.

METHODS

After performing a comprehensive literature review, two dietitians specialised in geriatrics developed a summary of potentially important content of the MOOC. Nine European malnutrition experts from different professional areas were then asked to contribute their expertise. The specific MOOC content was developed based on the recent literature and evidence-based guidelines. For the evaluation of the MOOC, a questionnaire with 41 questions was developed. Results were analysed using descriptive statistics and chi-square tests.

RESULTS

The final MOOC consists of five modules with 15 learning videos and supplementary material. The percentage of persons with good malnutrition knowledge increased from 76.1 % to 89.9 % (p < 0.001), while the percentage of persons with fair or little malnutrition knowledge decreased (p < 0.001). The course significantly improved the participants' knowledge of specific malnutrition topics, namely, methods and instruments to determine the nutritional status of older people, interventions to improve oral intake, medical nutrition and multidisciplinary cooperation (p < 0.001). Overall, 91.5 % of the participants rated the quality of the course as very good or good.

CONCLUSION

MOOCs may be an effective tool that can be used to improve knowledge in healthcare professionals. This provides new opportunities for successful multidisciplinary malnutrition management in clinical practice.

The effects of dental visits on the occurrence of acute hospitalization for systemic diseases among patients aged 75 years or older: A propensity score-matched study

BACKGROUND

Although several studies examined the association between oral status and the risk of systemic diseases, few have examined whether dental visits affect the occurrence of acute hospitalization due to systemic diseases. This study examined the effects of dental visits on preventing the occurrence of acute hospitalization due to systemic diseases in adults aged ≥ 75 years, in order to optimize the healthcare system for older adults.

METHODS

This propensity-score-matched retrospective cohort study was conducted using medical insurance claims data from Hokkaido, Japan. We analyzed 432,292 adult outpatients aged ≥ 75 years between September 2016 and February 2017 (baseline period). The exposure variable was visits to the dental office during the baseline period. The primary outcome variable was the occurrence of acute hospitalization due to pneumonia, urinary tract infections, cerebrovascular diseases, or coronary heart diseases between March 2017 and March 2019.

RESULTS

Among the 432,292 patients before propensity score matching, 149,639 (34.6%) had visited the dental office. One-to-one propensity score matching produced 149,289 matched pairs adjusted for the differences in all covariables (age, sex, copayment rate, annual health checkup, chronic diseases, and residential area). In these matched pairs, the risk ratio of the occurrence of acute hospitalization due to pneumonia, urinary tract infections, and cerebrovascular diseases was lower among patients who had visited dental office than among those who did not.

CONCLUSIONS

Dental visits appeared to be effective in preventing acute hospitalization due to systemic diseases, thus, dental care services would be an important component of healthcare for older adults.

Importance of nutritional assessment tools in the critically ill patient: A systematic review

Background

Among the risks of the critically ill patient, one of the aspects to be taken into account is the high probability of occurrence of malnutrition risk (40-50%). This process leads to increased morbimortality and worsening. The use of assessment tools allows the individualization of care.

Objective

To analyze the different nutritional assessment tools used during the admission of critically ill patients.

Methods

Systematic review of the scientific literature related to the nutritional assessment of critically ill patients. Between January 2017 and February 2022, articles were rescued from the electronic databases "Pubmed," "Scopus," "CINAHL" and "The Cochrane Library"; which will analyze which instruments are used during nutritional assessment in the ICU, as well as their impact on mortality and comorbidity of patients.

Results

The systematic review was made up of 14 scientific articles that met the selection criteria, obtained from seven different countries. The instruments described were: mNUTRIC, NRS 2002, NUTRIC, SGA, MUST and the ASPEN and ASPEN criteria. All the included studies demonstrated beneficial effects after nutritional risk assessment. mNUTRIC was the most widely used assessment instrument, with the best predictive validity for mortality and adverse outcomes.

Conclusion

The use of nutritional assessment tools makes it possible to know the real situation of patients, and by objectifying situations, to allow different interventions to improve the nutritional level of patients. The best effectiveness has been achieved using tools such as mNUTRIC, NRS 2002 and SGA.

Rate and risk factors of in-hospital and early post-discharge mortality in patients admitted to an internal medicine ward

BACKGROUND

We sought to quantify in-hospital and early post-discharge mortality rates in hospitalised patients.

METHODS

Consecutive adult patients admitted to an internal medicine ward were prospectively enrolled. The rates of in-hospital and 4-month post-discharge mortality and their possible associated sociodemographic and clinical factors (eg Cumulative Illness Rating Scale [CIRS], body mass index [BMI], polypharmacy, Barthel Index) were assessed.

RESULTS

1,451 patients (median age 80 years, IQR 69-86; 53% female) were included. Of these, 93 (6.4%) died in hospital, while 4-month post-discharge mortality was 15.9% (191/1,200). Age and high dependency were associated (p<0.01) with a higher risk of in-hospital (OR 1.04 and 2.15) and 4-month (HR 1.04 and 1.65) mortality, while malnutrition and length of stay were associated (p<0.01) with a higher risk of 4-month mortality (HR 2.13 and 1.59).

CONCLUSIONS

Several negative prognostic factors for early mortality were found. Interventions addressing dependency and malnutrition could potentially decrease early post-discharge mortality.

Malnutrition among patients with Type-2 Diabetes Mellitus

Objectives

The present study aims to evaluate the nutritional status of diabetic patients using Subjective Global Assessment (SGA) tool.

Methods

A prospective cross-sectional study was conducted at Endocrine and Medicine Department of Lady Reading Hospital from September 2019 to March 2020. A total of 359 patients diagnosed with Type-2 Diabetes Mellitus (T2DM) were included in the study. The malnutrition status was assessed using SGA, and clinical parameters including albumin and total leukocyte count (TLC).

Results

We have observed mild to moderate malnutrition among 48.2% patients, and severe malnutrition in 10.6% patients as per the SGA scoring. Among the factors associated with nutritional status were BMI (p<0.01), and presence of CAD (DM complication) (p=0.015). As per the correlation analysis, BMI had a significant negative correlation with nutritional status (r=-0.351; p<0.01).

Conclusion

It is concluded from the study results that there is a high prevalence of malnutrition among the enrolled diabetic patients.

Improving Administration and Documentation of Enteral Nutrition Support Therapy in a Veteran Affairs Health Care System: Use of Medication Administration Record and Bar Code Scanning Technology

OBJECTIVES

The goal of this project was to evaluate and improve the ordering, administration, documentation, and monitoring of enteral nutrition therapies within the inpatient setting in a Veteran's Health Administration system.

METHODS

An interdisciplinary team of clinicians reviewed the literature for best practices and revised the process for enteral nutrition support for hospitalized veterans. Interventions included training staff, revising workflows to include scanning patients and products, including enteral nutrition orders within the medication administration record (MAR), and using the existing bar code medication administration system for administration, documentation, and monitoring. Baseline and postprocess improvement outcomes over a year period were collected and analyzed for quality improvement opportunities.

RESULTS

Before process change, only 60% (33/55) of reviewed enteral nutrition orders were documented and 40% (22/55) were not documented in the intake flowsheet of the electronic health record. In the year after adding enteral nutrition therapies to the MAR and using bar code scanning, a total of 3807 enteral nutrition products were evaluated. One hundred percent of patients were bar code scanned, 3106/3807 (82%) products were documented as given, 447/3807 (12%) were documented as held (with comments), 12/3807 (<1%) were documented as missing/unavailable, and 242/3807 (6%) were documented as refused.

CONCLUSIONS

Inclusion of enteral nutrition order sets on the MAR and using bar code scanning technology resulted in sustained improvements in safety, administration, and documentation of enteral therapies for hospitalized veterans.

HOMEFOOD Randomised Trial - Six-Month Nutrition Therapy in Discharged Older Adults Reduces Hospital Readmissions and Length of Stay at Hospital Up to 18 Months of Follow-Up

BACKGROUND

Malnutrition is frequently observed in older adults and is associated with hospital readmissions, length of stay (LOS), and mortality in discharged patients.

OBJECTIVE

The aim of this study was to investigate effects of six-month nutrition therapy on hospital readmissions, LOS, mortality and need for long-term care residence 1-, 6-, 12- and 18-months post-discharge in older Icelandic adults.

DESIGN

Secondary analysis of a randomized controlled trial.

PARTICIPANTS

Participants (>65 years) were randomised into intervention (n=53) and control (n=53) before discharge from a geriatric unit.

INTERVENTION

The intervention group received nutrition therapy based on the Nutrition Care Process, including home visits, phone calls, freely delivered energy- and protein-rich foods and supplements for six months after hospital discharge.

MEASUREMENTS

The Icelandic electronic hospital registry was accessed to gain information on emergency room visits (ER), hospital readmissions, LOS, mortality and need for long-term care residence.

RESULTS

The intervention group had a lower proportion of participants with at least one readmission compared to control (1 month: 1.9% vs 15.8%, P=0.033; 6 months: 25.0% vs 46.2%, P=0.021; 12 months: 38.5% vs 55.8%, P=0.051; and 18 months: 51.9% vs 65.4%, P=0.107). There was also a lower total number of readmissions per participant (1 month: 0.02 vs 0.19, P=0.015; 6 month: 0.33 vs 0.77, P=0.014; 0.62 vs 1.12, P=0.044) and a shorter LOS (1 month: 0.02 vs 0.92, P=0.013; 6 months: 2.44 vs 13.21; P=0.006; 12 months: 5.83 vs 19.40, P=0.034; 18 months: 10.42 vs 26.00, P=0.033) in the intervention group. However, there were no differences between groups in ER visits, mortality and need for long-term care residence.

CONCLUSION

A six-month nutrition therapy in older Icelandic adults discharged from hospital reduced hospital readmissions and shortens LOS at the hospital up to 18-months post-discharge. However, it did neither affect mortality, ER, nor need of long-term care residence in this group.

Prediction of 30-Day Readmission in Hospitalized Older Adults Using Comprehensive Geriatric Assessment and LACE Index and HOSPITAL Score

(1) Background: Elders have higher rates of rehospitalization, especially those with functional decline. We aimed to investigate potential predictors of 30-day readmission risk by comprehensive geriatric assessment (CGA) in hospitalized patients aged 65 years or older and to examine the predictive ability of the LACE index and HOSPITAL score in older patients with a combination of malnutrition and physical dysfunction. (2) Methods: We included patients admitted to a geriatric ward in a tertiary hospital from July 2012 to August 2018. CGA components including cognitive, functional, nutritional, and social parameters were assessed at admission and recorded, as well as clinical information. The association factors with 30-day hospital readmission were analyzed by multivariate logistic regression analysis. The predictive ability of the LACE and HOSPITAL score was assessed using receiver operator characteristic curve analysis. (3) Results: During the study period, 1509 patients admitted to a ward were recorded. Of these patients, 233 (15.4%) were readmitted within 30 days. Those who were readmitted presented with higher comorbidity numbers and poorer performance of CGA, including gait ability, activities of daily living (ADL), and nutritional status. Multivariate regression analysis showed that male gender and moderately impaired gait ability were independently correlated with 30-day hospital readmissions, while other components such as functional impairment (as ADL) and nutritional status were not associated with 30-day rehospitalization. The receiver operating characteristics for the LACE index and HOSPITAL score showed that both predicting scores performed poorly at predicting 30-day hospital readmission (C-statistic = 0.59) and did not perform better in any of the subgroups. (4) Conclusions: Our study showed that only some components of CGA, mobile disability, and gender were independently associated with increased risk of readmission. However, the LACE index and HOSPITAL score had a poor discriminating ability for predicting 30-day hospitalization in all and subgroup patients. Further identifiers are required to better estimate the 30-day readmission rates in this patient population.

Assessment of Nutritional Status and Risk of Malnutrition Using Adapted Standard Tools in Patients with Mental Illness and in Need of Intensive Psychiatric Treatment

People with severe mental illness (SMI) are often in poor physical health, resulting in higher mortality and reduced life expectancy compared to the general population. Although eating habits are one of the main predictors of physical health, few studies assess the nutritional status and eating behavior of people with SMI. The aim of this study was to examine the nutritional status and risk of malnutrition in people with SMI who were in need of intensive psychiatric treatment. The cross-sectional study included 65 inpatients and 67 outpatients with psychotic or depressive disorders from the Psychiatric Hospital of the University of Zurich. Patients' assessments at admission included anthropometric measurements, such as weight and height, and interview data including severity of symptoms and functioning (SCL-K-9, PHQ-D, CGI, m-GAF), personal and medical data, nutrition risk screening tools (adapted NRS, MNA-SF), and laboratory values. The results showed that 32% of the inpatients and 34% of the outpatients were at risk of malnutrition, which was associated with higher levels of psychiatric symptoms and lower levels of functioning. Regardless, the body mass index (BMI) was overweight in both groups (mean BMI_inpatients = 25.3, mean BMI_outpatients = 27.9). These results indicate that a substantial proportion of psychiatric patients seems to be at risk of malnutrition, despite most being overweight, and hence they might benefit from nutritional support during their psychiatric treatment. Moreover, nutritional risk screening tools specifically developed for the mental healthcare setting are needed.

The impact of pre-transplant weight loss on survival following cardiac transplantation

BACKGROUND

Significant weight loss due to cardiac cachexia is an independent predictor of mortality in many heart failure (HF) clinical trials. The impact of significant weight loss while on the waitlist for heart transplant (HT) has yet to be studied with respect to post-transplant survival.

METHODS

Adult HT recipients from 2010 to 2021 were identified in the UNOS registry. Patients who experienced an absolute weight change from the time of listing to transplant were included and classified into two groups by percent weight loss from time of listing to time of transplant using a cut-off of 10%. The primary endpoint was 1-year survival following HT.

RESULTS

5951 patients were included in the analysis, of whom 763 (13%) experienced ≥10% weight loss from the time of listing to transplant. Weight loss ≥ 10% was associated with reduced 1-year post-transplant survival (86.9% vs. 91.0%, long-rank p = .0003). Additionally, weight loss ≥ 10% was an independent predictor of 1-year mortality in a multivariable model adjusting for significant risk factors (adjusted HR 1.23, 95% CI 1.04-1.46). In secondary analyses, weight loss ≥ 10% was associated with reduced 1-year survival independent of hospitalized status at time of transplant as well as obesity status at listing (i.e., body mass index [BMI] < 30 kg/m2 and BMI ≥ 30 kg/m2 ).

CONCLUSIONS

Preoperative weight loss ≥ 10% is associated with reduced survival in patients listed for HT. Nutrition interventions prior to transplant may prove beneficial in this population.

Absence of oral nutritional support in low food intake inpatients is associated with an increased risk of hospital-acquired pressure injury

BACKGROUND & AIMS

Hospital-acquired pressure injury (HAPI) incidence is a common burden in hospitals. Decreased food intake leading to malnutrition compromises body tissues involved in pressure injury occurrence. However, most tools for predicting pressure injuries do not include daily food intake monitoring nor consider further nutritional interventions. This study aimed to investigate clinical practices for food intake monitoring and its association with predicting HAPI risk, together with Norton Scale use, and whether the initiation or absence of oral nutritional supplements (ONS), separately from other nutritional interventions, was associated with HAPI incidence in low food intake inpatients, who consumed less than 50% of requirements.

METHODS

This observational cohort study covered a one-year period (08/2018-07/2019). Demographic and clinical data were extracted from computerized files of patients hospitalized ≥7 days, aged ≥60 years, and who ate orally. Patients receiving enteral or parenteral nutrition were excluded. Differences were studied between groups without and with HAPI grade ≥2. Subgroups divided by Norton Scale and intake, Norton Scale and albumin levels, food intake and initiation (or not) of any nutritional intervention versus ONS only, were examined for the consistency of association with HAPI.

RESULTS

Of the 5155 admissions during the study period, 895 patients fulfilled the inclusion criteria: 48% female, mean age 77.6 ± 9.1 years, 11% with MUST score ≥2. Nutritional intake was reported in 76% of patients, of them 22% had low food intake, and 9% of the study group developed HAPI grade ≥2. Regarding HAPI incidence, no differences were found between groups divided by MUST scores. Independent risk factors significantly associated with HAPI were Norton <14, albumin levels <3 g/dl, and low food intake. Not providing ONS in low food intake patients had an adjusted 3.49-fold (95%CI 1.57-7.75) increase in HAPI risk (6-fold for non-adjusted relative risk).

CONCLUSION

Failure to initiate ONS as part of nutritional support in low food intake patients is associated with high HAPI risk in these patients. Consequently, monitoring of daily food intake for identifying low intake patients should be integrated into routinely used tools such as the Norton Scale, and adherence to nutritional protocols should be addressed.

The dilemma in management of desmoid tumour: A case report

Introduction

Desmoid tumours are rare benign tumours. The tumours may develop sporadically or they may be linked to familial adenomatous polyposis (FAP) in Gardner’s syndrome.

Aim

This article highlights a young lady with an intra-abdominal desmoid tumour that manifested as an acute abdomen and we discuss our management strategy.

Case study

A 24-year-old lady with a known FAP who had undergone a panproctocolectomy with an ileal pouch-anal anastomosis and total thyroidectomy, later was complicated with acute abdomen for symptomatic desmoid tumour. Computed tomography of the abdomen showed a large intraperitoneal heterogenous mass with small bowel displacement and was confirmed by magnetic resonance imaging. An exploratory laparotomy and en-bloc resection of the tumour with an end ileostomy were performed.

Results and discussion

Intra-abdominal desmoid tumours usually present as a painless slow-growing mass, however, in severe form, it can cause bowel ischemia, intestinal obstruction, or deterioration of function in the ileoanal anastomosis, among post total colectomy. Surgery is indicated upfront in specific clinical scenarios namely complications (occlusion, perforation, or bleeding) or major cosmetic issues.

Conclusions

Desmoid tumour, despite being benign, is challenging to manage due to its compressing nature. As a key point, the diagnosis of a desmoid tumour should be suspected and followed up closely in patients with a previous history of FAP in combination with extracolonic manifestation.

Association between anemia and depression: The 2014, 2016, and 2018 Korea National Health and Nutrition Examination Survey

BACKGROUND

Several studies have reported an association between anemia and depression. However, whether anemia is independently associated with depression remains controversial. The current study aimed to investigate the association between anemia and depression according to sex in a large national sample population.

METHODS

Data from the 2014, 2016, and 2018 Korean National Health and Nutrition Examination Survey were analyzed, and 15,472 participants were included in this study. Anemia was defined as a hemoglobin level <13 g/dL in men and <12 g/dL in women. We defined a Patient Health Questionnaire-9 score ≥10 as depression and ≥5 as mild depressive symptoms.

RESULTS

The prevalence of depression was significantly higher in women with anemia than in women without anemia (8.9 % vs. 7.0 %, P = 0.036). In women, anemia was significantly associated with depression after adjusting all covariates in multilevel logistic regression analysis (odds ratio, 1.37; 95 % confidence interval, 1.08-1.75; P = 0.011). However, no significant association was observed in men.

LIMITATIONS

There is a limit to explaining the causal direction, and several factors may not have been considered as confounders. Also, patients with severe diseases were excluded from data acquisition. A structured diagnostic interview, other than the self-report method, was not conducted.

CONCLUSIONS

The findings of this study suggest that anemia is associated with depression in women but not in men. A decrease in tissue oxygenation, deterioration of physical performance due to anemia, and altered monoamine synthesis due to malnutrition may have an effect on depression.

Individualised Nutritional Care for Disease-Related Malnutrition: Improving Outcomes by Focusing on What Matters to Patients

Delivering care that meets patients' preferences, needs and values, and that is safe and effective is key to good-quality healthcare. Disease-related malnutrition (DRM) has profound effects on patients and families, but often what matters to patients is not captured in the research, where the focus is often on measuring the adverse clinical and economic consequences of DRM. Differences in the terminology used to describe care that meets patients' preferences, needs and values confounds the problem. Individualised nutritional care (INC) is nutritional care that is tailored to a patient's specific needs, preferences, values and goals. Four key pillars underpin INC: what matters to patients, shared decision making, evidence informed multi-modal nutritional care and effective monitoring of outcomes. Although INC is incorporated in nutrition guidelines and studies of oral nutritional intervention for DRM in adults, the descriptions and the degree to which it is included varies. Studies in specific patient groups show that INC improves health outcomes. The nutrition care process (NCP) offers a practical model to help healthcare professionals individualise nutritional care. The model can be used by all healthcare disciplines across all healthcare settings. Interdisciplinary team approaches provide nutritional care that delivers on what matters to patients, without increased resources and can be adapted to include INC. This review is of relevance to all involved in the design, delivery and evaluation of nutritional care for all patients, regardless of whether they need first-line nutritional care or complex, highly specialised nutritional care.

Individualised Nutritional Care for Disease-Related Malnutrition: Improving Outcomes by Focusing on What Matters to Patients

Delivering care that meets patients' preferences, needs and values, and that is safe and effective is key to good-quality healthcare. Disease-related malnutrition (DRM) has profound effects on patients and families, but often what matters to patients is not captured in the research, where the focus is often on measuring the adverse clinical and economic consequences of DRM. Differences in the terminology used to describe care that meets patients' preferences, needs and values confounds the problem. Individualised nutritional care (INC) is nutritional care that is tailored to a patient's specific needs, preferences, values and goals. Four key pillars underpin INC: what matters to patients, shared decision making, evidence informed multi-modal nutritional care and effective monitoring of outcomes. Although INC is incorporated in nutrition guidelines and studies of oral nutritional intervention for DRM in adults, the descriptions and the degree to which it is included varies. Studies in specific patient groups show that INC improves health outcomes. The nutrition care process (NCP) offers a practical model to help healthcare professionals individualise nutritional care. The model can be used by all healthcare disciplines across all healthcare settings. Interdisciplinary team approaches provide nutritional care that delivers on what matters to patients, without increased resources and can be adapted to include INC. This review is of relevance to all involved in the design, delivery and evaluation of nutritional care for all patients, regardless of whether they need first-line nutritional care or complex, highly specialised nutritional care.

Individualised Nutritional Care for Disease-Related Malnutrition: Improving Outcomes by Focusing on What Matters to Patients

Delivering care that meets patients’ preferences, needs and values, and that is safe and effective is key to good-quality healthcare. Disease-related malnutrition (DRM) has profound effects on patients and families, but often what matters to patients is not captured in the research, where the focus is often on measuring the adverse clinical and economic consequences of DRM. Differences in the terminology used to describe care that meets patients’ preferences, needs and values confounds the problem. Individualised nutritional care (INC) is nutritional care that is tailored to a patient’s specific needs, preferences, values and goals. Four key pillars underpin INC: what matters to patients, shared decision making, evidence informed multi-modal nutritional care and effective monitoring of outcomes. Although INC is incorporated in nutrition guidelines and studies of oral nutritional intervention for DRM in adults, the descriptions and the degree to which it is included varies. Studies in specific patient groups show that INC improves health outcomes. The nutrition care process (NCP) offers a practical model to help healthcare professionals individualise nutritional care. The model can be used by all healthcare disciplines across all healthcare settings. Interdisciplinary team approaches provide nutritional care that delivers on what matters to patients, without increased resources and can be adapted to include INC. This review is of relevance to all involved in the design, delivery and evaluation of nutritional care for all patients, regardless of whether they need first-line nutritional care or complex, highly specialised nutritional care.

Nutritional Assessment and Interventions in Elective Hip and Knee Arthroplasty: a Detailed Review and Guide to Management

PURPOSE OF REVIEW

8.5 to 50% of total joint arthroplasty (TJA) patients are reported to have preoperative malnutrition. The narrative review identifies the relationship between preoperative malnutrition for TJA patients and postoperative outcomes as well as the use of perioperative nutritional intervention to improve postoperative complications.

RECENT FINDINGS

Biochemical/laboratory, anthropometric, and clinical measures have been widely used to identify preoperative nutritional deficiency. Specifically, serum albumin is the most prevalent used marker in TJA because it has been proven to be correlated with protein-energy malnutrition due to the surgical stress response. However, there remains a sustained incidence of preoperative malnutrition in total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients due to a lack of agreement among the available nutritional screening tools and utilization of isolated laboratory, anthropometric, and clinical variables. Previous investigations have also suggested preoperative malnutrition to be a prognostic indicator of complications in general, cardiac, vascular, and orthopaedic surgery specialties. Serum albumin, prealbumin, transferrin, and total lymphocyte count (TLC) can be used to identify at-risk patients. It is important to employ these markers in the preoperative setting because malnourished TKA and THA patients have shown to have worse postoperative outcomes including prolonged length, increased reoperation rates, increased infection rates, and increased mortality rates. Although benefits from high-protein and high-anti-inflammatory diets have been exhibited, additional research is needed to confirm the use of perioperative nutritional intervention as an appropriate treatment for preoperative TJA patients.

Advances in knowledge of screening practices and their use in clinical practice to prevent malnutrition

Malnutrition is common among older adults and is associated with a progressive decline in overall health and increased mortality. With a rapidly ageing population, the detection, prevention and management of malnutrition require urgent attention within health service planning and delivery. Routine screening for malnutrition among older adults in community settings, which addresses aetiological as well as phenotypic factors, is considered an important step for prevention and early intervention. The aim of this review is to summarise current malnutrition screening literature and highlight research that seeks to understand and address community-based approaches to malnutrition screening and management. Key healthcare professionals (HCPs) that encounter community-dwelling older adults include general practitioners (GPs), community-based nurses, community pharmacists and a range of other health and social care professionals including dietitians, physiotherapists, speech and language therapists, and occupational therapists. The key barriers to implementing screening in primary care include lack of knowledge about malnutrition among non-dietetic HCPs, lack of resources allocated to managing malnutrition, lack of access to dietetic services, and poor GP knowledge about oral nutritional supplement prescribing. In addition, older adults have poor insight into the clinical condition and the associated negative health implications. Investment in education among HCPs and public awareness is required, as well as accompanying resources to successfully implement malnutrition screening programmes for community-dwelling older adults.