Risk for malnutrition in patients prior to vascular surgery

Perceptions, Experiences, Barriers and Facilitators Regarding Nutritional Intake of Patients with Chronic Limb Threatening Ischemia: A Qualitative Study

BACKGROUND

Patients with chronic limb threatening ischemia (CLTI) are at high risk for amputation and other cardiovascular adverse events. Nutrition-related symptoms and malnutrition are common in the CLTI population, and lead to worse clinical outcomes. Understanding of the factors influencing nutritional intake is required to determine whether optimization of nutritional intake in this population requires interventions. Therefore, this study aimed to describe perceptions and experiences on nutrition of patients with CLTI, and to identify perceived barriers and facilitators influencing their nutritional intake.

METHODS

In this phenomenological qualitative study, individual semi-structured, face-to-face interviews were conducted with patients with CLTI who lived independently. Interviews were transcribed verbatim, and reflexive thematic analysis was performed.

RESULTS

Twelve participants were interviewed. Five themes were generated: (1) lack of nutritional risk perception, (2) role of nutrition for health, functioning, and surviving, (3) multiple factors influencing nutritional intake, (4) limited nutritional advice, and (5) no intention to change current nutritional intake.

CONCLUSIONS

Patients with CLTI perceive nutritional intake as a necessity to survive and function. Patients express limited risk perception regarding adequate nutritional intake and undernutrition. Nutritional intake is mainly based on non-health-related factors, as habits and taste, and multiple barriers hinder nutritional intake. Patients received no or only limited nutritional advice. Together this leads to an expressed lack of intention to change nutritional intake. Findings of this study stress the urgency for patient-centered nutritional support, to increase nutrition-related knowledge and motivation, to prevent or treat undernutrition, and may improve clinical outcomes in patients with CLTI.

Multimodal prehabilitation for peripheral arterial disease patients with intermittent claudication - A pilot randomized controlled trial

OBJECTIVE

To establish the feasibility and safety of multimodal prehabilitation (MP), and to obtain pilot data on the change in quality of life, functional walking capacity, and the need for surgery for a full-scale trial.

DESIGN

Pilot randomized controlled trial that included patients older than 50 years old suffering from moderate to severe intermittent claudication and who were candidates for endovascular revascularization (ER). Participants were excluded if they presented with ischemic rest pain, gangrene or ulceration of the index leg, significant lesions in the iliac vessels, planned surgical bypass, comorbidities in which exercise was contraindicated or if they were unable to speak English or French.

METHODS

Participants were randomized in a 1:1 ratio to 12 weeks of MP or institutional standard of care (unsupervised walking advice). MP consisted of i)1 weekly supervised exercise session; ii) home-based exercise prescription; iii) nutritional counseling and supplementation iv) smoking cessation therapy and v) psychosocial support. Feasibility and safety were measured with recruitment and retention rates, as well as the occurrence of any adverse events. In addition, barriers to attend supervised sessions and compliance to each component were assessed. Change in functional walking capacity, health-related quality of life, and the rates of patients deciding not to undergo ER were collected and analyzed throughout the follow-up period of 12 months.

RESULTS

Of the 37 patients referred for eligibility, 27 (73%) accepted to participate in the trial and were randomized. Of the 27 patients included, 24 completed the 12-week program. Adherence to each prehabilitation component was 83% IQR [72,93] for supervised exercise, 90% [83,96] for home-based exercise and 69% [45,93] for nutritional sessions. 50% of patients were referred for and underwent psychosocial intervention and 40% of the active smokers enrolled in the smoking cessation program. No adverse events were observed during the program. The two main barriers for not fully adhering to the intervention were excessive pain while performing the exercises and the difficulty to keep up with the prescribed exercises. A statistically significant mean change (SD) was seen in the MP group vs standard of care for functional capacity, mean (SD) 6MWT 60 (74) vs -11 (40) meters p<0.05, and quality of life mean (SD) VascuQol 1.15 (0.54) vs -0.3 (1.09) points p<0.05. There was no statistically significant difference between groups in the rates of patients deciding to undergo ER during the 1-year follow-up period.

CONCLUSIONS

The results of this pilot trial demonstrate that MP is safe and feasible. A 12-week MP program seems to improve quality of life and functional walking capacity to a greater extent than unsupervised walking advice. There is a need for a large-scale trial to investigate the effectiveness of MP at improving quality of life and assessing its impact on the rates of patients deciding not to undergo or delay ER. The long-term functional and quality of life outcomes of the patients deciding to undergo ER after prehabilitation also needs to be assessed.

Malnutrition risk and frailty in head and neck cancer patients: coexistent but distinct conditions

PURPOSE

Both malnutrition and frailty are associated with adverse treatment outcomes. Malnutrition (risk) and frailty are each commonly present in patients with head and neck cancer (HNC). However, their coexistence and association is unknown. Main goal of this study is to determine the coexistence of, and the association between malnutrition risk and frailty in patients with HNC.

METHODS

In this retrospective analysis on prospectively collected data, newly diagnosed patients with HNC, enrolled in the OncoLifeS databiobank were included. The Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF) was used to assess malnutrition risk. The Groningen Frailty Indicator (GFI) was used to assess frailty status. Multivariate logistic regression analyses were performed, taking into account several patient- and tumor-related factors.

RESULTS

In total, 197 patients were included. Seventy-six patients (39%) had a medium or high malnutrition risk and 71 patients (36%) were frail. In 38 patients (19%), malnutrition risk coexisted with frailty. Patients with medium and high malnutrition risk were, respectively, 4.0 (95% CI 1.5-11.2) and 13.4 (95% CI 4.0-48.7) times more likely to be frail, compared to patients with low malnutrition risk. In turn, frail patients were 6.4 times (95% CI 2.6-14.9) more likely to have malnutrition risk compared to non-frail patients.

CONCLUSIONS

Malnutrition risk and frailty frequently coexist but not fully overlap in newly diagnosed patients with HNC. Therefore, screening for both conditions is recommended.

Effect of Body Mass Index on Early Outcomes of Endovascular Abdominal Aortic Aneurysm Repair

BACKGROUND

This study compares the presentation, management, and outcomes of patients undergoing endovascular abdominal aortic aneurysm repair (EVAR), based on their weight status as defined by their body mass index (BMI).

METHODS

Patients with primary EVAR for ruptured and intact abdominal aortic aneurysm (AAA) were identified in the National Surgical Quality Improvement Program database (2016-2019). Patients were categorized by weight status (underweight: BMI < 18.5 kg/m², normal weight: 18.5-24.9 kg/m², overweight: 25-29.9 kg/m², Obese I: 30-34.9 kg/m², Obese II: 35-39.9 kg/m², Obese III: > 40 kg/m²). Preoperative characteristics and 30-day outcomes were compared.

RESULTS

Of 3,941 patients, 4.8% were underweight, 24.1% normal weight, 37.6% overweight, and 22.5% with Obese I, 7.8% Obese II, and 3.3% Obese III status. Underweight patients presented with larger (6.0 [5.4-7.2] cm) and more frequently ruptured (25.0%) aneurysms than normal weight patients (5.5 [5.1-6.2] cm and 4.3%, P < 0.001 for both). Pooled 30-day mortality was worse for underweight (8.5%) compared to all other weight status (1.1-3.0%, P < 0.001), but risk-adjusted analysis demonstrated that aneurysm rupture (odds ratio [OR] 15.9, 95% confidence interval [CI] 8.98-28.0) and not underweight status (OR 1.75, 95% CI 0.73-4.18) accounted for increased mortality in this population. Obese III status was associated with prolonged operative time and respiratory complications after ruptured AAA, but not 30-day mortality (OR 0.82, 95% CI 0.25-2.62).

CONCLUSIONS

Patients at either extreme of the BMI range had the worst outcomes after EVAR. Underweight patients represented only 4.8% of all EVARs, but 21% of mortalities, largely attributed to higher incidence of ruptured AAA at presentation. Severe obesity, on the other hand, was associated with prolonged operative time and respiratory complications after EVAR for ruptured AAA. BMI, as an independent factor, was however not predictive of mortality for EVAR.

Risk Factors for Delayed Discharge and Adverse Outcomes Following Outpatient Billed Total Knee Arthroplasty

BACKGROUND

The volume of outpatient total knee arthroplasty (TKA) has increased with advances in perioperative protocols, patient selection, and recent policy changes regarding insurance authorization. This study analyzed 30-day outcomes from a national database to better understand risk factors for delayed discharge (length of stay [LOS] ≥1), readmission, and reoperation after outpatient TKA.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was utilized to collect TKA (CPT 27447) billed as outpatient surgery performed from 2013 to 2018. Patient demographics, comorbidities, and short-term outcomes were collected and compared in LOS 0 versus LOS ≥1 cohorts. Subgroup analysis was completed for TKA performed in 2018, after the Center for Medicare Services removal of TKA from the inpatient-only list.

RESULTS

A total of 13,669 patients had outpatient TKA performed from 2013 to 2018. Most patients had LOS ≥1 day (77.1%). The LOS 0 cohort demonstrated a lower 30-day readmission rate (1.8%) compared to LOS ≥1 (2.8%), P > .01. Both groups demonstrated a low 30-day reoperation rate, LOS 0 (0.7%) and LOS ≥1 (1.1%), P = .05. Regression analysis demonstrated risk factors for LOS ≥1 day included COPD, ASA ≥3, age >75, and BMI >35 kg/m². Regression analysis demonstrated male gender, age >75, ASA ≥3, and albumin <3.5 g/dL were risk factors for readmission. Hypertension was a risk factor for 30-day reoperation.

CONCLUSION

Risk factors for LOS ≥1 day include age >75, ASA ≥3, BMI >35 kg/m². In addition, BMI >35 kg/m² was a risk factor for readmission and reoperation. These findings reinforce appropriate patient selection when considering outpatient TKA.

Patient-Generated Subjective Global Assessment Short Form better predicts length of stay than Short Nutritional Assessment Questionnaire

OBJECTIVE

Malnutrition screening instruments used in hospitals mainly include criteria to identify characteristics of malnutrition. However, to tackle malnutrition in an early stage, identifying risk factors for malnutrition in addition to characteristics may be valuable. The aim of this study was to determine the predictive validity of the Patient-Generated Subjective Global Assessment (PG-SGA SF), which addresses malnutrition characteristics and risk factors, and the Short Nutritional Assessment Questionnaire (SNAQ), which addresses mainly malnutrition characteristics, for length of stay (LOS) in a mixed hospital population.

METHODS

Patients (N = 443) were screened with the PG-SGA SF and SNAQ in the first 72 h after admission to the lung, cardiology, or surgery ward. The McNemar-Bowker test was used to investigate the symmetry between the SNAQ and PG-SGA SF categorization for low, medium, and high risk. The predictive value of the PG-SGA SF and SNAQ was assessed by γ-regression before and after adjusting for several confounders.

RESULTS

Of the 443 patients included, 23% and 58% were categorized as being at medium/high risk for malnutrition according to the SNAQ and PG-SGA SF, respectively. The regression analysis indicated that LOS of high-risk patients according to PG-SGA SF was 36% longer than that of low-risk patients (P = 0.001). LOS in patients at high risk according to the SNAQ did not significantly differ from that of SNAQ low-risk patients.

CONCLUSIONS

The PG-SGA SF, as a proactive malnutrition screening instrument, predicts LOS in various hospital wards, whereas the SNAQ, as a reactive instrument, does not. Therefore, we recommend the PG-SGA SF for proactive screening for malnutrition risk.

Malnutrition screening on hospital admission: impact of overweight and obesity on comparative performance of MUST and PG-SGA SF

BACKGROUND/OBJECTIVES

Traditional malnutrition screening instruments, including the Malnutrition Universal Screening Tool (MUST), strongly rely on low body mass index (BMI) and weight loss. In overweight/obese patients, this may result in underdetection of malnutrition risk. Alternative instruments, like the Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF), include characteristics and risk factors irrespective of BMI. Therefore, we aimed to compare performance of MUST and PG-SGA SF in malnutrition risk evaluation in overweight/obese hospitalized patients.

SUBJECTS/METHODS

We assessed malnutrition risk using MUST (≥1 = increased risk) and PG-SGA SF (≥4 = increased risk) in adult patients at hospital admission in a university hospital. We compared results for patients with BMI < 25 kg/m² vs. BMI ≥ 25 kg/m².

RESULTS

Of 430 patients analyzed (58 ± 16 years, 53% male, BMI 26.9 ± 5.5 kg/m²), 35% were overweight and 25% obese. Malnutrition risk was present in 16% according to MUST and 42% according to PG-SGA SF. In patients with BMI < 25 kg/m², MUST identified 31% as at risk vs. 52% by PG-SGA SF. In patients with BMI ≥ 25 kg/m², MUST identified 5% as at risk vs. 36% by PG-SGA SF. Agreement between MUST and PG-SGA SF was low (к = 0.143). Of the overweight/obese patients at risk according to PG-SGA SF, 83/92 (90%) were categorized as low risk by MUST.

CONCLUSIONS

More than one-third of overweight/obese patients is at risk for malnutrition at hospital admission according to PG-SGA SF. Most of them are not identified by MUST. Awareness of BMI-dependency of malnutrition screening instruments and potential underestimation of malnutrition risk in overweight/obese patients by using these instruments is warranted.

Self-Completion of the Patient-Generated Subjective Global Assessment Short Form Is Feasible and Is Associated With Increased Awareness on Malnutrition Risk in Patients With Head and Neck Cancer

BACKGROUND

We aimed to assess feasibility of self-completion of the Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF) by head and neck cancer patients, and to assess self-reported increased awareness regarding malnutrition risk after self-completion.

METHODS

Participants were randomized to complete the PG-SGA SF by paper or app. Feasibility was assessed by time needed to complete the PG-SGA SF, perceived difficulty, and help needed during completion. Participants were asked if they knew what malnutrition was (yes/no) and if they could define "malnutrition." They were also asked 9 questions on whether they perceived increased awareness of malnutrition risk after having completed the PG-SGA SF and 2 on their intention to change lifestyle habits.

RESULTS

Of all participants (n = 59; 65.9 ± 12.6 years; 73% male), 55% completed the PG-SGA SF paper version and 46% the Pt-Global app. Median time needed for self-completion of the PG-SGA SF was 2 minutes 41 seconds (interquartile range: 1 minute 49 seconds-3 minutes 50 seconds). Forty-eight percent needed help with completion, indicating acceptable feasibility. Participants who completed the Pt-Global app needed help significantly more often (66%; 21/32) than those who completed the PG-SGA SF paper version (26%; 7/27) (P = 0.005). All difficulty scores were excellent. For 7/9 questions on malnutrition risk awareness, >50% of the participants answered positively.

CONCLUSION

The results of this study show that self-completion of the PG-SGA SF by head and neck cancer patients is feasible and that awareness regarding malnutrition risk may increase after completing the PG-SGA SF.

High prevalence of malnutrition both on hospital admission and predischarge

OBJECTIVES

In Dutch hospitals malnutrition screening is routinely performed at admission, but not during follow-up or before discharge. Therefore we evaluated nutritional status during hospitalization and predischarge in a routine care setting.

METHODS

The Patient-Generated Subjective Global Assessment (PG-SGA) was used to assess nutritional status (PG-SGA Categories: A = well nourished, B = moderate/suspected malnutrition, C = severely malnourished) in adult patients on four wards of a university hospital at admission, day 5, day 10, and day ≥15. Because data were obtained in the context of clinical routine, not all data points are available for all patients. Last assessment before discharge (within ≤4 d) was taken as predischarge measurement.

RESULTS

PG-SGA data at admission were obtained in 584 patients (age 57.2 ± 17.3 y, 51.4% women, body mass index 27.0 ± 5.5 kg/m²). Prevalence of PG-SGA stage B/C was 31% at admission, 56% on day 5 (n = 292), 66% on day 10 (n = 101), and 79% on day ≥15 (n = 14). PG-SGA predischarge data were available in 537 patients, 36% of whom were PG-SGA stage B/C. Of the 91 patients assessed both at admission and predischarge, 30% of well-nourished patients became malnourished and 82% of malnourished patients remained so.

CONCLUSIONS

Prevalence of malnutrition in hospitalized patients is high at admission (31%) and, importantly, also high predischarge (36%). Malnutrition is more prevalent in patients with a longer length of stay. These findings underscore the importance of follow-up of nutritional status in hospitalized patients and adequate transmural nutrition care after discharge to prevent malnutrition from remaining undetected and untreated.

Vascular Surgery Patients at Risk for Malnutrition Are at an Increased Risk of Developing Postoperative Complications

BACKGROUND

Malnutrition is an important risk factor for adverse postoperative outcomes such as infection and delayed wound healing, often resulting in longer hospital stay and higher readmission and mortality rates. The aim of this study is to assess the relationship between the risk for malnutrition prior to elective vascular surgery and postoperative complications.

METHODS

In this observational cross-sectional study, elective vascular surgery patients were included from January 2015 until November 2018. Included were percutaneous, carotid, endovascular, peripheral bypass, abdominal, lower extremity amputation, and other interventions. The patients were assessed for risk for malnutrition using the Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF), whereby <4 points was defined as low risk, 4-8 points as medium risk, and ≥9 points as high risk for malnutrition. Postoperative complications were registered using the Comprehensive Complication Index. Univariate and multivariate analyses were performed to evaluate the relationship between risk for malnutrition and postoperative complications.

RESULTS

Of 468 patients, 113 (24.1%) were found to be at risk for malnutrition (PG-SGA SF ≥4 points). Occurrence of postoperative complications (23.9% in the low risk vs. 51.9% in the high risk group, P = 0.006), length of hospital stay (5.5 ± 4.3 days in the low risk vs. 8.2 ± 5.1 in the high risk group, P = 0.005), 30-day readmission (4.7% in the low risk vs. 19.2% in the high risk group, P = 0.009), and Comprehensive Complication Index (median score of 0 in the low risk vs. 8.7 in the high risk group, P = 0.018) varied significantly between the 3 PG-SGA SF groups. After multivariate analysis, the medium risk for malnutrition group had a 1.39 (95% confidence interval 1.05-1.84) times higher Comprehensive Complication Index than the low risk for malnutrition group (P = 0.02).

CONCLUSIONS

Electively operated vascular surgery patients at risk for malnutrition are more likely to develop postoperative complications. This finding suggests that improving the nutritional status of vascular surgery patients prior to surgery has the potential to reduce the risk of complications.