Bedside measures of malnutrition and association with mortality in hospitalized adults

Prevalence and related assessment practices of adult hospital malnutrition in Africa: A scoping review

BACKGROUND AND AIMS

Globally, hospital malnutrition prevalence is estimated at 20-50%, with little known about the situation in African hospitals. The aim of this scoping review was to appraise the current evidence base regarding the prevalence of adult hospital malnutrition and related assessment practices in an African context.

METHODS

A comprehensive and exhaustive search strategy was undertaken to search seven electronic bibliographic databases (including Africa-specific databases) from inception until August 2022 for articles/resources reporting on the prevalence of adult hospital malnutrition in an African setting. Two reviewers independently reviewed abstracts and full-text articles and data extraction was undertaken in duplicate.

RESULTS

We screened the titles and abstracts of 7537 records and included 28 studies. Most of the included studies were conducted in the East African region (n = 12), with ten studies from South Africa. Most studies were single-centre studies (n = 22; 79%), including 23 to 2126 participants across all studies. A variety of study populations were investigated with most described as medical and surgical populations (n = 14; 50%). Malnutrition risk prevalence was reported to be between 23% and 74%, using a variety of nutritional screening tools (including MNA-SF/LF, NRS-2002, MUST, NRI, GNRI). Malnutrition prevalence was reported to be between 8% and 85%, using a variety of tools and parameters, including ASPEN and ESPEN guidelines, SGA, MNA-SF/LF, anthropometric and biochemical indices, with one study using the GLIM criteria to diagnose malnutrition.

CONCLUSIONS

Both malnutrition risk and malnutrition prevalence are alarmingly high in African adult hospitalised patients. The prevalence of malnutrition differs significantly among studies, owing in part to the variety of tools used and variability in cut-offs for measurements, underscoring the importance of adopting a standardised approach. Realities in the African context include limited nutritional screening and assessment, poor referral practices, and a unique disease burden. General awareness is needed, and routine nutritional screening practices with appropriate nutrition support action should be implemented as a matter of urgency in African hospitals.

KNUST aging and human immunodeficiency virus outcomes-Study protocol

INTRODUCTION

Globally, 7 million people with HIV (PWH) aged over 50 years exist. 5 million of them live in sub-Saharan Africa, the epicenter of the HIV epidemic. In Ghana, every 1 in 6 PWH is aged over 50 years. However, access to geriatric health care is grossly limited in Ghana and the sub-Saharan Africa region. This has resulted in a lack of focus on geriatric syndromes, a multi-factorial clinical condition common in older PWH, that do not fit discrete disease categories. Consequently, this gap threatens the life expectancy for aging PWH, necessitating the need to promptly fill it. The KNUST Aging and HIV Outcomes (KAHO) study will help identify priorities and opportunities for developing an effective integrated model of HIV and geriatric healthcare in Ghana.

METHODS AND ANALYSIS

The KAHO study will recruit 151 PWH aged 50 years and older at the Infectious Disease Unit (IDU) of the University Hospital, Kwame Nkrumah University of Science and Technology (KNUST). The study will be conducted over a 2-year period and participants will be seen at months 0, 6 and 12. Participants at each visit will be taken through assessments and questionnaires on geriatric health, cognition, social vulnerability, HIV-related conditions and they will provide biospecimens for laboratory testing. We will also conduct semi-structured qualitative interviews of PWH, healthcare providers, policy makers and study research assistants. Quantitative data will be analyzed using one sample proportion test and linear regression models appropriately. The Levesque's framework will be used as a guide to analyze qualitative data.

Body mass index and Mini Nutritional Assessment-Short Form as predictors of in-geriatric hospital mortality in older adults with COVID-19

BACKGROUND & AIMS

Overweight and obesity have been consistently reported to carry an increased risk for poorer outcomes in coronavirus disease 2019 (COVID-19) in adults. Existing reports mainly focus on in-hospital and intensive care unit mortality in patient cohorts usually not representative of the population with the highest mortality, i.e. the very old and frail patients. Accordingly, little is known about the risk patterns related to body mass and nutrition in very old patients. Our aim was to assess the relationship between body mass index (BMI), nutritional status and in-geriatric hospital mortality among geriatric patients treated for COVID-19. As a reference, the analyses were performed also in patients treated for other diagnoses than COVID-19.

METHODS

We analyzed up to 10,031 geriatric patients with a median age of 83 years of which 1409 (14%) were hospitalized for COVID-19 and 8622 (86%) for other diagnoses in seven geriatric hospitals in the Stockholm region, Sweden during March 2020-January 2021. Data were available in electronic hospital records. The associations between 1) BMI and 2) nutritional status, assessed using the Mini-Nutritional Assessment - Short Form (MNA-SF) scale, and short-term in-geriatric hospital mortality were analyzed using logistic regression.

RESULTS

After adjusting for age, sex, comorbidity, polypharmacy, frailty and the wave of the pandemic (first vs. second), underweight defined as BMI<18.5 increased the risk of in-hospital mortality in COVID-19 patients (odds ratio [OR] = 2.30; confidence interval [CI] = 1.17-4.31). Overweight and obesity were not associated with in-hospital mortality. Malnutrition; i.e. MNA-SF 0-7 points, increased the risk of in-hospital mortality in patients treated for COVID-19 (OR = 2.03; CI = 1.16-3.68) and other causes (OR = 6.01; CI = 2.73-15.91).

CONCLUSIONS

Our results indicate that obesity is not a risk factor for very old patients with COVID-19, but emphasize the role of underweight and malnutrition for in-hospital mortality in geriatric patients with COVID-19.

Nutrition Screening, Reported Dietary Intake, Hospital Foods, and Malnutrition in Critical Care Patients in Malawi

In low-income countries there are few data on hospital malnutrition. Reduced food intake combined with nutrient-poor foods served in hospitals contribute to nutritional risk. This study investigated whether reported dietary intake and disease state of hospitalized adults in critical care units was related to malnutrition determined by mid-upper arm circumference (MUAC). Adult in-patients (n = 126) in tuberculosis, burn, oncology, and intensive care units in two public tertiary hospitals in Malawi were screened for nutritional status using MUAC and a question on current dietary intake. The hospital menu was reviewed; portion sizes were weighed. The prevalence of moderate and severe malnutrition was 62%. Patients with organ-related diseases and infectious diseases had the highest rates of reduced reported dietary intake, 71.4% and 57.9%, respectively; however, there was no association between reported dietary intake and MUAC. In those unable to eat, however, the rate of severe malnutrition was 50%. The menu consisted of porridge and thickened corn-based starch with fried cabbage; protein foods were provided twice weekly. There was a nutrient gap of 250 calories and 13 gm protein daily. The findings support the need for increasing dietetic/nutrition services to prevent and treat malnutrition in hospitals using simple screening tools.

HIV Status and Antiretroviral Therapy as Predictors of Disability among Older South Africans: Overall Association and Moderation by Body Mass Index

Objectives: Among older people living with HIV (PLWH) and comparable individuals without HIV, we evaluated whether associations of HIV and antiretroviral therapy (ART) with disability depend on body mass index (BMI). Methods: We analyzed 4552 participants in the "Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa." (HAALSI) We compared prevalence of disability (≥1 impairment in basic activities of daily living) by HIV status, ART use, and BMI category, adjusting for age, sex, education, father's occupation, country of origin, lifetime alcohol use, and primary health-care utilization. Results: Among PLWH, those underweight had 9.8% points (95% confidence interval (CI): 1.2 to 18.4) higher prevalence of disability than those with normal BMI. Among ART users, those underweight had 11.9% points (95% CI: 2.2 to 21.6) higher prevalence of disability than those with normal BMI. Conclusions: We found no evidence that weight improvement associated with ART use is likely to increase disability.

The Problem of Hospital Malnutrition in the African Continent

This study aims to determine the prevalence of risk of malnutrition on admission and discharge in African hospitals, and to identify the association with selected indicators. In this multi-center prospective cohort study, adult patients from hospitals in South Africa, Kenya, and Ghana were screened on admission and discharge and contacted 3 months post-discharge. Relevant morbidity and mortality outcomes were assessed. At risk of malnutrition was indicated if NRS-2002 score ≥3. Adult patients (n = 2126; 43.11 years, IQR: 31.95-55.60; 52.2% female) were screened on admission and 61% were identified as at risk of malnutrition. The proportion of at-risk patients for the three hospitals in Kenya and Ghana (66.2%) were significantly higher than that of the three South African hospitals (53.7%) (Chi2 = 31.0; p < 0.001). Discharge risk of malnutrition was 71.2% (n = 394). Mean length of stay (LOS) was 6.46 ± 5.63 days. During hospitalization, 20.6% lost ≥5% body weight, 18.8% were referred for nutrition support, and discharge BMI (23.87 ± 7.38 kg/m2) was significantly lower than admission BMI (24.3 ± 7.3 kg/m2) (p < 0.001). Admission nutrition risk was associated with lower admission and discharge BMI (p < 0.001), longer LOS (p < 0.001), increased 3-month re-admission rates (Chi2 = 1.35; p = 0.245) and increased mortality (Chi2 = 21.68; p < 0.001). Nearly two-thirds of patients were at risk of malnutrition on admission. This was associated with longer LOS and greater hospital mortality. The nutritional status of patients deteriorated during hospitalization. Routine screening practices with appropriate nutrition support action should be implemented as a matter of urgency.

Predictability of a modified Mini- Nutritional- Assessment version on six-month and one-year mortality in hospitalized geriatric patients: a comparative analysis

Recently we introduced a modified Mini Nutritional Assessment (MNA) Short Form (MNA-SF) and Long Form (MNA-SF) with operationalization of the ‘mobility’ and ‘neuropsychological problems’ items of the MNA using scores on Barthel Index mobility item and Mini Mental State Examination and Geriatric Depression Scale scores. We have now evaluated the abilities of this modified MNA-SF and MNA-LF to predict mortality in comparison with the standard MNA-SF and MNA-LF and the Nutritional Risk Screening 2002 (NRS 2002) and the Malnutrition Universal Screening Tool (MUST). A prospective analysis was performed in 240 hospitalised geriatric patients aged ≥ 65 years. Malnutrition and/or malnutrition risk were assessed using the modified MNA-SF and MNA-LF, the standard MNA-SF and MNA-LF, and the NRS 2002 and MUST. The modified MNA-SF and MNA-LF and the standard MNA-SF and MNA-LF assessments (all p < 0.05), but not NRS 2002 or MUST (all p ≥ 0.05), predicted six-month and/or one-year mortality. Prediction of six-month and/or one-year mortality by the modified MNA-SF was comparable with predictions by the standard MNA-SF and MNA-LF (all p ≥ 0.05). The modified MNA-LF showed better prediction of six-month and one-year mortality than the standard MNA-SF and MNA-LF (all p < 0.05). The modified MNA-LF (all adjusted p < 0.05), but none of the other instruments (all adjusted p ≥ 0.05), predicted six-month and one-year mortality independently of age, sex, frailty, comorbidity and ADL disability burden. The modified MNA-SF and MNA-LF emerged as potentially valuable tools for predicting mortality in patients hospitalised on geriatric wards.

MALNUTRITION AND CLINICAL OUTCOMES IN SURGICAL PATIENTS WITH COLORECTAL DISEASE

BACKGROUND

Malnutrition is a frequent condition among hospitalized patients and a factor of increased risk of postoperative complication.

OBJECTIVE

This study aimed to evaluate the impact of malnutrition on phase angle (PA), body water distribution and clinical outcomes in surgical patients with colorectal disease.

METHODS

This retrospective study was performed in a tertiary hospital with 40 patients admitted electively. In the preoperative evaluation, global subjective assessment and bioelectrical impedance analysis were performed to determine nutritional status, PA, extracellular water (ECW), intracellular water (ICW) and total body water (TBW). In postoperative evaluation, the length of hospital stay and severe complications, according to Clavien-Dindo classification, were determined. The optimal PA cutoff for malnutrition screening was determined by ROC curve analysis.

RESULTS

Seventeen (42.5%) patients were diagnosed as malnourished and 23 (57.5%) as well-nourished according to global subjective assessment. Twelve (30.0%) patients developed severe complications. The malnourished group presented lower values of serum albumin (P=0.012), hematocrit (P=0.026) and PA (P=0.002); meanwhile, ECW/ICW (P=0.019) and ECW/TBW (P=0.047) were higher. Furthermore, 58.8% of malnourished patients developed severe postoperative complications compared to 8.7% of well-nourished. Malnutrition was independent predictor of severe postoperative complications (OR=15.00, IC: 2.63-85.68, P=0.002). The optimal PA cutoff obtained was 6.0º (AUC=0.82, P=0.001), yielding sensitivity, specificity, positive predictive value and negative predictive value of 76.5%, 87.0%, 81.3% and 83.4%, respectively.

CONCLUSION

Malnutrition was an independent predictive factor for severe complications in patients underwent to elective major coloproctological surgery. Besides that, malnutrition was associated with lower PA values and greater ratio of ECW. The PA provided great accuracy in nutritional screening, implying a useful marker of malnutrition.

An observational study of perioperative nutrition and postoperative outcomes in patients undergoing laparotomy at Queen Elizabeth Central Hospital in Blantyre, Malawi

Background

Nutritional status in patients undergoing surgery can influence their immune function, tissue repair and, hence, clinical outcomes. This study aimed to assess the perioperative nutrition and postoperative outcome of patients undergoing laparotomy at a tertiary hospital in Malawi.

Methods

A total of 25 patients were included in this prospective, observational study. The Subjective Global Assessment was used to classify each patient according to nutritional status. Handgrip strength was measured for each patient preoperatively and at day 3 postoperatively. Anthropometric measurements were also done. Protein and energy requirements for each participant were estimated and compared to the quantities provided by the hospital diet. Patients were followed up until discharge and outcome variables which included length of hospital stay and wound dehiscence or infectious complications were recorded.

Results

Of the study participants, 20% were well-nourished, 52% were moderately malnourished and 28% were severely malnourished. The median handgrip strength decreased at day 3 postoperatively from the preoperative handgrip strength. Well-nourished patients had higher handgrip strength than malnourished patients both preoperatively and postoperatively. Total energy and protein provided by the hospital diet were significantly lower than the estimated requirements for the patients. Severely malnourished patients had increased median length of hospital stay and increased rate of postoperative complications. Preoperative and postoperative day 3 handgrip strength correlated negatively with the number of postoperative complications and length of hospital stay.

Conclusion

This study showed high rates of malnutrition and inadequate in-hospital nutritional support which were associated with poor clinical outcomes, especially in severely malnourished patients. Proper nutritional assessment and provision of adequate nutritional support should be reinforced in surgical patients to promote favourable clinical outcomes postoperatively. Further studies with larger sample sizes in other patient populations and hospitals in Malawi are required in this area.

Predictive Effect of Malnutrition on Long-Term Clinical Outcomes among Older Men: A Prospectively Observational Cohort Study

OBJECTIVES

To determine whether nutritional status can predict 3-year cognitive and functional decline, as well as 4-year all-cause mortality in older adults.

DESIGN

Prospectively longitudinal cohort study.

SETTING AND PARTICIPANTS

The study recruited 354 men aged 65 years and older in the veteran's retirement community.

MEASURES

Baseline nutritional status was evaluated using the Mini-Nutritional Assessment-Short Form (MNA-SF). Cognitive function and Activities of Daily Living (ADL) function were determined by the Mini-Mental State Examination (MMSE) and the Barthel Index, respectively. Three-year cognitive and functional decline were respectively defined as a >3 point decrease in the MMSE scores and lower ADL scores than at baseline. Univariate and multivariable logistic regression analyses were conducted to identify nutritional status as a risk factor in poor outcome. The Kaplan-Meier method and Cox proportional regression models were used to estimate the effect of malnutrition risk on the mortality.

RESULTS

According to MNS-SF, the prevalence of risk of malnutrition was 53.1% (188/354). Multivariate logistic regression found risk of malnutrition significantly associated with 3-year cognitive decline (Adjusted odds ratio [OR] 2.07, 95% Confidence Interval [CI] 1.05-4.08, P =0.036) and functional decline (Adjusted OR 1.83, 95% CI 1.01-3.34, P =0.047) compared with normal nutritional status. The hazard ratio (HR) for all-cause mortality was 1.8 times higher in residents at risk of malnutrition (Adjusted HR 1.82, 95% CI 1.19-2.79, P =0.006).

CONCLUSIONS

Our results provide strong evidence that risk of malnutrition can predict not only cognitive and functional decline but also risk of all-cause mortality in older men living in a veteran retirement's community. Further longitudinal studies are needed to explore the causal relationship among nutrition, clinical outcomes, and the effect of an intervention for malnutrition.

Prognostic usefulness of arm circumference and nutritional screening tools in older patients with cardiovascular disease

BACKGROUND AND AIM

Arm circumference (AC) and nutritional screening tools have been shown to have prognostic capability in patients with cardiovascular disease (CVD). This study aimed to compare the prognostic predictive capabilities of AC and nutritional screening tools in older patients with CVD.

METHODS AND RESULTS

The study population consisted of 949 admitted patients ≥60 years old with CVD. Patients underwent AC measurement and nutritional screening before hospital discharge. We used the controlling nutritional status index (CONUT), the geriatric nutritional risk index (GNRI), and the prognostic nutritional index (PNI) as nutritional screening tools. The end point of the study was all-cause mortality. The mean age of the study population was 72.3 ± 7.2 years, and 68.2% of the patients were male. A total of 130 deaths occurred over a median follow-up period of 2.2 years (interquartile range, 1.1-3.8 years). After adjusting for other prognostic factors, AC (hazard ratio [HR]: 0.59; p < 0.001), CONUT (HR: 0.82; p = 0.016), GNRI (HR: 0.77; p = 0.040), and PNI (HR: 0.80; p = 0.014) were significant predictors of mortality. However, adding AC to the multivariate-adjusted model (0.739 vs. 0.714, respectively; p = 0.037), but not CONUT, GNRI, or PNI (0.724, 0.717, and 0.723 vs. 0.714; p = 0.072, p = 0.306, and p = 0.127, respectively), significantly increased the area under the curve on receiver operating characteristic curve.

CONCLUSIONS

AC, but not nutritional screening tools, plays a complementary role to preexisting prognostic factors for predicting prognosis in older patients with CVD.

A comprehensive nutritional survey of hospitalized patients: Results from nutritionDay 2016 in China

AIMS

Prevalence of malnutrition is a common and serious issue responsible for the morbidity and mortality rate among hospitalized patients. We aimed to provide an actual and comprehensive situation of the nutritional characteristics, nutritional support and the risk factors for malnutrition among hospitalized patients in China.

METHODS

We analyzed the data from nutritionDay audit 2016 in China. The international daylong cross-sectional survey was performed on November 10th, 2016 via filling out several questionnaires regarding information on patients' illness, food intake history, weight change and nutritional care. Re-assessment of patients' outcome questionnaire was performed 30 days later.

RESULTS

Total of 781 patients from 9 hospitals and 8 kinds of departments were enrolled in this report. Of these, malnutrition rate was 29.6%. Parenteral nutrition (251/344, 73.0%) was the primary nutrition support form in Chinese hospitals. However, 41.8% (136/325) of patients at nutritional risk or already diagnosed with malnutrition did not received any form of nutritional support, whereas 34.0% (155/456) well-nourished patients did. Patients with malnutrition had extended length of hospital stay and poor 30-day outcomes compared to well-nourished patients. Nutritional support could benefit nutritional risk or malnutrition patients, rather than well-nourished patients. Moreover, major lesion types, self-related health, food intake last week were independent risk factors of malnutrition (all p<0.05).

CONCLUSIONS

Chinese hospital staff is generally lack of knowledge and awareness of malnutrition. Self-related health, major lesion types and food intake are associated with malnutrition.

Food Insecurity as a Risk Factor for Outcomes Related to Ebola Virus Disease in Kono District, Sierra Leone: A Cross-Sectional Study

Studies have shown that people suffering from food insecurity are at higher risk for infectious and noncommunicable diseases and have poorer health outcomes. No study, however, has examined the association between food insecurity and outcomes related to Ebola virus disease (EVD). We conducted a cross-sectional study in two Ebola-affected communities in Kono district, Sierra Leone, from November 2015 to September 2016. We enrolled persons who were determined to have been exposed to Ebola virus. We assessed the association of food insecurity, using an adapted version of the Household Food Insecurity Access Scale, a nine-item scale well validated across Africa, with having been diagnosed with EVD and having died of EVD, using logistic regression models with cluster-adjusted standard errors. We interviewed 326 persons who were exposed to Ebola virus; 61 (19%) were diagnosed with EVD and 45/61 (74%) died. We found high levels (87%) of food insecurity, but there was no association between food insecurity and having been diagnosed with EVD. Among EVD cases, those who were food insecure had 18.3 times the adjusted odds of death than those who were food secure (P = 0.03). This is the first study to demonstrate a potential relationship between food insecurity and having died of EVD, although larger prospective studies are needed to confirm these findings.

Outcomes of patients with severe infection in Uganda according to adherence to the World Health Organization's Integrated Management of Adolescent and Adult Illness fluid resuscitation guidelines

PURPOSE

We determined outcomes in hospitalized patients in Uganda with World Health Organization's Integrated Management of Adolescent and Adult Illness (IMAI) defined septic shock (IMAI-shock) or severe respiratory distress without shock (IMAI-SRD) based on whether they received recommended fluid resuscitation according to IMAI guidelines.

MATERIALS AND METHODS

We performed a secondary analysis of a prospective cohort of adult septic patients in Uganda that included the volume of fluids patients received during the first 6h of resuscitation. We used logistic regression to determine predictors of outcomes.

RESULTS

We evaluated 122 patients with IMAI-shock and 32 patients with IMAI-SRD. For patients with IMAI-shock or IMAI-SRD, there was no difference in mortality between those that received IMAI recommended fluid volume and those that did not (30% vs 36%, p=0.788; 22% vs 57%, p=0.08). For patients with IMAI-shock, in-hospital mortality was associated with mid-upper arm circumference (adjusted odds ratio [aOR] 0.841, 95% confidence interval [CI] 0.722-0.979, p=0.026) and ambulation (aOR 0.247, 95%CI 0.084-0.727, p=0.011). We found no associations with in-hospital mortality for patients with IMAI-SRD.

CONCLUSION

IMAI recommended fluid resuscitation was not associated with better outcomes for patients with IMAI-shock or IMAI-SRD. Further studies are needed to optimize resuscitation for patients with severe infection in resource-limited settings such as Uganda.

Construction of Lambda, Mu, Sigma Values for Determining Mid-Upper Arm Circumference z Scores in U.S. Children Aged 2 Months Through 18 Years

BACKGROUND

Mid-upper arm circumference (MUAC) has proven highly predictive of morbidity and mortality associated with malnutrition better, in some cases, than other growth indicators, including body mass index (BMI) z scores and weight-for-height z scores. A recent consensus statement recommended the inclusion of MUAC and MUAC z scores in the nutrition assessment of children in the United States; however, the requisite data to permit z score calculations for children aged >5 years have not been published.

OBJECTIVE

This investigation was designed to generate lambda mu sigma (LMS) values to permit the calculation of MUAC z scores in U.S. children 2 months through 18 years of age.

DESIGN

Anthropometric data from the Centers for Disease Control and Prevention (CDC) National Health and Nutrition Examination Survey (1999-2012) were used for model development (n = 28,995). Smoothed centiles were constructed and compared with previously described CDC percentiles. Independently collected MUAC data from 2 different U.S. studies were used for external validation (n = 1438).

STATISTICAL ANALYSES

Goodness-of-fit was assessed visually and statistically by examining detrended quantile-quantile plots, Q statistics, and the distribution of z scores.

RESULTS

The curves generated in this investigation fit the raw data well with no systematic bias and no sacrifice in fit for children aged <12 months. The curves were consistent with those published by the CDC, and the distribution z scores approximated 0 ± 1 in all age groups.

CONCLUSIONS

These LMS values derived in this investigation can be used by clinicians to generate MUAC z scores for U.S. children.

Nutritional predictors of mortality after discharge in elderly patients on a medical ward

BACKGROUND

Malnutrition in elderly inpatients hospitalized on medical wards is a significant public health concern. The aim of this study was to investigate nutritional markers as mortality predictors following discharge in hospitalized medical elderly patients.

MATERIALS AND METHODS

This is a prospective observational cohort study with follow-up of 48 months. Two hundred and twenty-five individuals aged 60 and older admitted from the hospital emergency room in the past 48 h were investigated at the medical ward in the University hospital in Palermo (Italy). Anthropometric and clinical measurements, Mini-nutritional Assessment (MNA) questionnaire, bioelectrical (BIA) phase angle (PA), grip strength were obtained all within 48 h of admission. Mortality data were verified by means of mortality registry and analysed using Cox-proportional hazard models.

RESULTS

Ninety (40%) participants died at the end of follow-up. There were significant relationships between PA, MNA score, age and gender on mortality. Patients in the lowest tertile of PA (< 4·6°) had higher mortality estimates [I vs II tertile: hazard ratio (HR) = 3·40; 95% confidence interval (CI): 2·01-5·77; II vs III tertile: HR = 3·83; 95% CI: 2·21-6·64; log-rank test: χ(2) = 43·6; P < 0·001]. Similarly, the survival curves demonstrated low MNA scores (< 22) were associated with higher mortality estimates (HR = 1·85; 95% CI: 1·22-2·81 χ(2) = 8·2; P = 0·004).

CONCLUSIONS

The MNA and BIA-derived phase angle are reasonable tools to identify malnourished patients at high mortality risk and may represent useful markers in intervention trials in this high-risk subgroup.

Outcomes of patients with severe sepsis after the first 6 hours of resuscitation at a regional referral hospital in Uganda

INTRODUCTION

The optimal resuscitation strategy for patients with severe sepsis in resource-limited settings is unknown. Therefore, we determined the association between intravenous fluids, changes in vital signs and lactate after the first 6 hours of resuscitation from severe sepsis, and in-hospital mortality at a hospital in Uganda.

MATERIALS AND METHODS

We enrolled patients admitted with severe sepsis to Mbarara Regional Referral Hospital and obtained vital signs and point-of-care blood lactate concentration at admission and after 6 hours of resuscitation. We used logistic regression to determine predictors of in-hospital mortality.

RESULTS

We enrolled 218 patients and had 6 hour postresuscitation data for 202 patients. The median (interquartile range) age was 35 (26-50) years, 49% of patients were female, and 57% were HIV infected. The in-hospital mortality was 32% and was associated with admission Glasgow Coma Score (adjusted odds ratio [aOR], 0.749; 95% confidence interval [CI], 0.642-0.875; P < .001), mid-upper arm circumference (aOR, 0.876; 95% CI, 0.797-0.964; P = .007), and 6-hour systolic blood pressure (aOR, 0.979; 95% CI, 0.963-0.995; P = .009) but not lactate clearance of 10% or greater (aOR, 1.2; 95% CI, 0.46-3.10; P = .73).

CONCLUSIONS

In patients with severe sepsis in Uganda, obtundation and wasting were more closely associated with in-hospital mortality than lactate clearance of 10% or greater.

Simplifications of the mini nutritional assessment short-form are predictive of mortality among hospitalized young and middle-aged adults

OBJECTIVE

Measuring malnutrition in hospitalized patients is difficult in all settings. I evaluated associations of items in the mini nutritional assessment short-form (MNA-sf), a nutritional-risk screening tool previously validated in the elderly, with malnutrition among hospitalized patients in Uganda. I used results to construct two simplifications of this tool that may be applicable to young and middle-aged adults.

METHODS

I assessed the association of each MNA-sf item with the mid-upper arm circumference (MUAC), a specific measure of malnutrition at appropriate cut-offs. I incorporated only malnutrition-specific items into the proposed simplifications scoring each item according to its association with malnutrition. I assessed numbers classified to different score-levels by the simplifications and, via proportional hazards regression, how the simplifications predicted in-hospital mortality.

RESULTS

I analyzed 318 patients (median age 37, interquartile range 27 to 56). Variables making it into the simplifications were: reduced food intake, weight loss, mobility, and either BMI in kg/m(2) (categorized as <16, 16 to 16.9, and ≥17) or MUAC in centimeters (categorized as <16 or <17, 16 to 18.9 or 17 to 19.9, and ≥19 or ≥20 for females and males respectively). Compared to the traditional MNA-sf, the simplifications classified fewer patients as malnourished, yet remained strongly predictive of in-hospital mortality. In the MUAC-incorporating simplification, malnourished patients had 3.8-fold (95% CI 1.9 to 7.8) higher risk of in-hospital death than those not malnourished; adjusting for age, sex, and HIV status.

CONCLUSION

The MNA-sf simplifications described may provide an improved measure of malnutrition in hospitalized young and middle-aged adults.

A simple prognostic index based on admission vital signs data among patients with sepsis in a resource-limited setting

Introduction

In sub-Saharan Africa, vital signs are a feasible option for monitoring critically ill patients. We assessed how admission vital signs data predict in-hospital mortality among patients with sepsis. In particular, we assessed whether vital signs data can be incorporated into a prognostic index with reduced segmentation in the values of included variables.

Methods

Subjects were patients with sepsis hospitalized in Uganda, who participated in two cohort studies. Using restricted cubic splines of admission vital signs data, we predicted probability of in-hospital death in the development cohort and used this information to construct a simple prognostic index. We assessed the performance of the index in a validation cohort and compared its performance to that of the Modified Early Warning Score (MEWS).

Results

We included 317 patients (167 in the development cohort and 150 in the validation cohort). Based on how vital signs predicted mortality, we created a prognostic index giving a score of 1 for: respiratory rates ≥30 cycles/minute; pulse rates ≥100 beats/minute; mean arterial pressures ≥110/<70 mmHg; temperatures ≥38.6/<35.6°C; and presence of altered mental state defined as Glasgow coma score ≤14; 0 for all other values. The proposed index (maximum score = 5) predicted mortality comparably to MEWS. Patients scoring ≥3 on the index were 3.4-fold (95% confidence interval (CI) 1.6 to 7.3, P = 0.001) and 2.3-fold (95% CI 1.1 to 4.7, P = 0.031) as likely to die in hospital as those scoring 0 to 2 in the development and validation cohorts respectively; those scoring ≥5 on MEWS were 2.5-fold (95% CI 1.2 to 5.3, P = 0.017) and 1.8-fold (95% CI 0.74 to 4.2, P = 0.204) as likely to die as those scoring 0 to 4 in the development and validation cohorts respectively.

Conclusion

Among patients with sepsis, a prognostic index incorporating admission vital signs data with reduced segmentation in the values of included variables adequately predicted mortality. Such an index may be more easily implemented when triaging acutely-ill patients. Future studies using a similar approach may develop indexes that can be used to monitor treatment among acutely-ill patients, especially in resource-limited settings.