Nutritional screening - Evaluation and implementation of a simple Nutrition Risk Score

Geriatric nutritional risk index and adverse medical outcomes among Egyptian patients admitted to a geriatric hospital: a prospective cohort study

BACKGROUND

Elderly are one of the most heterogeneous and vulnerable groups who have a higher risk of nutritional problems. Malnutrition is prevalent among hospitalized elderly but underdiagnosed and almost undistinguishable from the changes in the aging process. The Geriatric Nutritional Risk Index (GNRI) is a tool created to predict nutrition-related complications in hospitalized patients. This study aims to measure the prevalence of nutritional risk using the GNRI among hospitalized elderly Egyptian inpatients and to determine the association between the GNRI and selected adverse clinical outcomes.

METHODS

A hospital-based prospective cohort study was conducted among 334 elderly patients admitted to a tertiary specialized geriatric university hospital in Cairo, Egypt from August 2021 to June 2022. Within 48 hours after hospital admission, socio-demographic characteristics, blood biomarkers, anthropometric measurements, and nutritional risk assessment by the GNRI score were obtained. Patients were divided into three groups based on their GNRI: high, low, and no nutritional risk (GNRI<92, 92-98, and >98) respectively. Patients were followed up for the occurrence of adverse outcomes during hospital stay (bed sores, Healthcare-Associated Infections (HAIs), hospital Length of Stay (LOS), and hospital mortality) and three months after discharge (non-improvement medical status, appearance of new medical conditions, hospital readmission and 90-day mortality). Multivariable regression and survival analysis were conducted.

RESULTS

The prevalence of high-nutritional risk was 45.5% (95% CI, 40%-51%). Patients with high risk had significantly longer LOS than those with no risk. The high-nutritional risk was significantly associated with the development of bed sores (Adjusted Odds Ratio (AOR) 4.89; 95% CI, 1.37-17.45), HAIs (AOR: 3.18; 95% CI, 1.48-6.83), and hospital mortality (AOR: 4.41; 95% CI, 1.04-18.59). The overall survival rate was significantly lower among patients with high-nutritional risk compared to those with no risk.

CONCLUSION

GNRI is a simple and easily applicable objective nutritional screening tool with high prognostic value in this Egyptian sample of patients. The findings of this study signal the initiation of the application of this tool to all geriatric hospitals in Egypt.

Enhanced recovery after surgery (ERAS) in colorectal surgery: implementation is still beneficial despite modern surgical and anesthetic care

PURPOSE

Enhanced recovery after surgery (ERAS) protocols have shown beneficial outcomes in the last 20 years. Nevertheless, simultaneously implemented technical improvements such as minimally invasive access or modified anesthesia care may play a crucial role in optimizing patient outcome. The aim of the study was to investigate the effect of ERAS implementation in a highly specialized colorectal center.

METHODS

This is a propensity score matched single-center study comparing the short-term outcomes of patients undergoing elective colorectal surgery in a society-indepedent ERAS program from January 2021 to August 2022 to standard perioperative care from January 2019 to December 2020.

RESULTS

Four hundred fifty-six patients were included in the propensity score matched analysis with 228 patients per group (ERAS vs. standard care). Minimally invasive access was used in 80.2% vs. 77.6% (p = 0.88), and there were 16.6% vs. 18.8% (p = 0.92) rectal procedures in the ERAS and standard care group, respectively. Major complications occurred in 10.1% vs. 11.4% (p = 0.65) and anastomotic leakage demanding operative revision in 2.2% vs. 2.6% (p = 0.68) in the ERAS and standard care group, respectively. ERAS lead to a lower number of non-surgical complications compared to standard care (57 vs. 79; p = 0.02). Mean length of stay (LOS) and mean costs per case were lower in ERAS compared to standard care (9.2 ± 5.6 days vs. 12.7 ± 7.4 days, p < 0.01; costs 33,727 ± 15,883 USD vs. 40,309 ± 29,738 USD, p < 0.01).

CONCLUSION

The implementation of an ERAS protocol may lead to a reduction of LOS, costs, and a lower number of non-surgical complications even in a highly specialized colorectal unit using modern surgical and anesthetic care. ( ClinialTrials.gov number NCT05773248).

AIWW: a new nutrition-screening tool for the oncologic population

Malnutrition is a common comorbidity among patients with cancer. However, no nutrition-screening tool has been recognized in this population. A quick and easy screening tool for nutrition with high sensitivity and easy-to-use is needed. Based on the previous 25 nutrition-screening tools, the Delphi method was made by the members of the Chinese Society of Nutritional Oncology to choose the most useful item from each category. According to these results, we built a nutrition-screening tool named age, intake, weight, and walking (AIWW). Malnutrition was defined based on the scored patient-generated subjective global assessment (PG-SGA). Concurrent validity was evaluated using the Kendall tau coefficient and kappa consistency between the malnutrition risks of AIWW, nutritional risk screening 2002 (NRS-2002), and malnutrition screening tool (MST). Clinical benefit was calculated by the decision curve analysis (DCA), integrated discrimination improvement (IDI), and continuous net reclassification improvement (cNRI). A total of 11,360 patients (male, n=6,024 (53.0%) were included in the final study cohort, and 6,363 patients had malnutrition based on PG-SGA. Based on AIWW, NRS-2002, and MST, 7,545, 3,469, and 1,840 patients were at risk of malnutrition, respectively. The sensitivities of AIWW, NRS-2002, and MST risks were 0.910, 0.531, and 0.285, and the specificities were 0.768, 0.946, and 0.975. The Kendall tau coefficients of AIWW, NRS-2002, and MST risks were 0.588, 0.501, and 0.326, respectively. The area under the curve of AIWW, NRS-2002, and MST risks were 0.785, 0.739, and 0.630, respectively. The IDI, cNRI, and DCA showed that AIWW is non-inferior to NRS-2002 (IDI: 0.002 (-0.009, 0.013), cNRI: -0.015 (-0.049, 0.020)). AIWW scores can also predict the survival of patients with cancer. The missed diagnosis rates of AIWW, NRS-2002, and MST were 0.09%, 49.0%, and 73.2%, respectively. AIWW showed a better nutrition-screening effect than NRS-2002 and MST for patients with cancer and could be recommended as an alternative nutrition-screening tool for this population.

Factors Associated with Significant Weight Loss in Hospitalised Patients with COVID-19: A Retrospective Cohort Study in a Large Teaching Hospital

SARS-CoV-2 infection (COVID-19) is associated with malnutrition risk in hospitalised individuals. COVID-19 and malnutrition studies in large European cohorts are limited, and post-discharge dietary characteristics are understudied. This study aimed to assess the rates of and risk factors for ≥10% weight loss in inpatients with COVID-19, and the need for post-discharge dietetic support and the General Practitioner (GP) prescription of oral nutritional supplements, during the first COVID-19 wave in a large teaching hospital in the UK. Hospitalised adult patients admitted between March and June 2020 with a confirmed COVID-19 diagnosis were included in this retrospective cohort study. Demographic, anthropometric, clinical, biochemical, and nutritional parameters associated with ≥10% weight loss and post-discharge characteristics were described. Logistic regression models were used to identify risk factors for ≥10% weight loss and post-discharge requirements for ongoing dietetic input and oral nutritional supplement prescription. From the total 288 patients analysed (40% females, 72 years median age), 19% lost ≥ 10% of their admission weight. The length of hospital stay was a significant risk factor for ≥10% weight loss in multivariable analysis (OR 1.22; 95% CI 1.08-1.38; p = 0.001). In addition, ≥10% weight loss was positively associated with higher admission weight and malnutrition screening scores, dysphagia, ICU admission, and artificial nutrition needs. The need for more than one dietetic input after discharge was associated with older age and ≥10% weight loss during admission. A large proportion of patients admitted to the hospital with COVID-19 experienced significant weight loss during admission. Longer hospital stay is a risk factor for ≥10% weight loss, independent of disease severity, reinforcing the importance of repeated malnutrition screening and timely referral to dietetics.

A Practical Approach to Identifying Pediatric Disease-Associated Undernutrition: A Position Statement from the ESPGHAN Special Interest Group on Clinical Malnutrition

ABSTRACT

Disease-associated undernutrition (DAU) is still common in hospitalized children and is generally accepted to be associated with adverse effects on disease outcomes; hence making proper identification and assessment essential in the management of the sick child. There are however several barriers to routine screening, assessment, and treatment of sick children with poor nutritional status or DAU, including limited resources, lack of nutritional awareness, and lack of agreed nutrition policies. We recommend all pediatric facilities to 1) implement procedures for identification of children with (risk of) DAU, including nutritional screening, criteria for further assessment to establish diagnosis of DAU, and follow-up, 2) assess weight and height in all children asa minimum, and 3) have the opportunity for children at risk to be assessed by a hospital dietitian. An updated descriptive definition of pediatric DAU is proposed as "Undernutrition is a condition resulting from imbalanced nutrition or abnormal utilization of nutrients which causes clinically meaningful adverse effects on tissue function and/or body size/composition with subsequent impact on health outcomes." To facilitate comparison of undernutrition data, it is advised that in addition to commonly used criteria for undernutrition such as z score < -2 for weight-for-age, weight-for-length, or body mass index <-2, an unintentional decline of >1inthese z scores over time should be considered as an indicator requiring further assessment to establish DAU diagnosis. Since the etiology of DAU is multifactorial, clinical evaluation and anthropometry should ideally be complemented by measurements of body composition, assessment of nutritional intake, requirements, and losses, and considering disease specific factors.

Prospective trial to evaluate the prognostic value of different nutritional assessment scores for survival in pancreatic ductal adenocarcinoma (NURIMAS Pancreas SURVIVAL)

BACKGROUND

Malnutrition is associated with poor survival in pancreatic cancer patients. Nutritional scores show great heterogeneity diagnosing malnutrition. The aim of this study was to find the score best suitable to identify patients with malnutrition related to worse survival after surgery for pancreatic ductal adenocarcinoma (PDAC). This study represents a follow-up study to the prospective NURIMAS Pancreas trial that evaluated short term impact of nutritional score results after surgery.

METHODS

Risk of malnutrition was evaluated preoperatively using 12 nutritional assessment scores. Patients were followed-up prospectively for at least 3 years. Patients at risk for malnutrition were compared with those not at risk according to each score using Kaplan-Meier survival statistics.

RESULTS

A total of 116 patients receiving a PDAC resection in curative intent were included. Malnutrition according to the Subjective Global Assessment score (SGA), the Short Nutritional Assessment Questionnaire (SNAQ), and the INSYST2 score was associated with worse overall survival (SGA: at-risk: 392 days; not at-risk: 942 days; P = 0.001; SNAQ: at-risk: 508 days; not at-risk: 971 days; P = 0.027; INSYST2: at-risk: 538 days; not at risk: 1068; P = 0.049). In the multivariate analysis, SGA (hazard ratio of death 2.16, 95% confidence interval 1.34-3.47, P = 0.002) was associated with worse overall survival.

CONCLUSIONS

Malnutrition as defined by the Subjective Global Assessment is independently associated with worse survival in resected PDAC patients. The SGA should be used to stratify PDAC patients in clinical studies. Severely malnourished patients according to the SGA profit from intensified nutritional therapy should be evaluated in a randomized controlled trial.

How to Handle Arterial Conduits in Liver Transplantation? Evidence From the First Multicenter Risk Analysis

OBJECTIVE

The aims of the present study were to identify independent risk factors for conduit occlusion, compare outcomes of different AC placement sites, and investigate whether postoperative platelet antiaggregation is protective.

BACKGROUND

Arterial conduits (AC) in liver transplantation (LT) offer an effective rescue option when regular arterial graft revascularization is not feasible. However, the role of the conduit placement site and postoperative antiaggregation is insufficiently answered in the literature.

STUDY DESIGN

This is an international, multicenter cohort study of adult deceased donor LT requiring AC. The study included 14 LT centers and covered the period from January 2007 to December 2016. Primary endpoint was arterial occlusion/patency. Secondary endpoints included intra- and perioperative outcomes and graft and patient survival.

RESULTS

The cohort was composed of 565 LT. Infrarenal aortic placement was performed in 77% of ACs whereas supraceliac placement in 20%. Early occlusion (≤30 days) occurred in 8% of cases. Primary patency was equivalent for supraceliac, infrarenal, and iliac conduits. Multivariate analysis identified donor age >40 years, coronary artery bypass, and no aspirin after LT as independent risk factors for early occlusion. Postoperative antiaggregation regimen differed among centers and was given in 49% of cases. Graft survival was significantly superior for patients receiving aggregation inhibitors after LT.

CONCLUSION

When AC is required for rescue graft revascularization, the conduit placement site seems to be negligible and should follow the surgeon's preference. In this high-risk group, the study supports the concept of postoperative antiaggregation in LT requiring AC.

Preoperative malnutrition in patients with colorectal cancer

Preoperative malnutrition in patients with colorectal cancer is associated with several postoperative consequences and poorer prognosis. Currently, there is a lack of a universal screening tool to assess nutritional status, and intervention to treat preoperative malnutrition is often neglected. This review summarizes and compares preoperative screening and interventional tools to help providers optimize malnourished patients with colorectal cancer for surgery. We found that nutritional screenings, such as the Subjectibe Global Assessment, Patient-Generated Subjective Global Assessment, Prognostic Nutritional Index, Nutrition Risk Index, Malnutrition Universal Screening Tool, Nutrition Risk Screening 2002, Nutrition Risk Score, serum albumin, and prealbumin, have all effectively predicted postoperative outcome. Physicians should consider which of these tools best fits their needs based on the their mode of assessment, efficiency, and specified parameters. Additionally, preoperative nutritional support, such as trimodal prehabilitation, modified peripheral parenteral nutrition, and N-3 fatty acid and arginine supplementation, which have also benefited patients postoperatively, ought to be implemented appropriately according to their ease of execution. Given the high prevalence of preoperative malnutrition in patients undergoing surgery for colorectal cancer, it is essential that health care providers assess and treat this malnutrition to reduce postoperative complications and length of hospital stay, and to improve prognosis to augment a patient’s quality of care.

Controlling Nutritional Status (CONUT) Score and Micronutrient Deficiency in Bariatric Patients: Midterm Outcomes of Roux-en-Y Gastric Bypass Versus One Anastomosis Gastric Bypass/Mini Gastric Bypass

BACKGROUND

Two of the most common bariatric procedures performed worldwide are Roux-en-Y gastric bypass (RYGB) and one anastomosis gastric bypass (OAGB). Comparative data regarding nutritional status are lacking and no previous study focus on malnutrition according to a validated score.

METHODS

Retrospective data from a single institution were reviewed. Anthropometric variables and nutritional data were assessed. The primary aim was to analyze and compare the nutritional status before and 3 years after RYGB vs OAGB using the controlling nutritional status (CONUT) score. The incidence of micronutrient deficiency and the remission of comorbidities in each group were defined as secondary outcomes.

RESULTS

Fifty-seven patients in each arm were enrolled. A 3-year mild malnutrition (CONUT score 2-3) was found in 38% and 37.05% in the RYGB and OAGB groups, respectively (p > 0.05). In terms of percentage of total weight loss (%TWL) and percentage of adjustable weight loss (%AWL), no differences were found between OAGB and RYGB groups. OAGB and RYGB patients had similar vitamin deficiencies. Anemia, hypoproteinemia, hypoalbuminemia, and hypocalcemia were comparable between groups. At 3-year follow-up, total protein and albumin values were similar between arms while prealbumin deficit was more frequent after OAGB than after RYGB. The rate of type 2 diabetes (87.5% in OAGB and 92% in RYGB), arterial hypertension (51.6% in OAGB and 58.3% in RYGB), and dyslipidemia (69.7% in OAGB and 78.6% in RYGB) remission was not significantly different between the two groups.

CONCLUSIONS

Postoperative CONUT score, micronutrient deficiency, comorbidity remission, and improvement of anthropometric parameters 3 years postoperatively were comparable between RYGB and OAGB groups.

Prospective study to evaluate the prognostic value of different nutritional assessment scores in liver surgery: NURIMAS Liver (DRKS00006340)

Background

Malnutrition is recognised as a preoperative risk factor for patients undergoing hepatic resection. It is important to identify malnourished patients and take preventive therapeutic action before surgery. However, there is no evidence regarding which existing nutritional assessment score (NAS) is best suited to predict outcomes of liver surgery.

Methods

All patients scheduled for elective liver resection at the surgical department of the University Hospital of Heidelberg and the Municipal Hospital of Karlsruhe were screened for eligibility. Twelve NASs were calculated before operation, and patients were categorised according to each score as being either at risk or not at risk for malnutrition. The association of malnutrition according to each score and occurrence of at least one major complication was the primary endpoint, which was achieved using a multivariate logistic regression analysis including established risk factors in liver surgery as covariates.

Results

The population consisted of 182 patients. The percentage of patients deemed malnourished by the NAS varied among the different scores, with the lowest being 2.20% (Mini Nutritional Assessment) and the highest 52.20% (Nutritional Risk Classification). Forty patients (22.0%) had a major complication. None of the scores were significantly associated with major complications.

Conclusions

None of the twelve investigated NAS defined a state of malnutrition that was independently associated with postoperative complications. Other means of measuring malnutrition in liver surgery should be investigated prospectively.

Assessment of Two Nutritional Screening Tools in Hospitalized Children

Aim: to evaluate validity and concordance of Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP) and Screening Tool for Risk On Nutritional status and Growth (STRONGkids) screening tools for assessment of nutritional risk in pediatric inpatients. Methods: Prospective longitudinal observational multicenter study in children aged 1 month or older admitted as inpatients. Weight, height, cause of admission, demographic data, length of stay, and nutritional interventions were recorded. STAMP and STRONGkids were applied within the first 72 h of admission. Anthropometric measurements were recorded again 12–18 months after admission. Results: Eighty-one patients with median age of 4.1 years completed the study. Agreement between tools was moderate (κ = 0.47). STAMP had a greater tendency to classify patients as high risk (12.3% vs. 2.5%). Both tools showed very weak correlation with height for age. All undernourished patients at the beginning and the end of the study were classified as medium or high risk by STAMP and STRONGkids (100% sensitivity), although specificity was below 50% in all cases. There were no differences in length of stay based on nutritional risk with any of the tools. Conclusions: STAMP and STRONGkids demonstrated moderate agreement, with high sensitivity but low specificity for the diagnosis of undernutrition. Further studies are required to analyze cost-effectiveness of these tools and nutritional interventions derived from them.

Evaluation of the effectiveness of eight screening tools in detecting risk of malnutrition in cirrhotic patients: the KIRRHOS study

Malnutrition risk screening in cirrhotic patients is crucial, as poor nutritional status negatively affects disease prognosis and survival. Given that a variety of malnutrition screening tools is usually used in routine clinical practice, the effectiveness of eight screening tools in detecting malnutrition risk in cirrhotic patients was sought. A total of 170 patients (57·1 % male, 59·4 (sd 10·5) years, 50·6 % decompensated ones) with cirrhosis of various aetiologies were enrolled. Nutritional screening was performed using the Malnutrition Universal Screening Tool, Nutritional Risk Index, Malnutrition Screening Tool, Nutritional Risk Screening (NRS-2002), Birmingham Nutritional Risk Score, Short Nutritional Assessment Questionnaire, Royal Free Hospital Nutritional Prioritizing Tool (RFH-NPT) and Liver Disease Undernutrition Screening Tool (LDUST). Malnutrition diagnosis was defined using the Subjective Global Assessment (SGA). Data on 1-year survival were available for 145 patients. The prevalence of malnutrition risk varied according to the screening tools used, with a range of 13·5–54·1 %. RFH-NPT and LDUST were the most accurate in detecting malnutrition (AUC = 0·885 and 0·892, respectively) with a high sensitivity (97·4 and 94·9 %, respectively) and fair specificity (73·3 and 58 %, respectively). Malnutrition according to SGA was an independent prognostic factor of within 1-year mortality (relative risk was 2·17 (95 % CI 1·0, 4·7), P = 0·049) after adjustment for sex, age, disease aetiology and Model for End-stage Liver Disease score, whereas nutrition risk according to RFH-NPT, LDUST and NRS-2002 showed no association. RFH-NPT and LDUST were the only screening tools that proved to be accurate in detecting malnutrition in cirrhotic patients.

Nal-IRI with 5-fluorouracil (5-FU) and leucovorin or gemcitabine plus cisplatin in advanced biliary tract cancer - the NIFE trial (AIO-YMO HEP-0315) an open label, non-comparative, randomized, multicenter phase II study

Background

Biliary tract cancer (BTC) has a high mortality. Primary diagnosis is frequently delayed due to mostly unspecific symptoms, resulting in a high number of advanced cases at the time of diagnosis. Advanced BTCs are in principle chemotherapy sensitive as determined by improved disease control, survival and quality of life (QoL). However, median OS does not exceed 11.7 months with the current standard of care gemcitabine plus cisplatin. Thereby, novel drug formulations like nanoliposomal-irinotecan (nal-IRI) in combination with 5- fluorouracil (5-FU)/leucovorin may have the potential to improve therapeutic outcomes in this disease.

Methods

NIFE is an interventional, prospective, randomized, controlled, open label, two-sided phase II study. Within the study, 2 × 46 patients with locally advanced, non-resectable or metastatic BTC are to be enrolled by two stage design of Simon. Data analysis will be done unconnected for both arms. Patients are allocated in two arms: Arm A (experimental intervention) nal-IRI mg/m², 46 h infusion)/5-FU (2400 mg/m², 46 h infusion)/leucovorin (400 mg/m², 0.5 h infusion) d1 on 14 day-cycles; Arm B (standard of care) cisplatin (25 mg/m², 1 h infusion)/gemcitabine (1000 mg/m², 0.5 h infusion) d1 and d8 on 21 day-cycles. The randomization (1:1) is stratified for tumor site (intrahepatic vs. extrahepatic biliary tract), disease stage (advanced vs. metastatic), age (≤70 vs. > 70 years), sex (male vs. female) and WHO performance score (ECOG 0 vs. ECOG 1). Primary endpoint of the study is the progression free survival (PFS) rate at 4 months after randomization by an intention-to-treat analysis in each of the groups. Secondary endpoints are the overall PFS rate, the 3-year overall survival rate, the disease control rate after 2 months, safety and patient related outcome with quality of life. The initial assessment of tumor resectability for locally advanced BTCs is planned to be reviewed retrospectively by a central surgical board. Exploratory objectives aim at establishing novel biomarkers and molecular signatures to predict response. The study was initiated January 2018 in Germany.

Discussion

The NIFE trial evaluates the potential of a nanoliposomal-irinotecan/5-FU/leucovorin combination in the first line therapy of advanced BTCs and additionally offers a unique chance for translational research.

Trial registration

Clinicaltrials.gov NCT03044587. Registration Date February 7th 2017.

Validity and Reliability of a Nutrition Screening Tool in Identifying Malnutrition Among Hospitalized Adult Patients

BACKGROUND

Malnutrition among hospitalized patients is closely associated with various medical complications. This study aimed to determine the validity and reliability of a 3-Minute Nutrition Screening (3-MinNS) tool in identifying the risk of malnutrition among hospitalized patients that can be administered by healthcare professionals.

METHODS

A cross-sectional study was conducted between January and December 2012. A total of 350 adult patients in a teaching hospital were screened for risk of malnutrition using 3-MinNS and Subjective Global Assessment (SGA). To assess interrater reliability, each patient was screened for risk of malnutrition using 3-MinNS by 2 different nurses on 2 different occasions within 24 hours after admission. To assess the validity of 3-MinNS, the level of risk of malnutrition identified by the nurses using 3-MinNS was compared with the risk of malnutrition as assessed by a dietitian using SGA within 48 hours after the patients' enrolment into the study. The sensitivity, specificity, and predictive values were calculated in detecting patients at risk of malnutrition. Interrater reliability was determined using κ statistics.

RESULTS

Using SGA, the estimated prevalence of moderate to severe malnutrition was 36.3% (127/350). There was 94% proportional agreement between 2 nurses using 3-MinNS, and interrater reliability was substantial (κ = 0.79, P < .001). The analysis showed that 3-MinNS had moderate sensitivity (61.4%-68.5%) but high specificity (95.1%).

CONCLUSIONS

The 3-MinNS is a reliable and valid screening tool for use by healthcare professionals for identifying newly admitted medical and surgical patients who are at risk of malnutrition.

Comparison of four nutritional screening tools for Korean hospitalized children

BACKGROUND/OBJECTIVES

Several nutritional screening tools were recently developed to screen the risk of malnutrition in hospitalized children, but have not been validated in Asia. We compared four nutritional screening tools for pediatric patients in evaluating nutritional risks in newly hospitalized children.

SUBJECTS/METHODS

Medical records of newly admitted pediatric patients between June 2016 and May 2017 at two tertiary hospitals were reviewed. Initial information by nurses and hospital records by doctors on baseline demographic, clinical, and anthropometric data at admission were collected in all subjects. Nutritional risks were evaluated using four nutritional screening tools including the pediatric nutritional risk score (PNRS), the screening tool for the assessment of malnutrition in pediatrics (STAMP), the paediatric Yorkhill malnutrition score (PYMS), and the screening tools for risk of nutritional status and growth (STRONGkids).

RESULTS

A total of 559 patients (310 boys and 249 girls, mean age 6.3 ± 5.5 years) were recruited. Patients in medical and surgical departments were 469 (83.9%) and 90 (16.1%), respectively. The prevalence of patients at risk of malnutrition were 31.1% for low risk, 52.2% for medium risk, and 16.6% for high risk by PNRS; 11.4%, 39.7%, and 48.8% by STAMP; 26.5%, 25.4%, and 48.1% by PYMS; and 35.6%, 58.9%, and 5.5% by STRONGkids. PNRS versus STRONGkids and STAMP versus PYMS showed moderate agreement (kappa = 0.566 and kappa = 0.495, respectively). PYMS and STAMP revealed a relatively high sensitivity of 87.8% and 77.6% for wasting.

CONCLUSION

Different nutritional screening tools revealed considerably different results in evaluating nutritional risks in newly hospitalized children. Since pediatric patients are at risk of malnutrition at admission and during hospitalization, screening tools should be applied properly according to the situation of each hospital.

Undernutrition in childhood: Clinically based assessment tools and biological markers: Where are we and where should we go?

Despite its association with poor clinical outcomes and increased hospital costs, as of today undernutrition still goes undetected in paediatric hospitals. The reported prevalence of undernutrition in paediatric patients varies considerably. This disparity is partly due to the diversity of methods for its detection and assessment, as well as to the lack of consensus regarding its definition. Several methods, based on varied combinations of morphology characteristics, estimated nutritional intakes and medical conditions have been developed during the last 25 years. However, these tools suffer from poor sensitivity and selectivity particularly in acute conditions. Also while having their own merit, these tools mainly view malnutrition from the energy standpoint, disregarding assessment of specific micronutrients such as minerals and vitamins. In this position paper we make the point that in the era of personalized medicine, present technology offers the possibility of going beyond the traditional nutritional tools for assessing patients' status, and propose the measurement of selected micronutrients and allied metabolic markers in nutritional workup schemes adapted to each clinical condition.

A review of the validity of malnutrition screening tools used in older adults in community and healthcare settings - A MaNuEL study

BACKGROUND

Older adults are at increased risk of malnutrition compared to their younger counterparts. Malnutrition screening should be conducted using a valid malnutrition screening tool. An aim of the Healthy Diet for a Healthy Life (HDHL) Joint Programming Initiative (JPI) 'Malnutrition in the Elderly Knowledge Hub' (MaNuEL) was to review the reported validity of existing malnutrition screening tools used in older adults.

METHODS

A literature search was conducted to identify validation studies of malnutrition screening tools in older populations in community, rehabilitation, residential care and hospital settings. A database of screening tools was created containing information on how each tool was validated.

RESULTS

Seventy-four articles containing 119 validation studies of 34 malnutrition screening tools used in older adults were identified across the settings. Twenty-three of these tools were designed for older adults. Sensitivity and specificity ranged from 6 to 100% and 12-100% respectively. Seventeen different reference standards were used in criterion validation studies. Acceptable reference standards were used in 68 studies; 38 compared the tool against the Mini Nutritional Assessment-Full Form (MNA-FF), 16 used clinical assessment by a nutrition-trained professional and 14 used the Subjective Global Assessment (SGA). Twenty-five studies used inappropriate reference standards. Predictive validity was measured in 14 studies and was weak across all settings.

CONCLUSIONS

Validation results differed significantly between tools, and also between studies using the same tool in different settings. Many studies have not been appropriately conducted, leaving the true validity of some tools unclear. Certain tools appear to be more valid for use in specific settings.

Nutritional Laboratory Markers in Malnutrition

Serum visceral proteins such as albumin and prealbumin have traditionally been used as markers of the nutritional status of patients. Prealbumin is nowadays often preferred over albumin due to its shorter half live, reflecting more rapid changes of the nutritional state. However, recent focus has been on an appropriate nutrition-focused physical examination and on the patient's history for diagnosing malnutrition, and the role of inflammation as a risk factor for malnutrition has been more and more recognized. Inflammatory signals are potent inhibitors of visceral protein synthesis, and the use of these proteins as biomarkers of the nutritional status has been debated since they are strongly influenced by inflammation and less so by protein energy stores. The current consensus is that laboratory markers could be used as a complement to a thorough physical examination. Other markers of the nutritional status such as urinary creatinine or 3-methylhistidine as indicators of muscle protein breakdown have not found widespread use. Serum IGF-1 is less influenced by inflammation and falls during malnutrition. However, its concentration changes are not sufficiently specific to be useful clinically as a marker of malnutrition, and serum IGF-1 has less been used in clinical trials. Nevertheless, biomarkers of malnutrition such as prealbumin may be of interest as easily measurable predictors of the prognosis for surgical outcomes and of mortality in severe illnesses.

Screening and assessment tools for early detection of malnutrition in hospitalised children: a systematic review of validation studies

OBJECTIVE

The aim of the present study was to identify all currently available screening and assessment tools for detection of malnutrition in hospitalised children, and to identify the most useful tools on the basis of published validation studies.

DESIGN

Systematic review.

DATA SOURCES

PubMed, CINAHL and MEDLINE were searched up to October 2017.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies in English that reported sensitivity, specificity and positive/negative predictive values (PPVs/NPVs) in the paediatric population were eligible for inclusion.

DATA EXTRACTION AND SYNTHESIS

Two authors independently screened all of the studies identified, and extracted the data. The methodological qualities of the studies included were assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool.

RESULTS

The 26 validation studies that met the inclusion criteria for this systematic review used eight screening and three assessment tools. The number of participants varied from 32 to 14 477. There was considerable variability in the chosen reference standards, which prevented direct comparisons of the predictive performances of the tools. Anthropometric measurements were used as reference standards in 16 of the identified studies, and full nutritional assessment in 5. The Pediatric Yorkhill Malnutrition Score (PYMS) screening tool performed better than Screening Tool for the Assessment of Malnutrition and Screening Tool for Risk On Nutritional status and Growth when compared in terms of anthropometric measurements, especially for body mass index (Se=90.9, Sp=81.9) and triceps skinfold thickness (Se=80.0, Sp=75.0). However, low PPVs indicated the problem of overprediction of positive cases, which was typical for all of the studies that used anthropometric measurements as the reference standard.

CONCLUSIONS

This systematic review identifies the need for definition of the gold standard for validation of screening tools. Anthropometry measurements using WHO or Centers for Disease Control and Prevention growth charts should be considered as the possible reference standard in future validation studies. We would recommend the use of PYMS for hospitalised paediatric patients without chronic conditions, in combination with full nutritional assessment.

PROSPERO REGISTRATION NUMBER

CRD42017077477.

Associations among Geriatric Nutrition Risk Index, bone mineral density, body composition and handgrip strength in patients receiving hemodialysis

OBJECTIVES

Malnutrition occurs as a complication of hemodialysis (HD) and has been identified as a risk factor for osteoporosis, sarcopenia, and low physical performance. The aim of this study was to assess the associations among nutrition, bone mineral density (BMD), body composition, and handgrip strength (HGS) in patients receiving HD.

METHODS

We enrolled 164 patients receiving HD who have undergone the dual energy x-ray absorptiometry (DXA) examination, categorized according to baseline Geriatric Nutritional Risk Index (GNRI) values calculated by serum albumin levels and body weight index. GNRI was used to evaluate nutritional status, and DXA to investigate BMD and body composition. Additionally, HGS test was performed. Multiple stepwise linear regression analysis was used to identify the factors associated with BMD, T-score, and HGS.

RESULTS

Compared with patients with tertile 1 of GNRI, those with tertile 3 of GNRI tend to have higher lumbar spine BMD and T-score, higher femoral neck BMD, higher total hip BMD, higher left distal mid-third radius BMD and T-score, higher fat mass index, higher android-to-gynoid ratio, higher lean mass index, and higher HGS. An increase in GNRI tertile was associated with an increase of BMD and a decrease of osteoporosis prevalence. The GNRI was positively correlated with BMD and T-score, body composition, and HGS. Low lean mass index and high parathyroid hormone were significantly associated with low BMD and T-score. Additionally, high GNRI and high left distal mid-third radius BMD were significantly associated with high HGS.

CONCLUSIONS

The present study demonstrated that good nutrition, indicated as high GNRI, resulted in higher BMD and T-score, lean mass index, and HGS in patients receiving HD. Using GNRI to evaluate nutritional status and using DXA to investigate BMD and body composition in patients receiving HD is important to bone health and physical performance.

Prevalence of Malnutrition in Pediatric Hospitals in Developed and In-Transition Countries: The Impact of Hospital Practices

Presently, undernutrition still goes undetected in pediatric hospitals despite its association with poor clinical outcomes and increased annual hospital costs, thus affecting both the patient and the health care system. The reported prevalence of undernutrition in pediatric patients seeking care or hospitalized varies considerably, ranging from 2.5 to 51%. This disparity is mostly due to the diversity of the origin of populations studied, methods used to detect and assess nutritional status, as well as the lack of consensus for defining pediatric undernutrition. The prevalence among inpatients is likely to be higher than that observed for the community at large, since malnourished children are likely to have a pre-existent disease or to develop medical complications. Meanwhile, growing evidence indicates that the nutritional status of sick children deteriorates during the course of hospitalization. Moreover, the absence of systematic nutritional screening in this environment may lead to an underestimation of this condition. The present review aims to critically discuss studies documenting the prevalence of malnutrition in pediatric hospitals in developed and in-transition countries and identifying hospital practices that may jeopardize the nutritional status of hospitalized children.

AdNut study: effectiveness of a high calorie and protein oral nutritional supplement with β-hydroxy-β-methylbutyrate in an older malnourished population in usual clinical practice

Objective

To evaluate the effectiveness of a high calorie and protein, β-hydroxy-β-methylbutyrate containing oral nutritional supplement (HP-HMB-ONS), on nutritional status, activities of daily living and quality of life (QoL) in old malnourished subjects.

Methods

We conducted an observational, prospective, open label, multicenter study. Participants were > 65 years, undernourished or at nutritional risk [Nutrition Risk Score (NRS) ≥ 3] and had been included on an ONS (HP-HMB-ONS twice daily for 12 weeks) per standard of care. Visits at baseline (V1), 6 weeks (V2) and 12 weeks (V3) were performed. The primary endpoints were gain of body weight, change in body mass index (BMI) and NRS 2002 index. Data from QoL (EQ-5D-3L) and activities of daily living (Katz index) were also collected.

Results

A total of 235 participants were included in the study. Of these 148 took at least a 75% of the HP-HMB-ONS and were included in the analysis (per protocol); median age was 80.0 (SD:8.3) years, 65.5% (n = 97) were female, 67.6% (n = 100) had 2 or more diseases. At V3, a statistically significant increase in weight (2.1 kg; SD: 3.8) (p < 0.001) and BMI (0.8 kg/m²; SD: 1.45) were found compared to V1, whereas NRS 2002 values decreased by 0.9 (SD: 1.2). A significant (p < 0.001) improvement in Katz index (mean change = 0.3; SD:1.4) and EQ-5D scoring (mean change = 0.5; SD:1.9) compared to V1, were also reported.

Conclusions

The results suggest that administration of a HP-HMB-ONS improve the nutritional status and may led to a significant improvement in patients' activities of daily living and QoL, independent of baseline BMI.

Malnutrition Risk in Hospitalized Children: A Descriptive Study of Malnutrition-Related Characteristics and Development of a Pilot Pediatric Risk-Assessment Tool

BACKGROUND

Underrecognition of pediatric malnutrition may affect nutrition interventions and outcomes. Pediatric malnutrition uses more specific etiology-based criteria but lacks clarity in implementation guidelines. Study goals were to identify malnutrition and risk among hospitalized patients, characterize malnutrition risk factors, and assess reliability of criteria against outcome measures.

MATERIALS AND METHODS

All children 44 weeks postmenstrual age-18 years, admitted for 48 hours during a 16-day period, were included (n = 528). Trained dietitians assessed patients in physical assessments (PA), growth, energy intake, increased nutrient losses (IL), altered absorption of nutrients (AA), hypermetabolism and inflammation, laboratory information, micronutrient deficiency, and functional status. Outcome data assessed were length of stay (LOS), intensive care unit (ICU) LOS, ventilation days, nutrition support, and dietitian intervention.

RESULTS

Malnutrition prevalence upon admission was 19.7%. Weight/length or BMI/age z-score (ZS) had no effect on LOS. AA and IL upon admission were independently associated with malnutrition (both, P<.01). Wasting and hypermetabolism were independently associated with longer LOS (P<.01). Other factors associated with longer LOS included IL and inflammation (P < .05). Those with hypermetabolism had significant ZS improvements if followed by a dietitian (P < .05). Wasting via PA was the only factor associated with longer ICU LOS (P < .05).

CONCLUSIONS

Identification of risk factors (wasting, hypermetabolism, AA, IL) beyond anthropometrics to define malnutrition and risk is important in prioritizing care in a tertiary pediatric facility. Of great significance is the ability of dietitian-based PA to predict LOS and need for intervention.

Nutritional Screening Tools among Hospitalized Children: from Past and to Present

Increased awareness of the importance of nutrition among hospitalized children has increased the use of nutrition screening tool (NST). However, it is not well known the NST for hospitalized children. Therefore, the purpose of this study is to understand the past and present state of adult and child NST and discuss the pros and cons of each NST.

Nutrition Status Among HIV-Positive and HIV-Negative Inpatients with Pulmonary Tuberculosis

BACKGROUND

The association between tuberculosis (TB) and malnutrition is well recognized. Considering the risk of mortality due to malnutrition in patients with TB, it is necessary to conduct a thorough nutrition assessment to identify individuals at nutrition risk. The study objective was to assess the nutrition status of hospitalized patients with TB, co-infected or not by human immunodeficiency virus (HIV).

METHODS

Patients with confirmed diagnosis of TB were included using a cross-sectional design. Nutrition assessment parameters included: body mass index (BMI), triceps skin-fold thickness (TSF), bioelectrical impedance analysis (BIA), mid-upper-arm circumference (MUAC), mid-arm muscle circumference (MAMC), food frequency questionnaire, Malnutrition Screening Tool (MST), Subjective Global Assessment (SGA), and serum levels of hemoglobin.

RESULTS

A total 108 patients completed the study. Forty-four patients (40.7%) were HIV positive. Considering the BMI, 36.1% of the patients met the criteria for nutrition deficiency. Body fat percentage was low in 27.8% of patients. In addition, more than half of the participants met criteria for malnutrition according to MUAC, MAMC, TSF, SGA, or MST. Malnutrition measured by MAMC was more frequent in HIV-positive patients (n=33, 75.0%) than in HIV-negative patients (n=31, 48.4%) (P = 0.010). Regarding the components of diet, selenium and vitamin C intake among HIV-positive patients was significantly lower than in HIV-negative patients.

CONCLUSIONS

We identified a high prevalence of malnutrition in hospitalized patients with pulmonary TB, regardless of the method used to assess nutrition status. In HIV-positive patients, malnutrition measured by MAMC was more frequent than in HIV-negative patients.

A Low Geriatric Nutrition Risk Index Is Associated with Progression to Dialysis in Patients with Chronic Kidney Disease

Evaluating nutritional status is crucial to detecting malnutrition in patients with chronic kidney disease (CKD). The Geriatric Nutritional Risk Index (GNRI) has been associated with overall and cardiovascular mortality in the dialysis population. The aim of this study was to evaluate whether the GNRI is associated with progression to dialysis in patients with moderate to advanced CKD. We enrolled 496 patients with stage 3-5 CKD who had received echocardiographic examinations, and categorized them according to baseline GNRI values calculated using the serum albumin level and body weight. The renal end-point was defined as the commencement of dialysis. During follow-up (mean, 25.2 ± 12.5 months; range, 3.3-50.1 months), 106 (21.4%) of the patients progressed to dialysis. The GNRI was positively correlated with the left ventricular ejection fraction (LVEF) (r = 0.111, p = 0.014), and negatively correlated with the left ventricular mass index (r = -0.116, p = 0.001), left ventricular hypertrophy (r = -0.095, p = 0.035), and LVEF < 50% (r = -0.138, p = 0.002). In multivariable Cox analysis, a low GNRI, female sex, high systolic blood pressure, high fasting glucose, and low estimated glomerular filtration rate were independently associated with progression to dialysis. A low GNRI was independently associated with progression to dialysis in our study cohort. The GNRI may be useful in predicting the risk of adverse renal outcomes in patients with CKD stages 3-5. Additional studies are needed to explore whether an improvement in GNRI delays CKD progression.

Nutritional risk in major abdominal surgery: NURIMAS Liver (DRKS00010923) - protocol of a prospective observational trial to evaluate the prognostic value of different nutritional scores in hepatic surgery

Background

Malnutrition is commonly known as a risk factor in surgical procedures. The nutritional status seems particularly relevant to the clinical outcome of patients undergoing hepatic resection. Thus, identifying affected individuals and taking preventive therapeutic actions before surgery is an important task. However, there are only very few studies, that investigate which existing nutritional assessment score (NAS) is suited best to predict the postoperative outcome in liver surgery.

Objective

Nutritional Risk in Major Abdominal Surgery (NURIMAS) Liver is a prospective observational trial that analyses the predictive value of 12 different NAS for postoperative morbidity and mortality after liver resection.

Methods

After admission to the surgical department of the University Hospital in Heidelberg or the municipal hospital of Karlsruhe, all patients scheduled for elective liver resection will be screened for eligibility. Participants will fill in a questionnaire and undergo a physical examination in order to evaluate nutritional status according to Nutritional Risk Index, Nutritional Risk Screening Score, Subjective Global Assessment, Malnutrition Universal Screening Tool, Mini Nutritional Assessment, Short Nutritional Assessment Questionnaire, Imperial Nutritional Screening System, Imperial Nutritional Screening System II, Nutritional Risk Classification and the ESPEN malnutrition criteria. Postoperative morbidity and mortality will be tracked prospectively throughout the postoperative course. The association of malnutrition according to each score and occurrence of at least one major complication will be analysed using both chi-squared tests and a multivariable logistic regression analysis. Already established risk factors in liver surgery will be added as covariates.

Discussion

NURIMAS Liver is a bicentric, prospective observational trial. The aim of this study is to investigate the predictive value of clinical nutritional assessment scores on postoperative morbidity and mortality after hepatic resection. This is necessary, as only a validated identification of malnourished patients at high risk for postoperative complications, enables targeted preventive action.

Prospective trial to evaluate the prognostic value of different nutritional assessment scores in pancreatic surgery (NURIMAS Pancreas)

BACKGROUND

Preoperative nutritional status has an impact on patients' clinical outcome. For pancreatic surgery, however, it is unclear which nutritional assessment scores adequately assess malnutrition associated with postoperative outcome.

METHODS

Patients scheduled for elective pancreatic surgery at the University of Heidelberg were screened for eligibility. Twelve nutritional assessment scores were calculated before operation, and patients were categorized as either at risk or not at risk for malnutrition by each score. The postoperative course was monitored prospectively by assessors blinded to the nutritional status. The primary endpoint was major complications evaluated for each score in a multivariable analysis corrected for known risk factors in pancreatic surgery.

RESULTS

Overall, 279 patients were analysed. A major complication occurred in 61 patients (21·9 per cent). The proportion of malnourished patients differed greatly among the scores, from 1·1 per cent (Nutritional Risk Index) to 79·6 per cent (Nutritional Risk Classification). In the multivariable analysis, only raised amylase level in drainage fluid on postoperative day 1 (odds ratio (OR) 4·91, 95 per cent c.i. 1·10 to 21·84; P = 0·037) and age (OR 1·05, 1·02 to 1·09; P = 0·005) were significantly associated with major complications; none of the scores was associated with, or predicted, postoperative complications.

CONCLUSION

None of the nutritional assessment scores defined malnutrition relevant to complications after pancreatic surgery and these scores may thus be abandoned.

Supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults

BACKGROUND

Supportive interventions such as serving meals in a dining room environment or the use of assistants to feed patients are frequently recommended for the management of nutritionally vulnerable groups. Such interventions are included in many policy and guideline documents and have implications for staff time but may incur additional costs, yet there appears to be a lack of evidence for their efficacy.

OBJECTIVES

To assess the effects of supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults.

SEARCH METHODS

We identified publications from comprehensive searches of the Cochrane Library, MEDLINE, Embase, AMED, British Nursing Index, CINAHL, SCOPUS, ISI Web of Science databases, scrutiny of the reference lists of included trials and related systematic reviews and handsearching the abstracts of relevant meetings. The date of the last search for all databases was 31 March 2013. Additional searches of CENTRAL, MEDLINE, ClinicalTrials.gov and WHO ICTRP were undertaken to September 2016. The date of the last search for these databases was 14 September 2016.

SELECTION CRITERIA

Randomised controlled trials of supportive interventions given with the aim of enhancing dietary intake in nutritionally vulnerable adults compared with usual care.

DATA COLLECTION AND ANALYSIS

Three review authors and for the final search, the editor, selected trials from titles and abstracts and independently assessed eligibility of selected trials. Two review authors independently extracted data and assessed risk of bias, as well as evaluating overall quality of the evidence utilising the GRADE instrument, and then agreed as they entered data into the review. The likelihood of clinical heterogeneity amongst trials was judged to be high as trials were in populations with widely different clinical backgrounds, conducted in different healthcare settings and despite some grouping of similar interventions, involved interventions that varied considerably. We were only able, therefore, to conduct meta-analyses for the outcome measures, 'all-cause mortality', 'hospitalisation' and 'nutritional status (weight change)'.

MAIN RESULTS

Forty-one trials (10,681 participants) met the inclusion criteria. Trials were grouped according to similar interventions (changes to organisation of nutritional care (N = 13; 3456 participants), changes to the feeding environment (N = 5; 351 participants), modification of meal profile or pattern (N = 12; 649 participants), additional supplementation of meals (N = 10; 6022 participants) and home meal delivery systems (N = 1; 203 participants). Follow-up ranged from 'duration of hospital stay' to 12 months.The overall quality of evidence was moderate to very low, with the majority of trials judged to be at an unclear risk of bias in several risk of bias domains. The risk ratio (RR) for all-cause mortality was 0.78 (95% confidence interval (CI) 0.66 to 0.92); P = 0.004; 12 trials; 6683 participants; moderate-quality evidence. This translates into 26 (95% CI 9 to 41) fewer cases of death per 1000 participants in favour of supportive interventions. The RR for number of participants with any medical complication ranged from 1.42 in favour of control compared with 0.59 in favour of supportive interventions (very low-quality evidence). Only five trials (4451 participants) investigated health-related quality of life showing no substantial differences between intervention and comparator groups. Information on patient satisfaction was unreliable. The effects of supportive interventions versus comparators on hospitalisation showed a mean difference (MD) of -0.5 days (95% CI -2.6 to 1.6); P = 0.65; 5 trials; 667 participants; very low-quality evidence. Only three of 41 included trials (4108 participants; very low-quality evidence) reported on adverse events, describing intolerance to the supplement (diarrhoea, vomiting; 5/34 participants) and discontinuation of oral nutritional supplements because of refusal or dislike of taste (567/2017 participants). Meta-analysis across 17 trials with adequate data on weight change revealed an overall improvement in weight in favour of supportive interventions versus control: MD 0.6 kg (95% CI 0.21 to 1.02); 2024 participants; moderate-quality evidence. A total of 27 trials investigated nutritional intake with a majority of trials not finding marked differences in energy intake between intervention and comparator groups. Only three trials (1152 participants) reported some data on economic costs but did not use accepted health economic methods (very low-quality evidence).

AUTHORS' CONCLUSIONS

There is evidence of moderate to very low quality to suggest that supportive interventions to improve nutritional care results in minimal weight gain. Most of the evidence for the lower risk of all-cause mortality for supportive interventions comes from hospital-based trials and more research is needed to confirm this effect. There is very low-quality evidence regarding adverse effects; therefore whilst some of these interventions are advocated at a national level clinicians should recognise the lack of clear evidence to support their role. This review highlights the importance of assessing patient-important outcomes in future research.

Proposal for An Algorithm for Screening for Undernutrition in Hospitalized Children

The prevalence of disease-related undernutrition in hospitalized children has not decreased significantly in the last decades in Europe. A recent large multicentric European study reported a percentage of underweight children ranging across countries from 4.0% to 9.3%. Nutritional screening has been put forward as a strategy to detect and prevent undernutrition in hospitalized children. It allows timely implementation of adequate nutritional support and prevents further nutritional deterioration of hospitalized children. In this article, a hands-on practical guideline for the implementation of a nutritional care program in hospitalized children is provided. The difference between nutritional status (anthropometry with or without additional technical investigations) at admission and nutritional risk (the risk of the need for a nutritional intervention or the risk for nutritional deterioration during hospital stay) is the focus of this article. Based on the quality control circle principle of Deming, a nutritional care algorithm, with detailed instructions specific for the pediatric population was developed and implementation in daily practice is proposed. Further research is required to prove the applicability and the merit of this algorithm. It can, however, serve as a basis to provide European or even wider guidelines.

Causes of inadequate intake of nutrients during the treatment of children with chemotherapy

PURPOSE

The purpose of the research was to explore nurses' perceptions of different causes of inadequate food intake in children treated with chemotherapy and to determine how often nurses identify these causes.

METHOD

Qualitative and quantitative approaches were used. Qualitative data were first gathered using semistructured interviews in a sample of six nurses and analysed by conventional content analysis. Based on the results of qualitative data and literature analysis, a 28-item questionnaire was developed and evaluated for its face validity in a sample of fifteen nurses. Questionnaires were then administered to twenty-seven nurses working at one pediatric oncology ward. Quantitative data were analysed using descriptive statistic.

RESULTS

The major themes that emerge from the content analysis, describing nurses' perceptions of causes of inadequate food intake in children undergoing chemotherapy, were as follows: physiological causes of eating problems, psychological causes of eating problems, change in food selection, hospital food and individual counselling. 13 causes of inadequate food intake were identified from the questionnaire data. Pain due to mucositis was the most commonly identified cause of inadequate food intake in children, followed by nausea and vomiting, altered taste, loss of appetite and an altered smell. Psychological causes of eating problems are rarely identified.

CONCLUSION

Nurses identify most of the physiological and psychological causes of inadequate food intake in children treated with chemotherapy. The early identification and management by nurses of inadequate food intakes should be part of the curriculum for nurse education as well as part of treatment planning in clinical environment.

Preoperative Nutrition and Prehabilitation

Enhanced recovery after surgery is the natural evolution of what were previously referred to as fast track programs and seeks to implement a series of interventions to improve and enhance recovery after major surgical procedures. Two important preoperative aspects are nutrition and prehabilitation. Identifying nutritionally deficient patients allows preoperative intervention to optimize their nutritional status. The contribution of cardiopulmonary exercise testing to the evaluation of perioperative risk, subsequent development of a training program, and the use of indices to risk stratify and measure improvement after a training program allow a personalized preoperative program to be developed for each patient.

Nutritional Risk in Major Abdominal Surgery: Protocol of a Prospective Observational Trial to Evaluate the Prognostic Value of Different Nutritional Scores in Pancreatic Surgery

BACKGROUND

The influence of patients' preoperative nutritional status on their clinical outcome has already been proven. Therefore, patients with malnutrition are in need of additional therapeutic efforts. However, for pancreatic surgery, evidence suggesting the adequacy of existing nutritional assessment scores to estimate malnutrition associated with postoperative outcome is limited.

OBJECTIVE

The aim of the observational trial "Nutritional Risk in Major Abdominal Surgery (NURIMAS) Pancreas" is to prospectively assess and analyze different nutritional assessment scores for their prognostic value on postoperative complications in patients undergoing pancreatic surgery.

METHODS

All patients scheduled to receive elective pancreatic surgery at the University Hospital of Heidelberg will be screened for eligibility. Preoperatively, 12 nutritional assessment scores will be collected and patients will be assigned either at risk or not at risk for malnutrition. The postoperative course will be followed prospectively and complications according to the Clavien-Dindo classification will be recorded. The prognostic value for complications will be evaluated for every score in a univariable and multivariable analysis corrected for known risk factors in pancreatic surgery.

RESULTS

Final data analysis is expected to be available during Spring 2016.

CONCLUSIONS

The NURIMAS Pancreas trial is a monocentric, prospective, observational trial aiming to find the most predictive clinical nutritional assessment score for postoperative complications. Using the results of this protocol as a knowledge base, it is possible to conduct nutritional risk-guided intervention trials to prevent postoperative complications in the pancreatic surgical population.

TRIAL REGISTRATION

germanctr.de: DRKS00006340; https://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00006340 (Archived by WebCite at http://www.webcitation.org/6bzXWSRYZ).

Accuracy of Nutritional Screening Tools in Assessing the Risk of Undernutrition in Hospitalized Children

OBJECTIVE

The aim of the present study was to evaluate the predictive accuracy of screening tools for assessing nutritional risk in hospitalized children in developed countries.

METHODS

The study involved a systematic review of literature (MEDLINE, EMBASE, and Cochrane Central databases up to January 17, 2014) of studies on the diagnostic performance of pediatric nutritional screening tools. Methodological quality was assessed using a modified QUADAS tool. Sensitivity and specificity were calculated for each screening tool per validation method. A meta-analysis was performed to estimate the risk ratio of different screening result categories of being truly at nutritional risk.

RESULTS

A total of 11 studies were included on ≥1 of the following screening tools: Pediatric Nutritional Risk Score, Screening Tool for the Assessment of Malnutrition in Paediatrics, Paediatric Yorkhill Malnutrition Score, and Screening Tool for Risk on Nutritional Status and Growth. Because of variation in reference standards, a direct comparison of the predictive accuracy of the screening tools was not possible. A meta-analysis was performed on 1629 children from 7 different studies. The risk ratio of being truly at nutritional risk was 0.349 (95% confidence interval [CI] 0.16-0.78) for children in the low versus moderate screening category and 0.292 (95% CI 0.19-0.44) in the moderate versus high screening category.

CONCLUSIONS

There is insufficient evidence to choose 1 nutritional screening tool over another based on their predictive accuracy. The estimated risk of being at "true nutritional risk" increases with each category of screening test result. Each screening category should be linked to a specific course of action, although further research is needed.

Implementation of a computerized system in pediatric wards to improve nutritional care: a cluster randomized trial

BACKGROUND/OBJECTIVES

Malnutrition occurs frequently in hospitalized children. We aimed to assess whether a computerized system could lead to improved clinical practices in malnourished children.

SUBJECTS/METHODS

Healthcare workers (242) from six departments in a pediatric university hospital participated in a cluster randomized trial, studying 1457 malnourished children hospitalized from September 2009 to August 2011. Following a baseline observational pre-intervention period, all departments were randomized into either intervention or control arms. A computerized malnutrition-screening system was implemented in the intervention group to automatically trigger a dietetic referral in real time. Furthermore, the nutrition support team conducted an awareness campaign with healthcare workers and a leadership-based strategy to reinforce the message during the entire study period. Adherence to practice guidelines (daily weights, investigation of etiology for malnutrition, management by a dietitian and application of refeeding protocols) was compared between pre- and post-intervention periods in both the intervention and trial arms.

RESULTS

When compared with the pre-intervention period, the clinical practices were significantly improved within the intervention arm for every outcome (P<0.01), whereas remained unchanged in the control arm. In addition, during the post-intervention period, malnutrition etiology investigation by physicians (adjusted odds ratio (OR) of 4.4, 95% confidence interval (CI) 1.7-11.8, P=0.003) and management by a dietitian (OR 2.7, 95% CI 1.0-6.9, P=0.046) occurred more frequently in the intervention clusters.

CONCLUSIONS

Implementation of an electronic system to detect malnutrition in real time was associated with a rapid improvement in clinical practices for better care of hospitalized children.

Comparison of Nursing Records and the Catholic Medical Center Nutritional Risk Screening as a Nutrition Screening Tool for Intensive Care Unit Patients

In the present study, we aimed to compare the results from nutritional risk screening based on nursing records with those using the Catholic Medical Center Nutritional Risk Screening (CMCNRS) tool. A cross-sectional study was performed involving 91 patients aged ≥ 18 years from an intensive care unit. We collected general characteristics of the patients and nutrition screening was conducted for each patient by using computerized hospital program for the nursing records as well as the CMCNRS conducted by clinical dietitians. The subjects were aged 64.0 ± 17.5 years, and 52 (57.1%) patients had a NPO (nothing by mouth) status. Neurological disease was the most common diagnosis (25.3%). Compared with the CMCNRS results from the clinical dietitians, the results for the nursing records had a sensitivity of 40.5% (95% CI 32.0-40.5) and a specificity of 100.0% (95% CI 92.8-100.0). The agreement was fair between the CMCNRS results obtained by clinical dietitians and the nursing records (k = 0.423). Analysis of the errors from the screening using the nursing records revealed significant differences for all subjective indicators (p < 0.001), compared with the CMCNRS by the clinical dietitians. Thus, after assessing the methods used for nutrition screening and the differences in the search results regarding malnourished status, we noted that the nursing records had a lower sensitivity than the screening by the CMCNRS.

Methods to evaluate the nutrition risk in hospitalized patients

The rate of malnutrition is substantially high both in the population and in chronic patients hospitalized because of different reasons. The rate of patients with no marked malnutrition at the time of hospitalization who develop malnutrition during hospitalization is also substantially high. Therefore, there are currently different screening methods with different targets to prevent malnutrition and its overlook. These methods should be simple and reliable and should not be time-consuming in order to be used in daily practice. Seven nutrition risk screening methods used in children have been established until the present time. However, no consensus has been made on any method as in adults. It should be accepted that interrogation of nutrition is a part of normal examination to increase awareness on this issue and to draw attention to this issue.