The prevalence and consequences of malnutrition risk in elderly Albanian intensive care unit patients

Exploring the Relationship between Acute Coronary Syndrome, Lower Respiratory Tract Infections, and Atmospheric Pollution

Background: Respiratory infections were found to be connected with the incidence of acute coronary syndrome (ACS). The proposed pathway of this connection includes inflammation, oxidative stress, pro-coagulation, and atherosclerotic plaque destabilization. This can cause rapture and thrombus formation, leading to ACS. Our study aimed to assess the risk factors for coronary artery thrombosis as a manifestation of ACS and for lower respiratory tract infections (LRTIs) in patients with ACS. Methods: The study included 876 patients with ACS from January 2014 to December 2018. Both the clinical data and air pollution data were analyzed. Statistical tests used for analysis included Student's t-test, the Mann-Whitney U-test, the Chi-squared test, and the odds ratio Altman calculation. Results: LRTIs were found in 9.13% patients with ACS. The patients with LRTI had a higher risk of coronary artery thrombosis (OR: 2.4903; CI: 1.3483 to 4.5996). Moreover, they had increased values of inflammatory markers, were older, had a lower BMI, and a higher rate of atrial fibrillation. The average atmospheric aerosols with a maximum diameter of 2.5 μm (PM2.5 concentration) from three consecutive days before hospitalization for ACS were higher in patients with LRTI. Conclusions: The occurrence of coronary artery thrombosis was higher among the patients with LRTI during ACS. PM2.5 exposition was higher in the three consecutive days before hospitalization in patients with LRTI during ACS.

Comparison of nutritional risk indices (PNI, GNRI, mNUTRIC) and HALP score in predicting adverse clinical outcomes in older patients staying in an intensive care unit

Malnutrition among critically ill older patients is a frequent problem in intensive care units (ICUs) and is associated with a higher risk of hospital/ICU length of stay (LOS) and mortality. The aim of this study was to evaluate malnutrition in older patients staying in an ICU using the hemoglobin, albumin, lymphocyte, platelet (HALP) score, modified nutrition risk in the critically Ill (mNUTRIC), prognostic nutritional index (PNI), and geriatric nutritional risk index (GNRI) and to determine the consistency between these tools and their association with clinical outcomes. This cross-sectional retrospective, observational, hospital-based study included 153 older patients (≥65 years of age), who were admitted to an internal medicine ICU. Sequential organ failure assessment (SOFA) scores and acute physiology and chronic health evaluation (APACHE) II were used to assess disease severity. Nutritional status was evaluated using mNUTRIC, GNRI, PNI, and HALP scores, and their association with ICU LOS and mortality was evaluated using ROC and regression analyses. The mortality rate of the patients was 43.1%. The risk of malnutrition was higher among non-survivors, with mNUTRIC scores showing a significant difference between the groups. The scores for all indices, except HALP, showed significant differences between the groups. APACHE-II, SOFA, and mNUTRIC were the strongest prognostic indices for ICU mortality, with mNUTRIC having the highest sensitivity and negative predictive value. The HALP score was not associated with ICU LOS or a significant prognostic factor for mortality. All indices except HALP were good indicators of clinical outcomes in the study population including older patients. Prospective studies in larger and specific patient populations are needed to draw a strict conclusion in this subject.

Association Between Geriatric Nutrition Risk Index and 90-Day Mortality in Older Adults with Chronic Obstructive Pulmonary Disease: a Retrospective Cohort Study

Background

Malnutrition adversely affects prognosis in various medical conditions, but its implications in older adults with Chronic Obstructive Pulmonary Disease (COPD) in the ICU are underexplored. The geriatric nutritional risk index (GNRI) is a novel tool for assessing malnutrition risk. This study investigates the association between GNRI and 90-day mortality in this population.

Methods

We selected older adults with COPD admitted to the ICU from Medical Information Mart for Intensive Care (MIMIC)-IV 2.2 database. A total of 666 patients were categorized into four groups based on their GNRI score: normal nutrition (>98), mild malnutrition (92-98), moderate malnutrition (82-91), and severe malnutrition (≤81) groups. We employed a restricted cubic spline (RCS) analysis to assess the presence of a curved relationship between them and to investigate any potential threshold saturation effect.

Results

In multivariate Cox regression analyses, compared with individuals had normal nutrition (GNRI in Q4 >98), the adjusted HR values for GNRI in Q3 (92-98), Q2 (82-91), and Q1 (≤81) were 1.81 (95% CI: 1.27-2.58, p=0.001), 1.23 (95% CI: 0.84-1.79, p=0.296), 2.27 (95% CI: 1.57-3.29, p<0.001), respectively. The relationship between GNRI and 90-day mortality demonstrates an L-shaped curve (p=0.016), with an approximate inflection point at 101.5.

Conclusion

These findings imply that GNRI is a useful prognostic tool in older adults with COPD in the ICU. An L-shaped relationship was observed between GNRI and 90-day mortality in these patients.

Relation between nutritional status on clinical outcomes of critically ill patients: emphasizing nutritional screening tools in a prospective cohort investigation

BACKGROUND

Malnutrition is a significant concern reported in adult critically ill patients, yet there is no gold standard to assess nutritional status in this population. This study examines the association between nutritional status and clinical outcomes in intensive care unit (ICU) patients using nutritional risk assessment tools and aims to look for the best tool.

METHOD

In a single-center prospective cohort study among 165 patients, the predictive performance of high or low malnutrition risk assessed by Nutritional Risk Screening (NRS), Modified Nutrition Risk in Critically Ill (m-NUTRIC), Mini-Nutritional-Assessment Short-Form (MNA-SF), Controlling Nutritional status (CONUT), and Prognostic Nutritional Index (PNI) were evaluated and compared for mortality, organ failure, length of hospitalization, and mechanical ventilation (MV).

RESULTS

Different assessment tools showed various nutritional statuses. m-NUTRIC and NRS-2002 were found to be associated more strongly relative to other tools with mortality (RR = 1.72; 95% CI, 1.42-2.08) and (RR = 1.37; 95% CI, 1.08-1.72), organ failure (RR = 1.69; 95% CI, 1.44-1.96) and (RR = 1.22; 95% CI, 0.99-1.48), MV (RR = 1.46; 95% CI, 1.27-1.65) and (RR = 1.21; 95% CI, 1.04-1.39) respectively. There was no correlation between malnutrition levels assessed by mentioned tools except for NRS-2002 and length of hospitalization. In predicting mortality or illness severity, the cut points were different for some tools like NUTRIC-score and all assessed outcomes (3.5), MNA-SF and mortality (6.5), CONUT with mortality, and MV (6.5).

CONCLUSIONS

A considerable proportion of patients admitted to the ICU are at high risk for malnutrition. Compared to other tools, m-NUTRIC and NRS-2002 proved superior in predicting clinical outcomes in critically ill patients. Other tools overestimated the risk of malnutrition in the ICU so couldn't predict clinical outcomes correctly.

Nutritional status and feeding regimen of critically ill patients in General Hospital of Agriculture in Hanoi, Vietnam

Background: Fully nutrition support for patients in developing countries like Vietnam is challenging. Aim: To estimate the prevalence of patients with nutritional risk at admission and describe feeding regimen of critically ill patients in a suburban hospital in Hanoi, Vietnam. Methods: An observational study was conducted among 154 patients at department of Intensive Care Unit (ICU). The Nutrition Risk Screening 2002 (NRS2002) and Modified Nutrition Risk in Critically Ill (mNUTRIC) were used for screening nutritional risk at admission. Body Mass Index (BMI), Mild-Upper Arm Circumference (MUAC), and personal information were recorded. The feeding regimen of patients was monitored from the first to seventh day. Results: the patients were aged 66.5 ± 15.4 years, with an APACHEII of 13.0 ± 5.5 and SOFA 3.1 ± 2.6: 47.4% were malnutrition by MUAC, 16.2% had a severely low BMI (<17.8), 20.8% had low BMI (17.8 to <20). According to NRS2002 and mNUTRIC, the prevalence of patients with high nutritional risk was 53.9% and 13%, respectively. The proportion of patients receiving less than 25 kcal/kg/day was 84%, 60%, and 47% on the first, the fifth, and the seventh day. Protein intake below 1.3 g/kg/day was 50% on the seventh day. Up to 27.4% of patients had no nutrition support on the first day. Conclusions: ICU patients had nutritional risk with high rate. The feeding regimen for patients achieved a progressive energy and protein intake over the first 7 days.

Prognostic value of different cut-off points of the NRS-2002 tool to identify nutritional risk in critically ill patients: a longitudinal study

The American Society of Parenteral and Enteral Nutrition recommends nutritional risk (NR) screening in critically ill patients with Nutritional Risk Screening - 2002 (NRS-2002) ≥ 3 as NR and ≥ 5 as high NR. The present study evaluated the predictive validity of different NRS-2002 cut-off points in intensive care unit (ICU). A prospective cohort study was conducted with adult patients who were screened using the NRS-2002. Hospital and ICU length of stay (LOS), hospital and ICU mortality, and ICU readmission were evaluated as outcomes. Logistic and Cox regression analyses were performed to evaluate the prognostic value of NRS-2002, and a receiver operating characteristic curve was constructed to determine the best cut-off point for NRS-2002. 374 patients (61·9 ± 14·3 years, 51·1 % males) were included in the study. Of these, 13·1 % were classified as without NR, 48·9 % and 38·0 % were classified as NR and high NR, respectively. An NRS-2002 score of ≥ 5 was associated with prolonged hospital LOS. The best cut-off point for NRS-2002 was a score ≥ 4, which was associated with prolonged hospital LOS (OR = 2·13; 95 % CI: 1·39, 3·28), ICU readmission (OR = 2·44; 95 % CI: 1·14, 5·22), ICU (HR = 2·91; 95 % CI: 1·47, 5·78) and hospital mortality (HR = 2·01; 95 % CI: 1·24, 3·25), but not with ICU prolonged LOS (P = 0·688). NRS-2002 ≥ 4 presented the most satisfactory predictive validity and should be considered in the ICU setting. Future studies should confirm the cut-off point and its validity in predicting nutrition therapy interaction with outcomes.

Ultrasound-based upper limb muscle thickness is useful for screening low muscularity during intensive care unit admission: A retrospective study

BACKGROUND & AIMS

Malnutrition is associated with poor outcomes. Muscle mass is an important malnutrition indicator included in Global Leadership Initiative on Malnutrition (GLIM) criteria. Although bioelectrical impedance analysis and dual-energy X-ray absorptiometry are common muscle mass assessment methods, they are unreliable during intensive care unit (ICU) admission due to the influence of dynamic fluid changes. We hypothesized that ultrasound-based upper limb muscle assessment would be useful for assessing muscularity at ICU admission.

METHODS

We retrospectively analyzed prospectively obtained ultrasound data from patients admitted to an ICU. We excluded patients without computed tomography (CT) imaging of the third lumbar vertebra within 2 days of ICU admission. Primary outcomes were the diagnostic utility of ultrasound-based upper limb muscle thickness for assessing low muscularity by CT. Low muscularity was defined as a skeletal muscle index of 36.0 cm2/m2 for males and 29.0 cm2/m2 for females at the cross-sectional area of the third lumbar vertebrae. Secondary outcomes of this study included the relationships between upper limb muscle thickness and biceps brachii muscle cross-sectional area, quadriceps femoris thickness, rectus femoris cross-sectional area.

RESULTS

Among 64 patients assessed by ultrasound, 52 had CT examination records and were included in the analysis. The mean age was 70 ± 13 years, and the mean body mass index was 23.3 ± 4.2 kg/m2. Upper limb muscle thickness had the discriminative power to assess low muscularity at an area under the curve of 0.77 (95% CI [confidence interval], 0.63-0.91); the cutoff value (26.8 cm) had 84.6% sensitivity and 66.7% specificity. The upper limb muscle index had the discriminative power to assess low muscularity at an area under the curve of 0.80 (95% CI, 0.68-0.93); the cutoff value (9.9 mm/m2) had 76.9% sensitivity and 71.8% specificity. Upper limb muscle thickness was correlated with upper limb muscle cross-sectional area, quadriceps femoris muscle thickness, rectus femoris muscle cross-sectional area (r = 0.39-0.76, p < 0.01, n = 52).

CONCLUSIONS

Ultrasound-based upper limb muscle thickness assessments can screen for low muscularity upon ICU admission.

Impact of malnutrition evaluated by the mini nutritional assessment on the prognosis of acute hospitalized older adults

Background

Malnutrition is prevalent among hospitalized older patients. Therefore, this study aimed to investigate the association between nutritional status [assessed using the Mini Nutritional Assessment (MNA) and serum albumin levels] and adverse outcomes in hospitalized older patients. We also aimed to compare the predictive utility of our findings.

Methods

This retrospective cohort study was conducted between January 2016 and June 2020. In total, 808 older patients (aged ≥ 65 years, mean age 82.8 ± 6.70 years, 45.9% male) admitted to the acute geriatric unit were included in our sample. Comprehensive geriatric assessments, including the MNA, were performed. Malnutrition and risk of malnutrition were defined as MNA < 17, albumin < 3.5 g/dL and 17 ≤ MNA ≤ 24, 3.5 g/dL ≤ albumin < 3.9 g/dL, respectively. The primary outcome was that patients could not be discharged to their own homes. The secondary outcomes were overall all-cause mortality, 3-month all-cause mortality, and incidence of geriatric syndrome, including delirium, falls, and newly developed or worsening pressure sores during hospitalization.

Results

Poor nutritional status was associated with older age; female sex; admission from the emergency room; high risk of pressure sores and falls; lower physical and cognitive function; higher depressive score; and lower serum albumin, protein, cholesterol, and hemoglobin levels. In the fully adjusted model, malnutrition assessed using the MNA predicted discharge to nursing homes or long-term care hospitals [odds ratio (OR) 5.822, 95% confidence interval (CI): 2.092-16.199, P = 0.001], geriatric syndrome (OR 2.069, 95% CI: 1.007-4.249, P = 0.048), and 3-month mortality (OR 3.519, 95% CI: 1.254-9.872, P = 0.017). However, malnutrition assessed using albumin levels could only predict 3-month mortality (OR 3.848, 95% CI: 1.465-10.105, P = 0.006). The MNA predicted 3-month mortality with higher precision than serum albumin levels (P = 0.034) when comparing the areas under the receiver operating characteristic curve.

Conclusion

Nutritional risk measured by the MNA was an independent predictor of various negative outcomes in hospitalized older patients. Poor nutritional status assessed by serum albumin levels, the most widely used biochemical marker, could predict mortality, but not the development of geriatric syndrome or discharge location reflecting functional status.

Nutrition therapy in the older critically ill patients: A scoping review

Introduction: There is a lack of guidelines or formal systematic synthesis of evidence for nutrition therapy in older critically ill patients. This study is a scoping review to explore the state of evidence in this population. Method: MEDLINE and Embase were searched from inception until 9 February 2022 for studies that enrolled critically ill patients aged ≥60 years and investigated any area of nutrition therapy. No language or study design restrictions were applied. Results: Thirty-two studies (5 randomised controlled trials) with 6 topics were identified: (1) nutrition screening and assessments, (2) muscle mass assessment, (3) route or timing of nutrition therapy, (4) determination of energy and protein requirements, (5) energy and protein intake, and (6) pharmaconutrition. Topics (1), (3) and (6) had similar findings among general adult intensive care unit (ICU) patients. Skeletal muscle mass at ICU admission was significantly lower in older versus young patients. Among older ICU patients, low muscularity at ICU admission increased the risk of adverse outcomes. Predicted energy requirements using weight-based equations significantly deviated from indirect calorimetry measurements in older vs younger patients. Older ICU patients required higher protein intake (>1.5g/kg/day) than younger patients to achieve nitrogen balance. However, at similar protein intake, older patients had a higher risk of azotaemia. Conclusion: Based on limited evidence, assessment of muscle mass, indirect calorimetry and careful monitoring of urea level may be important to guide nutrition therapy in older ICU patients. Other nutrition recommendations for general ICU patients may be used for older patients with sound clinical discretion. Keywords: Critical care nutrition, geriatric patients, intensive care medicine, older adults, scoping review

Development, Validation and Acceptability of a Newly Developed Nutrition Resource Kit for At-Risk and Malnourished Elderly in Health Clinics Setting

Introduction: The elderly population is highly vulnerable to malnutrition, including those in the community. The use of nutrition education as part of nutrition intervention is able to improve their nutritional status. Hence, provision of a nutrition resource kit addressing the needs of at-risk and malnourished elderly would be advantageous. This research aimed to develop, validate and evaluate the acceptance of a newly developed nutrition resource kit, which served as an educational material among at-risk and malnourished elderly in Malaysian health clinics. Methods: This study was conducted in three phases: Phase I comprised of qualitative needs assessment to identify the types of nutrition resource kit needed; Phase II was the development and validation of the nutrition resource kit; while Phase III was acceptance evaluation, which involved individual in-depth interview and triangulation. Results: An A5-sized booklet with incorporation of an educational video in a QR code was developed. Both printed material and educational video had excellent content and face validity. Suggestions by experts and elderly from validation were considered and revision was done accordingly. Acceptance evaluation revealed four themes: 1) positive acceptance, 2) elderly-friendly, 3) valuable, and 4) individual preference. Triangulation data revealed that all elderly positively evaluated both resources. Additional suggestions given by elderly were considered for improvement. Conclusion: This newly developed nutrition resource kit, both in the printed and electronic format, was well-accepted among the at-risk and malnourished elderly. It could be used as an important reference for the elderly, especially those attending health clinics, in treating and preventing malnutrition.

Geriatric Nutritional Risk Index is Associated with Hospital Death in Elderly Patients with Multiple Organ Dysfunction Syndrome: A Retrospective Study Based on the MIMIC-III Database

Purpose

Elderly patients with multiple organ dysfunction syndrome (MODS) have a higher mortality during hospitalization in the intensive care unit (ICU). Elderly patients often suffer from malnutrition. On the basis of the MIMIC-III database, this study analyzed the effect of the baseline nutritional status on the death of elderly patients with MODS during hospitalization.

Materials and Methods

Elderly patients with MODS were screened out from MIMIC-III 1.4 database. The geriatric nutritional risk index (GNRI) was calculated and used to group patients into: normal nutrition (GNRI > 98) and malnutrition (GNRI ≤ 98) groups. The malnutrition group was divided into mild (92–98), moderate (82–91), and severe (≤81) groups. The differences in the baseline data and the incidence of adverse events between groups were compared. The GAM model was used to determine whether a curve relationship was present between the hospital death of elderly patients with MODS and GNRI and analyze the threshold saturation effect. The multivariate logistic regression was used to calculate the odds ratio (OR) of in-hospital deaths in different GNRI groups. The interaction test was performed to find subgroups with differences.

Results

A total of 2456 elderly patients with MODS were enrolled. A total of 1,273 (51.8%) and 1183 (48.2%) patients were in the normal nutrition and malnutrition groups, respectively. The mortality rate of patients in the normal nutrition group during hospitalization was lower than that in the malnutrition group (206/1273 vs. 292/1183, X2 = 27.410, P < 0.001; OR = 0.59, 95% CI: 0.48–0.72). The GAM model fitting analysis showed a threshold saturation effect at GNRI = 92. Adjusted OR values with GNRI ≥ 92 began to change to 1, and GNRI and death had no association. At GNRI < 92, high GNRI related to low risk of death. Subgroup analysis of patients with GNRI < 92 showed that the risk of death in elderly male patients was lower than that of female patients.

Conclusion

GNRI is related to the severity of illness in elderly patients with MODS. At GNRI < 92, moderate to severe malnutrition increases the risk of death in elderly patients with MODS during hospitalization.

Oral Health of Elderly People in Institutionalized Care and Three-Month Rehabilitation Programme in Southern Poland: A Case-Control Study

Demographic ageing is a global growing process and the quality of ageing is an important parameter in this process. The aim of the study was to analyse the distribution of remaining dentition in relation to oral hygiene indicators among elderly people remaining in institutional care and those who participated in a 3-month rehabilitation program, aimed at increasing time of independent functioning, in southern Poland. The patients underwent a questionnaire and clinical examination. An analysis of missing teeth was performed, plaque index, and gingival index were measured. Residents of the Municipal Health Centre for Older and Dependent People (n = 50) had a higher incidence of missing teeth in the maxilla (88.4%), mandible (77.6%), as well as in the maxilla and mandible combined (83%) than residents of the Daily Medical Care House (n = 30). The distribution of the remaining teeth, in both groups, corresponds to the outlets of the large salivary glands. The group of 53.8% of patients with dry mouth had PI scored 3. Residents with dry mouth were more likely to have plaque deposits and gingival inflammation. It is necessary to develop and implement an oral care program for patients with reduced saliva secretion, with a particular focus on dependents.

The relationship of the geriatric nutritional risk index to mortality and length of stay in elderly patients with acute respiratory failure: A retrospective cohort study

BACKGROUND

Elderly people with acute respiratory failure (ARF) have prolonged length of hospital stay (LOS) and high mortality rates. Malnutrition is negatively correlated with these LOS and mortality. However, no tools have been used to detect the risk of malnutrition and assist in designing nutritional support for these patients. The geriatric nutritional risk index (GNRI) is reported as a novel tool for evaluating the risk of malnutrition. The aim of this study is to explore the relationship of the GNRI score with mortality and LOS in elderly patients with ARF.

METHODS

Data of elderly patients diagnosed with ARF were retrieved from the Medical Information Mart for Intensive Care III (MIMIC-III) database. A total of 1250 patients were divided into two groups based on their GNRI score: the malnutrition risk group (GNRI ≤ 98) and no risk group (GNRI > 98). The primary endpoints of this study were hospital mortality and hospital LOS.

RESULTS

The higher GNRI score was associated with lower hospital mortality and shorter hospital LOS. Odds ratio (OR) for hospital mortality of patients with nutritional risk (GNRI ≤ 98) was 1.264 (95% CI:1.067-1.497) in the adjusted model. Patients with GNRI ≤98 had longer hospital LOS (adjusted OR: 1.142, 95%CI: 1.044-1.250) compared with those with GNRI > 98. Subgroup analysis showed that higher GNRI was only significantly associated with lower hospital mortality in the patients that did not undergo mechanical ventilator (MV) treatment (adjusted OR: 0.985, 95% CI: 0.977-0.992, P < 0.01). Kaplan-Meier curve analysis showed that the 90-day survival was significantly lower in the group with nutrition risk (GNRI≤98) compared with the no risk group (GNRI > 98, p < 0.05).

CONCLUSION

These findings imply that GNRI is a useful prognostic tool in elderly patients with ARF.

Malnutrition in Older Adults-Recent Advances and Remaining Challenges

Malnutrition in older adults has been recognised as a challenging health concern associated with not only increased mortality and morbidity, but also with physical decline, which has wide ranging acute implications for activities of daily living and quality of life in general. Malnutrition is common and may also contribute to the development of the geriatric syndromes in older adults. Malnutrition in the old is reflected by either involuntary weight loss or low body mass index, but hidden deficiencies such as micronutrient deficiencies are more difficult to assess and therefore frequently overlooked in the community-dwelling old. In developed countries, the most cited cause of malnutrition is disease, as both acute and chronic disorders have the potential to result in or aggravate malnutrition. Therefore, as higher age is one risk factor for developing disease, older adults have the highest risk of being at nutritional risk or becoming malnourished. However, the aetiology of malnutrition is complex and multifactorial, and the development of malnutrition in the old is most likely also facilitated by ageing processes. This comprehensive narrative review summarizes current evidence on the prevalence and determinants of malnutrition in old adults spanning from age-related changes to disease-associated risk factors, and outlines remaining challenges in the understanding, identification as well as treatment of malnutrition, which in some cases may include targeted supplementation of macro- and/or micronutrients, when diet alone is not sufficient to meet age-specific requirements.

Impact of the Malnutrition on Mortality in Elderly Patients Undergoing Percutaneous Coronary Intervention

Purpose

Malnutrition has been shown to be related to adverse clinical outcomes in patients with heart failure, hypertension, atrial fibrillation and other cardiovascular diseases. However, in the patients with coronary artery disease (CAD) undergoing percutaneous coronary interventions (PCI), especially in the elderly, the association of nutritional state and all-cause mortality remains unknown. We aimed to investigate the association of malnutrition with all-cause mortality in the elder patients undergoing PCI.

Patients and Methods

Based on the largest retrospective and observational cohort study from January 2007 to December 2017, the Controlling Nutritional Status (CONUT) score was applied to 21,479 consecutive patients with age ≥60 who undergoing PCI for nutritional assessment. Participants were classified as absent, mild, moderate and severe malnutrition by CONUT score. The Kaplan-Meier method was used to compare all-cause mortality among the above four groups. Multivariable Cox proportional hazard regression analyses were performed to examine the association of malnutrition with all-cause mortality.

Results

According to the CONUT score, 48.19%, 15.08% and 0.94% patients were mildly, moderately and severely malnourished, respectively. During a median follow-up of 5.16 years (interquartile range: 3.02 to 7.89 years), 3173 (14.77%) patients died. Kaplan-Meier analysis showed that the risk of all-cause mortality was significantly higher in patients with a worse nutritional status. Compared with normal nutritional state, malnutrition was associated with significantly increased risk for all-cause mortality (adjusted hazard ratio for mild, moderate and severe degrees of malnutrition, respectively: 1.20 [95% confidence interval (CI): 1.09 to 1.33], 1.32 [95% CI: 1.17 to 1.49] and 1.76 [95% CI: 1.33 to 2.33]).

Conclusion

Malnutrition is prevalent among elderly patients with CAD undergoing PCI, and is strongly related to the all-cause mortality increasing. For elderly patients with CAD undergoing PCI, it is necessary to assess the status of nutrition, and evaluate the efficacy of nutritional interventions.

Nutritional risk in critically ill patients: how it is assessed, its prevalence and prognostic value: a systematic review

CONTEXT

Nutritional risk (NR) screening is the first step of nutrition care process. Few data are available in literature about its prevalence, nor, to our knowledge, is a universally accepted reference method for the intensive care unit (ICU).

OBJECTIVE

The aim for this systematic review was to summarize evidence regarding the prevalence of NR and the predictive validity of different tools applied for NR screening of critically ill patients.

DATA SOURCES

The PubMed, Embase, and Scopus databases were searched up to December 2019 using the subject headings related to critically ill patients and NR screening. The current systematic review is registered with PROSPERO (identifier: CRD42019129668).

DATA EXTRACTION

Data on NR prevalence, predictive validity of nutritional screening tools, and interaction between caloric-protein balance and NR in outcome prediction were collected.

DATA ANALYSIS

Results were summarized qualitatively in text and tables, considering the outcomes of interest.

RESULTS

From 15 669 articles initially identified, 36 fulfilled the inclusion criteria, providing data from 8 nutritional screening tools: modified Nutrition Risk in the Critically Ill (mNUTRIC; n = 26 studies) and Nutritional Risk Screening-2002 (NRS-2002; n = 7 studies) were the most frequent; the NR prevalence was 55.9% (range, 16.0% to 99.5%). Nutritional risk was a predictor of 28-day and ICU mortality in 8 studies. Interactions between caloric-protein balance and NR on outcome prediction presented were scarcely tested and presented heterogeneous results (n = 8).

CONCLUSIONS

Prevalence of NR in patients in the ICU varies widely; a satisfactory predictive validity was observed, especially when mNUTRIC or NRS-2002 were applied.

Risk Factors for 28-Day Mortality in a Surgical ICU: A Retrospective Analysis of 347 Cases

Purpose

Advances in surgical techniques and intensive care over the past decades have significantly reduced the mortality rates of critically ill surgical patients. However, evaluations of risk factors associated with mortality in surgical intensive care units (ICUs) are limited. The aim of this study was to analyze the independent risk factors for 28-day mortality of surgical ICU patients.

Patients and Methods

The clinical data of adult patients who were admitted to the surgical ICU in the First Affiliated Hospital of Xi’an Jiaotong University from June 2013 to June 2017 were collected. Univariate and multivariable logistic regression analyses were performed to examine risk factors associated with 28-day mortality.

Results

A total of 347 patients were included in this analysis. The overall 28-day mortality rate was 32.6%. The major causes of surgical ICU admission were gastrointestinal diseases (46.7%), infection (20.5%), trauma (8.9%), respiratory diseases (8.9%) and cardiovascular diseases (6.6%). The univariate analysis showed age, total bilirubin, prothrombin time, international normalized ratio, arterial lactate level, APACHE II and SOFA score at ICU admission were significantly associated with 28-day mortality. In the multivariate analysis, however, age [Odds Ratio (OR): 2.899, 95% CI: 1.427–5.890, P=0.003], hypertension [OR: 3.630, 95% CI: 1.545–8.531, P=0.003], platelet count [OR: 1.004, 95% CI: 1.001–1.007, P=0.015], arterial lactate level [OR: 1.186, 95% CI: 1.088–1.293, P<0.001] and SOFA score [OR: 1.289, 95% CI: 1.131–1.469, P<0.001] were identified as the independent risk factors for 28-day mortality of patients in the surgical ICU.

Conclusion

In patients admitted to the surgical ICU, age 65 and older, a high arterial lactate level and SOFA score at ICU admission were associated with increased 28-day mortality.

Effect of Tubular Feeding with the Measurement of Gastric Residual Volume on Ventilator Associated Pneumonia

Background

Several measures have been taken to prevent the onset of ventilator-associated pneumonia (VAP), one of which is measuring the gastric residual volume. The purpose of this study is to compare the effect of two tube feeding methods with and without gastric residual volume measurement on VAP.

Materials and Methods

This clinical trial was performed on the study population of patients with endotracheal tubes hospitalized in Intensive Care Units 1 and 2 of Golestan hospital, Ahvaz, Iran. Overall, 70 patients who met the inclusion criteria were randomly divided into groups 1 and 2. Groups 1 and 2 were fed with and without measuring gastric residual volume, respectively. The incidence of pneumonia was assessed using the Modified Clinical Pulmonary Infection Score prior to the intervention and on the fifth day post- intervention. The data were analyzed by the SPSS software version 22.

Results

The incidence of VAP was 9.12% in the group with gastric residual volume measurement and 7.14% in the other group. There was no significant difference between the two groups (P=0.827) regarding VAP prevalence.

Conclusion

Monitoring gastric residual v olume requires aspiration and repeated measurements of gastric contents, resulting in increased nursing workload. Moreover, if the gastric residual volume is high, the patient will be deprived of calorie intake and subjected to malnutrition. As a result, removing the monitoring of gastric residual volume from the care setting and focusing on interventions proven to reduce VAP can be more helpful.

Comparison of Modified NUTRIC, NRS-2002, and MUST Scores in Iranian Critically Ill Patients Admitted to Intensive Care Units: A Prospective Cohort Study

BACKGROUND

There are no data on the validity of the modified Nutrition Risk in the Critically Ill (m-NUTRIC)-score and Nutritional Risk Screening 2002 (NRS-2002)-score in Iranian intensive care unit (ICU) patients. The Malnutrition Universal Screening Tool (MUST) is still used in most Iranian ICUs. Our goal was to test the validity of these tools in the Iranian ICU population.

METHODS

The association between nutrition risk scores and outcomes (longer length of stay [LOS], prolonged mechanical ventilation [MV], and 28-day mortality) was assessed using the multivariable logistic regression. The performance of nutrition risk tools to predict 28-day mortality was assessed using the receiver operating characteristic curve. A logistic regression model was used to test the interaction between nutrition risk category, energy adequacy, and 28-day mortality.

RESULTS

Four hundred forty patients were included. Both the m-NUTRIC and NRS-2002 scores were significantly associated with all 3 outcomes (all P < .001). However, no significant association was identified between the MUST and all 3 outcomes (P > .05). The area under the curve for predicting 28-day mortality was 0.806 (95% CI, 0.756-0.851), 0.695 (95% CI, 0.632-0.752), and 0.551 (95% CI, 0.483-0.612) for m-NUTRIC, NRS-2002, and MUST, respectively. Greater energy adequacy was associated with a lower 28-day mortality rate in patients with high m-NUTRIC but not in those with low m-NUTRIC score (P interaction = .015).

CONCLUSION

In the Iranian ICU population, the m-NUTRIC score may be a valid tool for identifying patients who would benefit from more aggressive nutrition therapy.

Are Edentulousness, Oral Health Problems and Poor Health-Related Quality of Life Associated with Malnutrition in Community-Dwelling Elderly (Aged 75 Years and Over)? A Cross-Sectional Study

As the population ages, the risk of becoming malnourished increases. Research has shown that poor oral health can be a risk factor for malnutrition in institutionalized elderly. However, it remains unclear whether oral health problems, edentulousness and health-related quality of life also pose a risk for malnutrition in community-dwelling older adults. In this cross-sectional observational study, 1325 community-living elderly (≥75 years) were asked to complete questionnaires regarding nutritional status, oral status (edentulous, remaining teeth, or implant-supported overdentures), oral health problems, health-related quality of life (HRQoL), frailty, activities of daily living (ADL) and complexity of care needs. Univariate and multivariate logistic regression analyses were performed with nutritional status as dependent variable. Of the respondents, 51% (n = 521) were edentulous, 38.8% (n = 397) had remaining teeth and 10.2% (n = 104) had an implant-supported overdenture. Elderly with complex care needs were malnourished most frequently, followed by frail and robust elderly (10%, 4.5% and 2.9%, respectively). Malnourished elderly reported more frequent problems with chewing and speech when compared with well-nourished elderly (univariate analysis). However, multivariate analysis did not show an association between malnutrition and oral health problems and edentulousness, although HRQoL was associated with malnutrition (odds ratio (OR) 0.972, confidence interval (CI) 0.951–0.955). Based on the results of this cross-sectional study, it can be concluded that poor HRQoL is significantly associated with malnutrition; however, edentulousness and oral health problems are not.

Permissive or Trophic Enteral Nutrition and Full Enteral Nutrition Had Similar Effects on Clinical Outcomes in Intensive Care: A Systematic Review of Randomized Clinical Trials

The aim of this study was to systematically review the effect of permissive underfeeding/trophic feeding on the clinical outcomes of critically ill patients. A systematic review of randomized clinical trials to evaluate the mortality, length of stay, and mechanical ventilation duration in patients randomized to either hypocaloric or full-energy enteral nutrition was performed. Data sources included PubMed and Scopus and the reference lists of the articles retrieved. Two independent reviewers participated in all phases of this systematic review as proposed by the Cochrane Handbook, and the review was reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 7 randomized clinical trials that included a total of 1,717 patients were reviewed. Intensive care unit length of stay and mechanical ventilation duration were not statistically different between the intervention and control groups in all randomized clinical trials, and mortality rate was also not different between the groups. In conclusion, hypocaloric enteral nutrition had no significantly different effects on morbidity and mortality in critically ill patients when compared with full-energy nutrition. It is still necessary to determine the safety of this intervention in this group of patients, the optimal amount of energy provided, and the duration of this therapy.

Feeding the critically ill obese patient: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to identify effective enteral nutritional regimens targeting protein and calorie delivery for the critically ill obese patient on morbidity and mortality.More specifically, the review question is:In the critically ill obese patient, what is the optimal enteral protein and calorie target that improves mortality and morbidity?

BACKGROUND

The World Health Organization (WHO) defines obesity as abnormal or excessive fat accumulation that may impair health, or, empirically, as a body mass index (BMI) ≥ 30 kg/m. Twenty-eight percent of the Australian population is obese with the prevalence rising to 44% in rural areas, and there is evidence that rates of obesity are increasing. The prevalence of obese patients in intensive care largely mirrors that of the general population. There is concern, however, that this may also be rising. A recently published multi-center nutritional study of critically ill patients reported a mean BMI of 29 in their sample, suggesting that just under 50% of their intensive care population is obese. It is inevitable, therefore, that the intensivist will care for the critically ill obese patient.Managing the critically ill obese patient is challenging, not least due to the co-morbid diseases frequently associated with obesity, including diabetes mellitus, cardiovascular disease, dyslipidaemia, sleep disordered breathing and respiratory insufficiency, hepatic steatohepatitis, chronic kidney disease and hypertension. There is also evidence that metabolic processes differ in the obese patient, particularly those with underlying insulin resistance, itself a marker of the metabolic syndrome, which may predispose to futile cycling, altered fuel utilization and protein catabolism. These issues are compounded by altered drug pharmacokinetics, and the additional logistical issues associated with prophylactic, therapeutic and diagnostic interventions.It is entirely plausible that the altered metabolic processes observed in the obese intensify and compound the metabolic changes that occur during critical illness. The early phases of critical illness are characterized by an increase in energy expenditure, resulting in a catabolic state driven by the stress response. Activation of the stress response involves up-regulation of the sympathetic nervous system and the release of pituitary hormones resulting in altered cortisol metabolism and elevated levels of endogenous catecholamines. These produce a range of metabolic disturbances including stress hyperglycemia, arising from both peripheral resistance to the effects of anabolic factors (predominantly insulin) and increased hepatic gluconeogenesis. Proteolysis is accelerated, releasing amino acids that are thought to be important in supporting tissue repair, immune defense and the synthesis of acute phase reactants. There is also altered mobilization of fuel stores, futile cycling, and evidence of altered lipoprotein metabolism. In the short term this is likely to be an adaptive response, but with time and ongoing inflammation this becomes maladaptive with a concomitant risk of protein-calorie malnutrition, immunosuppression and wasting of functional muscle tissue resulting from protein catabolism, and this is further compounded by disuse atrophy. Muscle atrophy and intensive care unit (ICU) acquired weakness is complex and poorly understood, but it is postulated that the provision of calories and sufficient protein to avoid a negative nitrogen balance mitigates this process. Avoiding lean muscle mass loss in the obese intuitively has substantial implications, given the larger mass that is required to be mobilized during their rehabilitation phase.There is, in addition, evolving evidence that hormones derived from both the gut and adipose tissue are also involved in the response to stress and critical illness, and that adipose tissue in particular is not a benign tissue bed, but rather should be considered an endocrine organ. Some of these hormones are thought to be pro-inflammatory and some anti-inflammatory; however both the net result and clinical significance of these are yet to be fully elucidated.The provision of adequate nutrition has become an integral component of supportive ICU care, but is complex. There is ongoing debate within critical care literature regarding the optimal route of delivery, the target dose, and the macronutrient components (proportion of protein and non-protein calories) of nutritional support. A number of studies have associated caloric deficit with morbidity and mortality, with the resultant assumption that prescribing sufficient calories to match energy expenditure will reduce morbidity and mortality, although the evidence base underpinning this assumption is limited to observational studies and small, randomized trials.There is research available that suggests hyper-caloric feeding or hyper-alimentation, particularly of carbohydrates, may result in increased morbidity including hyperglycemia, liver steatosis, respiratory insufficiency with prolonged duration of mechanical ventilation, re-feeding syndrome and immune suppression. But the results from studies of hypo-caloric and eucaloric feeding regimens in critically ill patients are conflicting, independent of the added metabolic complexities observed in the critically ill obese patient.Notwithstanding the debate regarding the dose and components of nutritional therapy, there is consensus that nutrition should be provided, preferably via the enteral route, and preferably initiated early in the ICU admission. The enteral route is preferred for a variety of reasons, not the least of which is cost. In addition there is evidence to suggest the enteral route is associated with the maintenance of gut integrity, a reduction in bacterial translocation and infection rates, a reduction in the incidence of stress ulceration, attenuation of oxidative stress, release of incretins and other entero-hormones, and modulation of systemic immune responses. Yet there is evidence that the initiation of enteral nutritional support for the obese critically ill patient is delayed, and that when delivered is at sub-optimal levels. The reasons for this remain obscure, but may be associated with the false assumption that every obese patient has nutritional reserves due to their adipose tissues, and can therefore withstand longer periods with no, or reduced nutritional support. In fact obesity does not necessarily protect from malnutrition, particularly protein and micronutrient malnutrition. It has been suggested by some authors that the malnutrition status of critically ill patients is a stronger predictor of mortality than BMI, and that once malnutrition status is controlled for, the apparent protective effects of obesity observed in several epidemiological studies dissipate. This would be consistent with the large body of evidence that associates malnutrition (BMI < 20 kg/m) with increased mortality, and has led some authors to postulate that the weight-mortality relationship is U-shaped. This has proven difficult to demonstrate, however, due to recognized confounding influences such as chronic co-morbidities, baseline nutritional status and the nature of the presenting critical illness.This has led to interest in nutritional regimens targeting alternative calorie and protein goals to protect the obese critically ill patient from complications arising from critical illness, and particularly protein catabolism. However, of the three major nutritional organizations, the American Society of Parenteral and Enteral Nutrition (ASPEN) is the only professional organization to make specific recommendations about providing enteral nutritional support to the critically ill obese patient, recommending a regimen targeting a hypo-caloric, high-protein goal. It is thought that this regimen, in which 60-70% of caloric requirements are provided promotes steady weight loss, while providing sufficient protein to achieve a neutral, or slightly positive, nitrogen balance, mitigating lean muscle mass loss, and allowing for wound healing. Targeting weight loss is proposed to improve insulin sensitivity, improve nursing care and reduce the risk of co-morbidities, although how this occurs and whether it can occur over the relatively short time frame of an intensive care admission (days to weeks) remains unclear. Despite these recommendations observational data of international nutritional practice suggest that ICU patients are fed uniformly low levels of calories and protein across BMI groups.Supporting the critically ill obese patient will become an increasingly important skill in the intensivist's armamentarium, and enteral nutritional therapy forms a cornerstone of this support. Yet, neither the optimal total caloric goal nor the macronutrient components of a feeding regimen for the critically ill obese patient is evident. Although the suggestion that altering the macronutrient goals for this vulnerable group of patients appears to have a sound physiological basis, the level of evidence supporting this remains unclear, and there are no systematic reviews on this topic. The aim of this systematic review is to evaluate existing literature to determine the best available evidence describing a nutritional strategy that targets energy and protein delivery to reduce morbidity and mortality for the obese patient who is critically ill.

Effects that passive cycling exercise have on muscle strength, duration of mechanical ventilation, and length of hospital stay in critically ill patients: a randomized clinical trial

Objective

To evaluate the effects that passive cycling exercise, in combination with conventional physical therapy, have on peripheral muscle strength, duration of mechanical ventilation, and length of hospital stay in critically ill patients admitted to the ICU of a tertiary care university hospital.

Methods

This was a randomized clinical trial involving 38 patients (≥ 18 years of age) on mechanical ventilation who were randomly divided into two groups: control (n = 16), receiving conventional physical therapy; and intervention (n = 22), receiving conventional physical therapy and engaging in passive cycling exercise five days per week. The mean age of the patients was 46.42 ± 16.25 years, and 23 were male. The outcomes studied were peripheral muscle strength, as measured by the Medical Research Council scale, duration of mechanical ventilation, and length of hospital stay.

Results

There was a significant increase in peripheral muscle strength (baseline vs. final) in both groups (control: 40.81 ± 7.68 vs. 45.00 ± 6.89; and intervention: 38.73 ± 11.11 vs. 47.18 ± 8.75; p < 0.001 for both). However, the range of increase in strength was higher in the intervention group than in the control group (8.45 ± 5.20 vs. 4.18 ± 2.63; p = 0.005). There were no significant differences between the groups in terms of duration of mechanical ventilation or length of hospital stay.

Conclusions

The results suggest that the performance of continuous passive mobilization on a cyclical basis helps to recover peripheral muscle strength in ICU patients. (ClinicalTrials.gov Identifier: NCT01769846 [http://www.clinicaltrials.gov/]).

Is total lymphocyte count related to nutritional markers in hospitalized older adults?

ABSTRACT BACKGROUND Older patients are commonly malnourished during hospital stay, and a high prevalence of malnutrition is found in hospitalized patients aged more than 65 years. OBJECTIVE To investigate whether total lymphocyte count is related to other nutritional markers in hospitalized older adults. METHODS Hospitalized older adults (N=131) were recruited for a cross-sectional study. Their nutritional status was assessed by the Nutritional Risk Screening (NRS), anthropometry, and total lymphocyte count. The statistical analyses included the chi-square test, Fisher's exact test, and Mann-Whitney test. Spearman's linear correlation coefficient determined whether total lymphocyte count was correlated with the nutritional markers. Multiple linear regression determined the parameters associated with lymphocyte count. The significance level was set at 5%. RESULTS According to the NRS, 41.2% of the patients were at nutritional risk, and 36% had mild or moderate depletion according to total lymphocyte count. Total lymphocyte count was weakly correlated with mid-upper arm circumference (r=0.20507); triceps skinfold thickness (r=0.29036), and length of hospital stay (r= -0.21518). Total lymphocyte count in different NRS categories differed significantly: older adults who were not at nutritional risk had higher mean and median total lymphocyte count ( P =0.0245). Multiple regression analysis showed that higher lymphocyte counts were associated with higher triceps skinfold thicknesses and no nutritional risk according to the NRS. CONCLUSION Total lymphocyte count was correlated with mid-upper arm circumference, triceps skinfold thickness, and nutritional risk according to the NRS. In multiple regression the combined factors that remained associated with lymphocyte count were NRS and triceps skinfold thickness. Therefore, total lymphocyte count may be considered a nutritional marker. Other studies should confirm these findings.