Respiratory sarcopenia screening in dialysis patients: cross-sectional and multicentre study protocol

BACKGROUND

Respiratory sarcopenia is characterized by the weakness of respiratory muscles associated with sarcopenia due to aging or systemic diseases such as chronic kidney disease (CKD). Patients with CKD undergoing dialysis are particularly susceptible to respiratory muscle weakness caused by factors such as fluid overload and electrolyte imbalance. This weakness not only affects ventilation but also impairs oxygen uptake and delivery to muscle tissue, potentially leading to severe sarcopenia. Thus, the objective of this study is to conduct a respiratory sarcopenia screening in patients with CKD undergoing haemodialysis (HD) and peritoneal dialysis (PD).

METHODS

This is an observational, cross-sectional and multicentre study conducted between March 2023 and March 2025. The study was approved by the Research Ethics Committee at two centres. Sarcopenia diagnosis is determined based on low handgrip strength and amount of appendicular skeletal muscle mass, assessed through bioelectrical impedance analysis. Respiratory sarcopenia is diagnosed in patients with sarcopenia who have low inspiratory muscle strength, evaluated through a manovacuometry test. The severity of sarcopenia and respiratory sarcopenia is defined, respectively, by low physical performance (measured using the Short Physical Performance Battery and Timed-Up and Go test) and pulmonary performance (measured through spirometry). Thus, this study will include 81 patients undergoing dialysis (41 on HD and 40 on PD) from three participating centres.

DISCUSSION

The literature has been focused on respiratory function in CKD; however, the relationship with sarcopenia remains understudied. We believe that, similar to appendicular skeleton muscles, the axial skeleton muscles are also likely to weaken with the presence of chronic disease, such as CKD.

Factors associated with diet quality among Brazilian individuals with cardiovascular diseases

BACKGROUND

An individual's dietary pattern contributes in different ways to the prevention and control of recurrent cardiovascular events. However, the quality of the diet is influenced by several factors. The present study aimed to evaluate the quality of the diet of individuals with cardiovascular diseases and determine whether there is an association between sociodemographic and lifestyle factors.

METHODS

This is a cross-sectional study carried out with individuals with atherosclerosis (coronary artery disease, cerebrovascular disease or peripheral arterial disease) recruited from 35 reference centres for the treatment of cardiovascular disease in Brazil. Diet quality was assessed according to the Modified Alternative Healthy Eating Index (mAHEI) and stratified into tertiles. For comparing two groups, the Mann-Whitney or Pearson's chi-squared tests were used. However, for comparing three or more groups, analysis of variance or Kruskal-Wallis was used. For the confounding analysis, a multinomial regression model was used. p < 0.05 was considered statistically significant.

RESULTS

In total, 2360 individuals were evaluated: 58.5% male and 64.2% elderly. The median (interquartile range [IQR]) of the mAHEI was 24.0 (20.0-30.0), ranging from 0.4 to 56.0 points. When comparing the odds ratios (ORs) for the low (first tertile) and medium (second tertile) diet quality groups with the high-quality group (third tertile), it was observed that there was an association between diet quality with a family income of 1.885 (95% confidence intervals [CI] = 1.302-2.729) and 1.566 (95% CI = 1.097-2.235), as well as physical activity of 1.391 (95% CI = 1.107-1.749) and 1.346 (95% CI = 1.086-1.667), respectively. In addition, associations were observed between diet quality and region of residence.

CONCLUSIONS

A low-quality diet was associated with family income, sedentarism and geographical area. These data are extremely relevant to assist in coping with cardiovascular disease because they enable an assessment of the distribution of these factors in different regions of the country.

Malnutrition screening tool and malnutrition universal screening tool as a predictors of prolonged hospital stay and hospital mortality: A cohort study

BACKGROUND & AIMS

Different nutrition screening tools have been proposed to screen inpatients, although, there is still no consensus regarding the reference method for identifying patients at nutritional risk. This retrospective cohort study aimed to evaluate the concurrent and predictive validity of the Malnutrition Screening Tool (MST) and Malnutrition Universal Screening Tool (MUST) to identify inpatients at nutritional risk.

METHODS

Data from electronic medical records were collected from adult and elderly inpatients in wards of a public tertiary hospital (Hospital de Clínicas de Porto Alegre, Brazil) over one year. Only the first nutritional evaluation was considered for each patient. GLIM criteria was used for malnutrition status (concurrent validity) and hospital stay length and mortality were outcomes to predictive validity.

RESULTS

A total of 5270 patients were included in this study. The mean patient age was 59 ± 16 years old, and 50.7% were males. More than 60% of the patients (65.8%) were admitted to a surgical unit, 63.8% had mild disease-related metabolic stress, 50.7% experienced prolonged hospital stays (more than ten days), and 1.9% of the patients died. Considering the availability of nutritional data, it was possible to perform nutritional screening of 98.1% of patients by MST and 96.7% of patients by MUST. A higher proportion of patients at risk were identified by MUST (53.6%) as compared to MST (21.3%; P < 0.001). MST had 89.9% of Specificity, 60.4% of PPV, 94.6% of NPV, and a moderate agreement with malnutrition by GLIM criteria (κ = 0.591; P < 0.001). A prolonged hospital stay was positively associated with the classification of nutritional risk based on both screening tools. Death was positively associated with nutritional risk by MST (hazard ratio [HR] 2.09; 95% confidence interval [CI] 1.37-3.16) and by MUST (HR 1.79; 95% CI 1.00-3.18) after adjustment based on sex, age, admission type (surgical or clinical), and disease-related metabolic stress.

CONCLUSIONS

MST may be good concurrent validity to malnutrition by GLIM criteria as compared to MUST. However, both risk nutritional tools were positively associated with predicting a prolonged hospital stay and mortality.

Handgrip strength in patients with acute decompensated heart failure: Accuracy as a predictor of malnutrition and prognostic value

OBJECTIVES

The aim of this study was to determine whether handgrip strength (HGS) has diagnostic accuracy for malnutrition assessment and whether it is an independent predictor of 90-d mortality in patients with acute decompensated heart failure (ADHF).

METHODS

This cohort study evaluated patients with ADHF within 36 h of hospital admission. Subjective global assessment and handgrip dynamometry were performed and the patients' medical records were analyzed. Mortality was monitored by phone contact and/or medical record search after 90 d. Diagnostic accuracy was tested with receiver operating characteristic (ROC) curves, and survival was tested in a Cox model.

RESULTS

The sample consisted of 161 patients with ADHF who were predominantly male (62%) and older (77%), with a mean age of 68 y (60-75 y) and an ejection fraction of 37.7% ± 16.2%. According to subjective global assessment, 60% were suspected of malnourishment or were moderately or severely malnourished and these patients had lower HGS values than the well-nourished patients (P < 0.001). The ROC curve for HGS was sufficiently accurate to assess malnutrition (area under the curve [AUC] = 0.696; 95% confidence interval [CI], 0.614-0.779; P < 0.001) and had very good accuracy to predict severe malnutrition (AUC = 0.817; 95% CI, 0.711-0.923, P < 0.001). When analyzed by sex, HGS could only accurately detect malnutrition in men, although it could detect severe malnutrition in both men and women. During the 90-d follow-up period, there were 16 deaths (9.9%). An HGS cutoff value of 25.5 kg for men was considered significant for 90-d mortality (hazard ratio, 8.6; 95% CI, 1.1-70.9; P = 0.045).

CONCLUSION

The results suggested that HGS is an independent indicator of malnutrition in patients with ADHF and can serve as a prognostic marker of 3-mo mortality in men.

Management model of primary health services and interprofessional practice in Brazil

Background

Brazilian primary health care is organized by decentralized Family Health Strategy composed with interprofessional teams. This study focused on finding out how are the relationship between the management model of primary health services and interprofessional practice.

Methods

Qualitative study, part of a mixed-methods sequential explanatory design. Thirteen semi-structured interviews were conducted with health managers from six Brazilian municipalities. Data were collected between October and December 2018 and applied content analysis.

Results

The results allow three major content categories, 1) “Characteristics of management models to support interprofessional practice”: continuous communication among managers, health care professional and patients is the principal attribute of management. The interviewed mentioned the need to communicate with teams using regular meetings and technological resources. They recognize the availability of interprofessional practice in favour of dialogue, shared decision and physical space. In order to patient engagement, they adopted open communication with patients focused on spontaneous demands. 2)”Management actions for comprehensive care”: the interviewed recognized the lack of services integration and interprofessional teams. They mentioned participatory management strategies as team meetings in health services and engagement in public health council to shared health planning. 3)”Challenges for management interprofessional practice”: Challenges considered the lack of permanent policies focused on patient needs, frequent changes of the municipal managers and health care professionals, the lack of planning actions, and the need to meet spontaneous management demands.

Conclusions

Management practices can support interprofessional practice and comprehensive care however challenges are related to non-permanent policies, unplanning actions and spontaneous management demands.

Key messages

Communication is the principal attribute of the management model of primary health services to reinforce interprofessional practice. Compreehensive care depends on patient and interprofessional teamwork engagement for share decision making.

Team Climate in Primary Health Care in a region of São Paulo countryside, Brazil

Background

Interprofessional teams are responsible for Primary Care at Brazilian HealthCare System. Teamwork climate is considered a key for quality of healthcare services and care perceived; it results in perceptions about a team, considering aspects that influence their relationship and effectiveness. The study aims to analyse the teamwork climate of Primary Care workers.

Methods

Survey cross-sectional carried out in a region of São Paulo countryside with 419 Primary Care professionals from 60 teams of public health services. We collect data through the Team Climate Inventory with 38 items and 4 factors. We analysed the data using a psychometric, factorial confirmatory analysis. This research is part of the Universal CNPq Project, process 431461/20163, and all ethical concerns were observed.

Results

In the sample 47 (11.2%) were nurses, 143 (34.1%) community health workers, 87 (20.7%) nursing assistants and 27 (6.4%) physicians and 115 (27,6%) other health professionals. Cronbach was &gt;0,90 in all factors of Team Climate Inventory and the correlation was confirmed with p &lt; 0,05. In the factor 1 - Team Participation M = 3,79, DP = 0,66; factor 2 - Support to new ideas M = 3,66, DP = 0,68; factor 3 - Team objectives M = 5,04, DP = 0,98; factor 4 - Tasks orientation M = 4,92, DP = 1,30 with p-value 0,001 to all factors. Tukey's post hoc analysis indicated that the group with less than one year in the teams (M = 5.31) had a significantly higher average when compared to groups with 6 to 10 years in the team (M = 4.91) and 11 years old or more (M = 5.04).

Conclusions

Results showed a good team climate in the sample, the potential to strengthen the teams and the relevance of working time together to get better results for patient health care. The magnitude of the public health impact by reporting on the team climate indicators of the 60 Brazilian teams are local and international relevance.

Key messages

The time of work together in a team can be a predictor of clear objectives in teamwork. The team climate recognizing can promote reinforce of the teamwork and the results to Public Health. Policy makers and managers can apply these results to build workforce management actions.

Dietary vitamin K intake and stability of anticoagulation with coumarins: evidence derived from a clinical trial

BACKGROUND

Dietary vitamin K intake has been considered a major factor that influences stability of oral anticoagulation (OA) with coumarins. Few studies have evaluated the relationship between amounts of dietary vitamin K intake and stability of anticoagulation.

OBJECTIVE

To assess whether high dietary vitamin K intake is associated to stability of International Normalized Ratio (INR) of the prothrombin time.

METHODS

We performed a sub-analysis of a randomized clinical trial involving outpatients from the anticoagulation clinic of a university hospital. INR and vitamin K intake were prospectively collected at baseline, 15, 30, 60 and 90 days after randomization. Patients were considered with a stable anticoagulation when their INR coefficient of variation was less than 10%. Dietary vitamin K intake was assessed by a food frequency questionnair and a score of intake was derived.

RESULTS

We studied 132 patients on chronic OA (57 ± 13 years; 55% males); 23 patients (17%) were achieved stable anticoagulation. Stable and unstable patients had no significant differences in baseline characteristics. The dietary vitamin K score over the entire follow-up for stable patients was significantly lower than that for unstable patients (p = 0.012).

DISCUSSION

Our findings suggest that INR stability could be achieved with relatively low amounts of dietary vitamin K.

Insulin resistance, body fat percentage, and lipid abnormalities as risk factors for cardiovascular diseases in renal transplant recipients: a 1-year analysis

The aim of this study was to evaluate changes in body mass index (BMI), body fat percentage (BF%), insulin resistance, and lipid profile in 32 patients during the first year after renal transplantation by anthropometric measures. The homeostasis model assessment index (HOMA) was calculated for insulin resistance estimation. Anthropometric measures and biochemical markers were evaluated at the time of transplantation (T(0)), and prospectively at 3 (T(3)), 6 (T(6)), 9 (T(9)), and 12 (T(12)) months posttransplantation. The HOMA index decreased significantly at 3 months after transplantation (T(3)) (2.4 +/- 1.5 vs 1.5 +/- 1.1; P < .01); however, an increment was observed at T(6) and T(9) (1.8 +/- 0.8 and 2 +/- 1.5, respectively), remaining stable at T(12) (2 +/- 1.7). BMI and BF% increased significantly over 12 months (23.3 +/- 2.7 vs 24.4 +/- 2.7 kg/m(2); P = .001 and 23.7 +/- 7.8 vs 25.6 +/- 7.7 %; P = .002). Total cholesterol, low-density lipoprotein cholesterol and triglyceride levels showed significant increases starting at T(3). In conclusion, insulin resistance decreased transitorily post-renal transplantation. BMI, BF%, and lipid profile showed unfavorable changes during the first year post-renal transplantation.

Leptin serum levels in the first year post-renal transplantation

The aim of the present study was to evaluate the serum levels of leptin in the first year post-renal transplantation. Thirty-two patients and 19 healthy individuals were included. Serum leptin and biochemical markers were evaluated prospectively starting at transplant time (t(0)), and then every 3 months up to 1 year posttransplantation. The mean serum levels of leptin were higher in the pretransplant (t(0)) evaluation as compared with a control group of healthy volunteers (11.9 [9.2-25.2] and 7.7 [5.2-9.9] ng/mL, respectively; P < .0001). Leptinemia decreased significantly in the first 3 months after the renal transplantation (t(3)) (11.9 [9.2-25.2] to 7.1 [4.14-12.5] ng/mL; P < .0001) increased at t(6) to 10.6 (5.6-14.6) ng/mL and remained stable at t(9) (9.0 [5.2-18.3] ng/mL) and t(12) (9.3 [4.9-16.4] ng/mL). No correlation was found between leptin and renal function at any time during the study. In conclusion, during the first posttransplant year the serum leptin levels decreased significantly in relation to pretransplant period.

[Cardiac attacks in patients with acute Chagas disease in a family micro-outbreak, in Abaetetuba, Brazilian Amazon]

The authors describe the main clinical findings relative to cardiac involvement, in patients with acute Chagas' disease (CD) in yet another familial micro-epidemic episode of CD in Amazon region. Thirteen patients were studied with acute Chagas' disease, resident in the city of Abaetetuba in Pará state; they were submitted to clinical and heart evaluation, with electrocardiograph and echocardiograph exams. Ventricular extrasystole occurred in 38.5% of the cases. Right bundle branch block and 1st and 2nd degree atrioventricular block were found in 30.8% of the patients. Attention is called to two findings in the Doppler echocardiography: pericardiac involvement and an image suggestive of aneurismatic formation in two patients. The findings reveal acute heart disease, with evidence of cardiomyopathy and alterations in the conduction system of the heart, bearing similarity with the description of the disease in endemic areas.