Outpatient screening with the Royal Free Hospital-Nutrition Prioritizing Tool for patients with cirrhosis at risk of malnutrition

OBJECTIVES

Malnutrition is common among inpatients with cirrhosis. However, data on the prevalence of malnutrition among stable ambulatory patients with cirrhosis is lacking. We sought to investigate the prevalence of patents at risk of malnutrition (ARMN) among ambulatory patients with cirrhosis using the Royal Free Hospital-Nutrition Prioritizing Tool (RFH-NPT) and the Malnutrition Universal Screening Tool (MUST) and compare their correlation to clinical outcomes.

METHODS

Patients attending an outpatient liver cirrhosis clinic at a tertiary hospital were screened for ARMN using both the RFH-NPT and MUST (defined by a score of ≥2 for either tool). Differences in clinical outcomes after 6 mo were compared.

RESULTS

There were 134 patients recruited. The RFH-NPT identified more ARMN patients compared with MUST (32.8% versus 8.2%; P < 0.01; Cohen κ, 0.27 [95% CI, 0.12-0.42]; P < 0.001). Fluid overload at recruitment was the only independent predictor of disagreement between the RFH-NPT and MUST (odds ratio [OR], 43.14; 95% CI, 8.70-214.00; P < 0.001). There was a trend toward an increased risk of mortality for ARMN patients by the RFH-NPT (hazard ratio, 3.58; 95% CI, 0.81-15.83; P = 0.06) but not by the MUST (P = 0.62). The incidence of hospital admissions in ARMN patients was higher by the RFH-NPT, with an incidence rate ratio of 13.27 (95% CI, 5.11-43.70; P < 0.001), but not in ARMN patients by the MUST (P = 0.85). Being ARMN by the RFH-NPT was the only independent predictor of hospital admissions (OR, 15.08; 95% CI, 2.47-91.98; P = 0.003).

CONCLUSIONS

The RFH-NPT identified more ARMN patients when compared with the MUST, especially among patients with fluid overload. Patients at risk of malnutrition were at an increased risk of hospital admissions and possibly death.

The association between GLIM criteria defined malnutrition and 2-year unplanned hospital admission in outpatients with unintentional weight loss: A retrospective cohort study

BACKGROUND

This study aimed to assess malnutrition using the Global Leadership Initiative on Malnutrition (GLIM) criteria and Subjective Global Assessment (SGA) at baseline and determine the GLIM criteria that best predicted unplanned hospitalization in unintentional weight loss (UWL) outpatients.

METHODS

We performed a retrospective cohort study of 257 adult outpatients with UWL. The GLIM criteria and SGA agreement were reported using Cohen's kappa coefficient. Kaplan-Meier survival curves and adjusted Cox regression analyses were used for survival data. Logistic regression was used for the other correlation analysis.

RESULTS

This study collected data from 257 patients for 2 years. Based on the GLIM criteria and SGA, malnutrition prevalence was 79.0% and 72.0%, respectively (k = 0.728, P < 0.001). Using SGA as a standard, GLIM had a sensitivity of 97.8%, a specificity of 69.4%, a positive predictive value of 89.2%, and a negative predictive value of 92.6%. Malnutrition was associated with higher rates of unplanned hospital admission independent of other prognostic factors (GLIM: hazard ratio (HR) 2.85, 95% confidence interval (CI): 1.22 to 6.68; SGA: HR 2.07, 95% CI: 1.13 to 3.79). Of the five GLIM criteria-related diagnostic combinations, disease burden or inflammation was the most important to predict unplanned hospital admission in multivariable analysis (HR 3.27, 95% CI: 2.03 to 5.28).

CONCLUSION

There was good agreement between the GLIM criteria and SGA. GLIM-defined malnutrition, as well as all five GLIM criteria-related diagnosis combinations, had the potential to predict unplanned hospital admissions in UWL outpatients within 2 years. This article is protected by copyright. All rights reserved.

Nutritional status and its effect on complications in patients with colorectal cancer

BACKGROUND

Nutritional status is an important factor for predicting the risk of developing complications after a surgical procedure. Many nutritional assessments are used in clinical practice, but their role in predicting postoperative outcomes is unknown. Therefore, the aim of this study was to assess the utility of nutritional risk factors at the diagnosis of colorectal cancer (CRC) for predicting early postsurgical complications.

METHODS

This was a prospective observational study including 127 patients with CRC at diagnosis. Their preoperative nutritional status was analyzed by body mass index (BMI), triceps and subscapular skinfolds and two nutritional scales: the Patient-Generated Subjective Global Assessment (PG-SGA) and the Malnutrition Universal Screening Tool (MUST). The outcome variables, including postoperative complications, length of hospital stay and mortality, were analyzed.

RESULTS

Patients identified as malnourished by PG-SGA score had prolonged hospital stays (p = 0.01). The risk of infection was increased in older patients (hazard ratio, HR 1.12; 95% confidence interval, CI 1.04-1.21) but was not associated with nutritional status. Early wound dehiscence was increased in patients with higher BMI (HR 1.15; 95% CI 1.01-1.29), with higher subscapular skinfold thickness and increased age (HR 1.05; 95% CI 1.05-1.10). Postoperative mortality was not significantly associated with nutritional status.

CONCLUSION

Malnourished patients, as identified by the PG-SGA score, stayed longer in hospital than patients who were not malnourished, while increased BMI was recognized as a risk factor for wound dehiscence.

The relation between Malnutrition Universal Screening Tool (MUST), computed tomography-derived body composition, systemic inflammation, and clinical outcomes in patients undergoing surgery for colorectal cancer

BACKGROUND

Nutritional status is an important factor affecting a patient's clinical outcomes. Early identification of patients who are at risk of malnutrition is important to improve clinical outcomes and reduce health cost. The Malnutrition Universal Screening Tool (MUST) has been recommended as part of the routine nursing assessment for all patients at hospital admission.

OBJECTIVE

The aim of this study was to examine the association between nutritional status (MUST), systemic inflammatory response (SIR), body composition, and clinical outcomes in patients undergoing surgery for colorectal cancer.

METHODS

The malnutrition risk was examined using MUST in patients admitted for surgery for colorectal cancer between March 2013 and June 2016. Preoperative computed tomography scans were used to define the body composition. The presence of SIR was evidenced by the modified Glasgow prognostic score and the neutrophil to lymphocyte ratio. Postoperative complications, severity of complication, length of hospital stay, and mortality were considered as outcome measures.

RESULTS

The study included 363 patients (199 males, 164 females); 21% of the patients presented with a medium or high nutritional risk. There were significant associations between MUST and subcutaneous adiposity (P < 0.001), visceral obesity (P < 0.001), and low skeletal muscle index (P < 0.001). No statistically significant association was identified between MUST score and presence of any complication or severity of complication. On multivariate analysis, MUST remained independently associated with the length of hospital stay (OR: 2.17; 95% CI: 1.45, 3.26; P < 0.001). Kaplan-Meier survival curves showed an increased number of deaths for patients at medium or high risk of malnutrition (P < 0.001). This association was found to be independent of other confounding factors (HR: 1.45; 95% CI: 1.06, 1.99; P = 0.020).

CONCLUSIONS

MUST score is an independent marker of risk in those undergoing surgery for colorectal cancer and should remain a key part of preoperative assessment.

Food for thought. Malnutrition risk associated with increased risk of healthcare-associated infection

BACKGROUND

Infection and malnutrition are interconnected. UK and Irish guidelines recommend the Malnutrition Universal Screening Tool (MUST) for nutritional risk screening. Patients with a MUST score of ≥2 are considered at high risk of malnutrition and referral for nutritional assessment is recommended.

AIM

To explore the association between healthcare-associated infection (HCAI) and the MUST score categories of patients.

METHODS

This was a cross-sectional study in May 2017 on ten representative wards in our institution. Patient demographics, MUST score, presence of medical devices, HCAI and antimicrobial use were collected.

FINDINGS

Of 240 patients, the HCAI prevalence was 10.4% (N = 25) and 26% (N = 63) were at high risk of malnutrition (MUST score ≥2). Patients with HCAI were more likely to have had surgery (odds ratio (OR): 5.5; confidence interval (CI): 2.1-14.3; P < 0.001), a central vascular catheter (OR: 10.0; CI: 3.6-27.2; P < 0.001), or a urinary catheter in situ (OR: 7.5; CI: 2.8-20.0; P < 0.001), and to have a high risk of malnutrition (OR: 4.3; CI: 1.7-11.2; P < 0.001). A higher MUST score remained a significant predictor of a patient having HCAI on multivariate regression analysis (CI: 0.2-0.6; P < 0.001).

CONCLUSION

Patients at risk of malnutrition when assessed with the MUST were more likely to have HCAI. However, prospective studies are required to investigate the temporal association between MUST and HCAI and which interventions best address malnutrition risk and HCAI reduction in different settings.

Value of sarcopenia assessed by computed tomography for the prediction of postoperative morbidity following oncological colorectal resection: A comparison with the malnutrition screening tool

BACKGROUND

Computed tomography (CT) can be used for accurate estimation of whole-body muscle mass and muscle density and for detection of sarcopenia. The goal of this study was to evaluate the additional value of CT measured sarcopenia and muscle attenuation alongside the Malnutrition Universal Screening Tool (MUST) for the prediction of post-operative morbidity after oncological colorectal resection, whilst correcting for known risk factors.

METHODS

A prospective cohort study of 80 patients undergoing elective colorectal surgery in the Netherlands. Patients were screened for nutritional risk upon admission using the MUST. Additionally, preoperative CT scans were used to determine skeletal muscle mass for the detection of sarcopenia and muscle attenuation. Univariate and multivariable analyses were performed to evaluate associations between the MUST, muscle attenuation and sarcopenia on the one hand and post-operative complications measured by the Clavien-Dindo score on the other hand.

RESULTS

American Society of Anesthesiology-classification (ASA) ≥3, age ≥70, MUST ≥2 and lower than median muscle attenuation were significantly associated with a higher risk for postoperative complications (Clavien-Dindo score ≥2) (p ≤ 0.05), whereas sarcopenia was not (p = 0.59). Multivariate analyses showed that only MUST ≥2 remained significantly associated with postoperative complications when corrected for age (p = 0.03, OR 5.8, 95%CI 1.1-29.6), but not when corrected for age ≥70 and ASA ≥3. Muscle attenuation and sarcopenia were not significantly associated with postoperative complications.

CONCLUSION

Our results suggest that using CT measured sarcopenia may have only little additional value over the MUST for the prediction of increased short-term post-operative morbidity after oncological colorectal surgery. It also underlines the importance of currently implemented easy-to-use nutritional screening tools (MUST) and raises the question of the evaluation of muscle quality versus quantity in body composition imaging. However, further research is needed to investigate the role of sarcopenia for predicting outcome after colorectal surgery, and investigate the role of muscle attenuation measurements for the prediction of muscle function. CATEGORY OF SUBMISSION: observational study.

Enhancing the quality of oral nutrition support for hospitalized patients: a mixed methods knowledge translation study (The EQONS study)

AIM

The aim of this study was to report a multifaceted knowledge translation intervention to facilitate use of the Malnutrition Universal Screening Tool and innovation in nutritional care for patients at risk of malnutrition.

BACKGROUND

Malnutrition among hospitalized patients is a widespread problem leading to adverse health outcomes. Despite evidence of the benefits of malnutrition screening and recommendations for achieving good nutrition, shortfalls in practice continue.

DESIGN

A mixed method integrated knowledge translation study.

METHODS

The knowledge translation intervention comprised nutrition champions supported by knowledge translation facilitators and an action planning process. Data collection was undertaken over 18 months between 2011-2012 in a hospital in England. Data comprised observation of mealtimes, audit of patient records, survey of nurses and semi-structured interviews with nutrition champions, knowledge translation facilitators, senior ward nurses and nurse managers.

FINDINGS

Statistically significant relationships (Chi Square) were observed between self-reported confidence of nurses (a) to assess patients using the Malnutrition Universal Screening Tool, (b) to teach colleagues how to use the Malnutrition Universal Screening Tool and (c) to ensure that patients were assessed within 24 hours of admission. Ward-based nutrition champions facilitated successful innovation in nutrition support. Contextual factors operating at micro (ward), meso (organization) and macro (healthcare system) levels acted as barriers and enablers for change.

CONCLUSION

Nutrition champions were successful in increasing the timely assessment of patients at risk of malnutrition and promoting innovation in nutritional care. Support from knowledge translation facilitators helped nutrition champions develop their role and work collaboratively with senior ward nurses to implement action plans for improving nutrition.

Risk of malnutrition and zinc deficiency in community-living elderly men and women: the Tromsø Study

OBJECTIVE

Elderly people may be at particular risk of Zn deficiency due to an increased prevalence of malnutrition. The aim of the present study was to evaluate the Zn status in community-living elderly people at risk of malnutrition.

DESIGN

Cross-sectional population-based survey. Individuals at risk of malnutrition were identified by the Malnutrition Universal Screening Tool. Zn status was assessed by measuring serum Zn. Logistic regression was performed to evaluate the association between the risk of malnutrition and Zn deficiency.

SETTING

Municipality of Tromsø, Norway.

SUBJECTS

Random sample of 743 men and 778 women aged 65-87 years.

RESULTS

Zn deficiency was found in 10.1% of the participants, including 13.1% of the men and 7.3% of the women. Among the men and women at risk of malnutrition, 31.0% and 12.7%, respectively, had Zn deficiency. In a model adjusted for age, gender, serum albumin and smoking status, Zn deficiency was positively associated with the risk of malnutrition (OR=2.2; 95% CI 1.3, 3.6).

CONCLUSIONS

Overall, Zn deficiency was found in one out of ten community-living elderly people and was associated with the risk of malnutrition. Our results encourage the assessment of Zn status in elderly people at risk of malnutrition, with a special emphasis on elderly men.