Influence of nutritional status on clinical outcomes among hospitalized patients with COVID-19.

BACKGROUND AND AIMS: Several factors that worsen the prognosis of the new coronavirus SARS-CoV-2 have been identified, such as obesity or diabetes. However, despite that nutrition may change in a lockdown situation, little is known about the influence of malnutrition among subjects hospitalized due to COVID-19. Our study aimed to assess whether the presence of malnutrition among patients admitted due to COVID-19 had any impact on clinical outcomes compared with patients with the same condition but well nourished. METHODS: 75 patients admitted to hospital due to COVID-19 were analyzed cross-sectionally. Subjective Global Assessment (SGA) was completed by phone interview. Clinical parameters included were extracted from the electronic medical record. RESULTS: According to the SGA, 27 admitted due to a COVID-19 infection had malnutrition. Patients not well nourished were older than patients with a SGA grade A (65 ± 14.1 vs 49 ± 15.1 years; p < 0.0001). Length of hospital stay among poorly nourished patients was significantly higher (18.4 ± 15.6 vs 8.5 ± 7.7 days; p = 0.001). Mortality rates and admission to ICU were greater among subjects with any degree of malnutrition compared with well-nourished patients (7.4% vs 0%; p = 0.05 and 44.4% vs 6.3%; p < 0.0001). CRP (120.9 ± 106.2 vs 60.8 ± 62.9 mg/l; p = 0.03), D-dimer (1516.9 ± 1466.9 vs 461.1 ± 353.7 ng/mL; p < 0.0001) and ferritin (847.8 ± 741.1 vs 617.8 ± 598.7mcg/l; p = 0.03) were higher in the group with malnutrition. Haemoglobin (11.6 ± 2.1 vs 13.6 ± 1.5 g/dl; p < 0.0001) and albumin 3.2 ± 0.7 vs 4.1 ± 0.5 g/dl; p < 0.0001) were lower in patients with any degree of malnutrition. CONCLUSIONS: The presence of a poor nutritional status is related to a longer stay in hospital, a greater admission in the ICU and a higher mortality.

RISK FACTORS FOR HYPOGLYCEMIA IN INPATIENTS WITH TOTAL PARENTERAL NUTRITION AND TYPE 2 DIABETES: A POST HOC ANALYSIS OF THE INSUPAR STUDY.

Objective: Treatment of hyperglycemia with insulin is associated with increased risk of hypoglycemia in type 2 diabetes mellitus (T2DM) patients receiving total parenteral nutrition (TPN). The aim of this study was to determine the predictors of hypoglycemia in hospitalized T2DM patients receiving TPN. Methods: Post hoc analysis of the INSUPAR study, which is a prospective, open-label, multicenter clinical trial of adult inpatients with T2DM in a noncritical setting with indication for TPN. Results: The study included 161 patients; 31 patients (19.3%) had hypoglycemic events, but none of them was severe. In univariate analysis, hypoglycemia was significantly associated with the presence of diabetes with end-organ damage, duration of diabetes, use of insulin prior to admission, glycemic variability (GV), belonging to the glargine insulin group in the INSUPAR trial, mean daily grams of lipids in TPN, mean insulin per 10 grams of carbohydrates, duration of TPN, and increase in urea during TPN. Multiple logistic regression analysis showed that the presence of diabetes with end-organ damage, GV, use of glargine insulin, and TPN duration were risk factors for hypoglycemia. Conclusion: The presence of T2DM with end-organ damage complications, longer TPN duration, belonging to the glargine insulin group, and greater GV are factors associated with the risk of hypoglycemia in diabetic noncritically ill inpatients with parenteral nutrition. Abbreviations: ADA = American Diabetes Association; BMI = body mass index; CV% = coefficient of variation; DM = diabetes mellitus; GI = glargine insulin; GV = glycemic variability; ICU = intensive care unit; RI = regular insulin; T2DM = type 2 diabetes mellitus; TPN = total parenteral nutrition.

Regular insulin added to total parenteral nutrition vs subcutaneous glargine in non-critically ill diabetic inpatients, a multicenter randomized clinical trial: INSUPAR trial.

BACKGROUND: There is no established insulin regimen in T2DM patients receiving parenteral nutrition. AIMS: To compare the effectiveness (metabolic control) and safety of two insulin regimens in patients with diabetes receiving TPN. DESIGN: Prospective, open-label, multicenter, clinical trial on adult inpatients with type 2 diabetes on a non-critical setting with indication for TPN. Patients were randomized on one of these two regimens: 100% of RI on TPN or 50% of Regular insulin added to TPN bag and 50% subcutaneous GI. Data were analyzed according to intention-to-treat principle. RESULTS: 81 patients were on RI and 80 on GI. No differences were observed in neither average total daily dose of insulin, programmed or correction, nor in capillary mean blood glucose during TPN infusion (165.3 ± 35.4 in RI vs 172.5 ± 43.6 mg/dL in GI; p = 0.25). Mean capillary glucose was significantly lower in the GI group within two days after TPN interruption (160.3 ± 45.1 in RI vs 141.7 ± 43.8 mg/dL in GI; p = 0.024). The percentage of capillary glucose above 180 mg/dL was similar in both groups. The rate of capillary glucose ≤70 mg/dL, the number of hypoglycemic episodes per 100 days of TPN, and the percentage of patients with non-severe hypoglycemia were significantly higher on GI group. No severe hypoglycemia was detected. No differences were observed in length of stay, infectious complications, or hospital mortality. CONCLUSION: Effectiveness of both regimens was similar. GI group achieved better metabolic control after TPN interruption but non-severe hypoglycemia rate was higher in the GI group. CLINICAL TRIAL REGISTRY: This trial is registered at clinicaltrials.gov as NCT02706119.

Prevalence of diabetes, prediabetes, and stress hyperglycemia: insulin therapy and metabolic control in patients on total parenteral nutrition (prospective multicenter study).

OBJECTIVE: The prevalence of carbohydrate metabolism disorders in patients who receive total parenteral nutrition (TPN) is not well known. These disorders can affect the treatment, metabolic control, and prognosis of affected patients. The aims of this study were to determine the prevalence in noncritically ill patients on TPN of diabetes, prediabetes, and stress hyperglycemia; the factors affecting hyperglycemia during TPN; and the insulin therapy provided and the metabolic control achieved. METHODS: We undertook a prospective multicenter study involving 19 Spanish hospitals. Noncritically ill patients who were prescribed TPN were included, and data were collected on demographic, clinical, and laboratory variables (glycated hemoglobin, C-reactive protein [CRP], capillary blood glucose) as well as insulin treatment. RESULTS: The study included 605 patients. Before initiation of TPN, the prevalence of known diabetes was 17.4%, unknown diabetes 4.3%, stress hyperglycemia 7.1%, and prediabetes 27.8%. During TPN therapy, 50.9% of patients had at least one capillary blood glucose of >180 mg/dL. Predisposing factors were age, levels of CRP and glycated hemoglobin, the presence of diabetes, infectious complications, the number of grams of carbohydrates infused, and the administration of glucose-elevating drugs. Most (71.6%) patients were treated with insulin. The mean capillary blood glucose levels during TPN were: known diabetes (178.6 ± 46.5 mg/dL), unknown diabetes (173.9 ± 51.9), prediabetes (136.0 ± 25.4), stress hyperglycemia (146.0 ± 29.3), and normal (123.2 ± 19.9) (P<.001). CONCLUSION: The prevalence of carbohydrate metabolism disorders is very high in noncritically ill patients on TPN. These disorders affect insulin treatment and the degree of metabolic control achieved.

Hypoglycemia in noncritically ill patients receiving total parenteral nutrition: a multicenter study. (Study group on the problem of hyperglycemia in parenteral nutrition; Nutrition area of the Spanish Society of Endocrinology and Nutrition).

OBJECTIVE: Hypoglycemia is a common problem among hospitalized patients. Treatment of hyperglycemia with insulin is potentially associated with an increased risk for hypoglycemia. The aim of this study was to determine the prevalence and predictors of hypoglycemia (capillary blood glucose <70 mg/dL) in hospitalized patients receiving total parenteral nutrition (TPN). METHODS: This prospective multicenter study involved 19 Spanish hospitals. Noncritically ill adults who were prescribed TPN were included, thus enabling us to collect data on capillary blood glucose and insulin dosage. RESULTS: The study included 605 patients of whom 6.8% (n = 41) had at least one capillary blood glucose <70 mg/dL and 2.6% (n = 16) had symptomatic hypoglycemia. The total number of hypoglycemic episodes per 100 d of TPN was 0.82. In univariate analysis, hypoglycemia was significantly associated with the presence of diabetes, a lower body mass index (BMI), and treatment with intravenous (IV) insulin. Patients with hypoglycemia also had a significantly longer hospital length of stay, PN duration, higher blood glucose variability, and a higher insulin dose. Multiple logistic regression analysis showed that a lower BMI, high blood glucose variability, and TPN duration were risk factors for hypoglycemia. Use of IV insulin and blood glucose variability were predictors of symptomatic hypoglycemia. CONCLUSIONS: The occurrence of hypoglycemia in noncritically ill patients receiving PN is low. A lower BMI and a greater blood glucose variability and TPN duration are factors associated with the risk for hypoglycemia. IV insulin and glucose variability were predictors of symptomatic hypoglycemia.

Cardiovascular risk profile in Mediterranean patients submitted to bariatric surgery and intensive lifestyle intervention: impact of both interventions after 1 year of follow-up.

BACKGROUND: The aim was to compare obesity-related cardiovascular (CV) risk factors (classic and emerging) and the estimated CV risk at 10 years (calculated by REGICOR) in obese Mediterranean patients submitted to bariatric surgery and intensive lifestyle intervention at baseline and after 1 year of follow-up. METHODS: Patients submitted to bariatric surgery (n = 108) and standardized program of therapeutic changes in lifestyle (n = 90) were retrospectively included. Clinical history, physical examination, and laboratory analysis were routinely determined before weight loss intervention and at 1 year follow-up. RESULTS: Seventy-five percent of the surgery patients had a CV risk lower than 5 % and not one patient had a 10-year CV risk higher than 15 %. The percentage of patients with comorbidities (diabetes and sleep apnea syndrome) was higher in the surgery group. Seventeen of the surgery patients had no comorbidities. The improvement in CV risk profile was significant higher in the surgery group. CV risk benefit of both intervention groups was related to baseline higher CV risk, with type 2 diabetes with poor metabolic control and high cholesterol levels being the most important predictors for surgery patients. Neither body mass index nor excess of weight loss was related to CV risk improvement. CONCLUSIONS: Mediterranean patients undergoing a weight loss intervention have a low CV risk. In comparison with lifestyle intervention, surgery induces a better improvement of CV risk. This benefit is related to estimated CV risk, presence of diabetes, and cholesterol levels at baseline. These observations should be taken into account in order to optimize health resources.

Nutrition-related risk indexes and long-term mortality in noncritically ill inpatients who receive total parenteral nutrition (prospective multicenter study).

BACKGROUND: Malnutrition in hospitalized patients is associated with an increased risk of death, in both the short and the long term. AIMS: The purpose of this study was to determine which nutrition-related risk index predicts long-term mortality better (three years) in patients who receive total parenteral nutrition (TPN). METHODS: This prospective, multicenter study involved noncritically ill patients who were prescribed TPN during hospitalization. Data were collected on Subjective Global Assessment (SGA), Nutritional Risk Index (NRI), Geriatric Nutritional Risk Index (GNRI), body mass index, albumin and prealbumin, as well as long-term mortality. RESULTS: Over the 1- and 3-year follow-up periods, 174 and 244 study subjects (28.8% and 40.3%) respectively, died. Based on the Cox proportional hazards survival model, the nutrition-related risk indexes most strongly associated with mortality were SGA and albumin (<2.5 g/dL) (after adjustment for age, gender, C-reactive protein levels, prior comorbidity, mean capillary blood glucose during TPN infusion, diabetes status prior to TPN, diagnosis, and infectious complications during hospitalization). CONCLUSIONS: The SGA and very low albumin levels are simple tools that predict the risk of long-term mortality better than other tools in noncritically ill patients who receive TPN during hospitalization.

Assessment of risk factors and test performance on malnutrition prevalence at admission using four different screening tools.

BACKGROUND & AIMS: Malnutrition is very common in patients when admitted to the hospital. The aim of the present study was: a) to determine the prevalence of malnutrition at admission in a tertiary care hospital and identify risk factors for malnutrition, and b) to test the sensitivity and specificity of different screening tests for malnutrition compared to subjective global assessment (SGA). METHODS: We conducted a prospective study at 24h of admission in order to assess malnutrition in 537 adult subjects (56.4% males, mean age of 61.3±17.7 years) using 4 different screening tools: mininutritional assessment short form (MNA-SF), nutritional risk screening 2002 (NRS2002), malnutrition universal screening tool (MUST), and SGA. Anthropometrics and co-morbidities were registered. RESULTS: The overall rate of undernutrition was 47.3%. Specific rates were 54.2% in patients > 65y vs. 40.7% < 65y (p = 0.002) and 63.4% in medical vs. 34.0% surgical department (p < 0.001). Identified risk factors of malnutrition at admission were: the presence of heart disease (OR 1.74 CI 95% 1.16-2.60 p = 0.007) for MNASF (AUC 0.62); liver disease (OR 4.45 CI 95% 1.9410.22 p < 0.001), > 65y (OR 2.10 CI 95% 1.19-3.93 p = 0.011), medicine department (OR 3.58 CI 95% 1.93-6.62 p < 0.001) for SGA (AUC 0.96); lung disease (OR 3.34 CI 95% 1.45-7.73 p = 0.005), medicine department (OR 2.55 CI 95%1.09-5.98 p = 0.032) for NRS 2002 (AUC 0.97). Recent unintentional weight loss was a common factor. CONCLUSIONS: Undernourishment at hospital admission is frequent. Comorbidities may contribute to the presence of undernutrition at admission. Nonetheless, SGA, NRS2002, MNA-SF or MUST can be used in our setting.

Antecedentes y objetivos: La desnutrición es muy frecuente en los pacientes que ingresan en el hospital. El objetivo de nuestro estudio es a) determinar la prevalencia de desnutrición al ingreso en un hospital de tercer nivel e identificar los factores de riesgo para desnutrición. b) Estudiar la sensibilidad y especifidad de diferentes test de cribado de desnutrición comparados con las valoración global subjetiva (VGS). Material y métodos: Realizamos un estudio prospectivo a las 24 h del ingreso hospitalario a individuos (56.4% hombres con una edad media de 61,3 ± 17 años) utilizando 4 test de cribado diferentes: mininutritional assessment short form (MNA-SF), nutritional risk screening 2002 (NRS2002), malnutrition universal screening tool (MUST) y VGS. Además, se recogieron medidas antropométricas y comorbilidades. Resultados: La prevalencia global de desnutrición fue de 47.3%. Las tasas específicas fueron 54,2% para > 65 años, 40,7% en < 65 años (p = 0,002), 63,4% en las áreas médicas, 34,0% áreas quirúrgicas (p < 0,001). Los factores que influían en la presencia de desnutrición al ingreso fueron: cardiopatía (OR 1,74 IC 95% 1,16-2,60 p = 0,007) en el MNA-SF (AUC 0,62); hepatopatía (OR 4,45 IC 95% 1.9410,22 p < 0,001), > 65años (OR 2,10 IC 95% 1,19-3,93 p = 0,011), áreas médicas (OR 3,58 IC 95% 1,93-6,62 p < 0,001) en la VGS (AUC 0,96); neumopatía (OR 3,34 IC 95% 1,45-7,73 p = 0,005), áreas médicas (OR 2,55 IC 95% 1,09-5,98 p = 0,032) en el NRS 2002 (AUC 0,97). La pérdida de peso involuntaria fue común a todos los test. Conclusiones: La desnutrición es frecuente al ingreso hospitalario. La presencia de comorbilidades puede influir en la presencia de desnutrición al ingreso, sin embargo, podemos utilizar cualquiera de los tests propuestos para su detección en nuestro hospital.

Parenteral nutrition-associated hyperglycemia in non-critically ill inpatients increases the risk of in-hospital mortality (multicenter study).

OBJECTIVE: Hyperglycemia may increase mortality in patients who receive total parenteral nutrition (TPN). However, this has not been well studied in noncritically ill patients (i.e., patients in the nonintensive care unit setting). The aim of this study was to determine whether mean blood glucose level during TPN infusion is associated with increased mortality in noncritically ill hospitalized patients. RESEARCH DESIGN AND METHODS: This prospective multicenter study involved 19 Spanish hospitals. Noncritically ill patients who were prescribed TPN were included prospectively, and data were collected on demographic, clinical, and laboratory variables as well as on in-hospital mortality. RESULTS: The study included 605 patients (mean age 63.2 ± 15.7 years). The daily mean TPN values were 1.630 ± 323 kcal, 3.2 ± 0.7 g carbohydrates/kg, 1.26 ± 0.3 g amino acids/kg, and 0.9 ± 0.2 g lipids/kg. Multiple logistic regression analysis showed that the patients who had mean blood glucose levels >180 mg/dL during the TPN infusion had a risk of mortality that was 5.6 times greater than those with mean blood glucose levels <140 mg/dL (95% CI 1.47-21.4 mg/dL) after adjusting for age, sex, nutritional state, presence of diabetes or hyperglycemia before starting TPN, diagnosis, prior comorbidity, carbohydrates infused, use of steroid therapy, SD of blood glucose level, insulin units supplied, infectious complications, albumin, C-reactive protein, and HbA1c levels. CONCLUSIONS: Hyperglycemia (mean blood glucose level >180 mg/dL) in noncritically ill patients who receive TPN is associated with a higher risk of in-hospital mortality.

Comparisons of body volumes and dimensions using three-dimensional photonic scanning in adult Hispanic-Americans and Caucasian-Americans.

BACKGROUND: We studied whether significant differences exist between Hispanic-Americans (H-A) and Caucasian-Americans (C-A) in body dimensions using a newly validated three-dimensional photonic scanner (3DPS). METHODS: We compared two cohorts of 34 adult U.S.-based H-A (19 females) and 40 adult C-A (25 females) of similar age and body mass index (BMI, kg/m(2)). We measured total body volume (TBV), trunk volume (TV), and other body dimensions, including waist and hip circumferences, estimated percentage body fat (%fat), calculated TV/TBV, and waist-to-hip ratio. RESULTS: For female cohorts, there were no significant differences in age, weight, height, and 3DPS-measured variables between the two ethnic cohorts. For male cohorts, C-A had greater height (p = 0.014), but there were no significant differences in absolute or proportional volumes or dimensions between the two cohorts. CONCLUSIONS: Results demonstrate that, in these H-A and C-A cohorts of similar age and BMI, total and regional body volumes and dimensions, as well as their proportions, approximate each other very closely in both sexes; these variables also show similar relationships with %fat in each sex. This is in contradistinction to previous study reports using other measurement techniques.