Phase Angle Is a Stronger Predictor of Hospital Outcome than Subjective Global Assessment-Results from the Prospective Dessau Hospital Malnutrition Study.

This prospective cohort study of 16,943 consecutive patients compared phase angle (PhA, foot-to-hand at 50 kHz) and subjective global assessment (SGA) to predict outcomes length of hospital stay (LOS) and in-hospital mortality in patients at risk of malnutrition (NRS-2002 ≥ 3). In 1505 patients, the independent effects on LOS were determined by competing risk analysis and on mortality by logistic regression. In model I, including influence factors age, sex, BMI, and diagnoses, malnourished (SGA B and C) patients had a lower chance for a regular discharge (HR 0.74; 95%CI 0.69−0.79) and an increased risk of mortality (OR 2.87; 95%CI 1.38−5.94). The association of SGA and outcomes regular discharge and mortality was completely abrogated when PhA was added (model II). Low PhA reduced the chance of a regular discharge by 53% in patients with a PhA ≤ 3° (HR 0.47; 95%CI 0.39−0.56) as compared to PhA > 5°. Mortality was reduced by 56% for each 1° of PhA (OR 0.44; 95%CI 0.32−0.61). Even when CRP was added in model III, PhA ≤ 3° was associated with a 41% lower chance for a regular discharge (HR 0.59; 95%CI 0.48−0.72). In patients at risk of malnutrition, the objective measure PhA was a stronger predictor of LOS and mortality than SGA.

Geo-economic variations in epidemiology, ventilation management and outcome of patients receiving intraoperative ventilation during general anesthesia- posthoc analysis of an observational study in 29 countries.

BACKGROUND: The aim of this analysis is to determine geo-economic variations in epidemiology, ventilator settings and outcome in patients receiving general anesthesia for surgery. METHODS: Posthoc analysis of a worldwide study in 29 countries. Lower and upper middle-income countries (LMIC and UMIC), and high-income countries (HIC) were compared. The coprimary endpoint was the risk for and incidence of postoperative pulmonary complications (PPC); secondary endpoints were intraoperative ventilator settings, intraoperative complications, hospital stay and mortality. RESULTS: Of 9864 patients, 4% originated from LMIC, 11% from UMIC and 85% from HIC. The ARISCAT score was 17.5 [15.0-26.0] in LMIC, 16.0 [3.0-27.0] in UMIC and 15.0 [3.0-26.0] in HIC (P = .003). The incidence of PPC was 9.0% in LMIC, 3.2% in UMIC and 2.5% in HIC (P < .001). Median tidal volume in ml kg- 1 predicted bodyweight (PBW) was 8.6 [7.7-9.7] in LMIC, 8.4 [7.6-9.5] in UMIC and 8.1 [7.2-9.1] in HIC (P < .001). Median positive end-expiratory pressure in cmH2O was 3.3 [2.0-5.0]) in LMIC, 4.0 [3.0-5.0] in UMIC and 5.0 [3.0-5.0] in HIC (P < .001). Median driving pressure in cmH2O was 14.0 [11.5-18.0] in LMIC, 13.5 [11.0-16.0] in UMIC and 12.0 [10.0-15.0] in HIC (P < .001). Median fraction of inspired oxygen in % was 75 [50-80] in LMIC, 50 [50-63] in UMIC and 53 [45-70] in HIC (P < .001). Intraoperative complications occurred in 25.9% in LMIC, in 18.7% in UMIC and in 37.1% in HIC (P < .001). Hospital mortality was 0.0% in LMIC, 1.3% in UMIC and 0.6% in HIC (P = .009). CONCLUSION: The risk for and incidence of PPC is higher in LMIC than in UMIC and HIC. Ventilation management could be improved in LMIC and UMIC. TRIAL REGISTRATION: Clinicaltrials.gov , identifier: NCT01601223.

How reliably can ultrasound help determine muscle and adipose tissue thickness in clinical settings? An assessment of intra- and inter-examiner reliability in the USVALID study.

BACKGROUND/OBJECTIVES: Ultrasound is used to measure muscle and adipose tissue thickness at the bedside. This study was aimed at determining the intra- and inter-examiner reliability for marking points to measure adipose tissue and muscle thickness and assessing it in terms of the performance and evaluation of the corresponding ultrasound scans. SUBJECTS/METHODS: Intra- and inter-examiner reliability was tested in 120 patients. Limb lengths were measured to mark three and two measuring points on both the thighs and upper arms, respectively. Ultrasound scans were performed at each measuring point to evaluate muscle and adipose tissue thickness. RESULTS: Regarding the marking of the measuring points, intra- and inter-examiner reliability were high to very high, with correlation coefficients ranging from 0.74 to 0.96. In the performance and evaluation of adipose tissue thickness, all measuring points showed a high to very high reliability, with correlation coefficients ranging from 0.70 to 0.97. In the performance and evaluation of muscle thickness, the ventral measuring point on the thigh and the anterior measuring point on the upper arm showed the best reliability, with high to very high correlation coefficients ranging from 0.77 to 0.93. CONCLUSIONS: In terms of intra- and inter-examiner reliability, the ventral measuring point on the thigh and the anterior measuring point on the upper arm can be strongly recommended for ultrasound measurements of muscle and adipose tissue thickness.

Characteristics of hospitalized patients prescribed oral nutrition supplements in Thailand: A cross-sectional nutrition day survey.

BACKGROUND AND OBJECTIVES: Despite the proven benefits of oral nutrition supplements (ONS), its prescription in Thailand are far less than it should mainly due to limitation of reimbursement. Our aim was to compare hospital outcomes between hospitalized patients receiving only hospital food to those receiving hospital food with ONS. METHODS AND STUDY DESIGN: An annual cross-sectional survey, NutritionDay (nD), in Thailand was conducted in 2 hospitals from 2010 to 2015. The hospital outcomes were followed at day 30 after first evaluation. Logistic regression and Cox regression were performed to compare outcome between groups. RESULTS: 524 hospitalized patients, 472 with only hospital food and 52 with ONS, were included. Patients with ONS had longer hospital stay prior to recruitment, reported more physical dependencies, and ate less food. The ONS group was less likely to be discharged within 30 days as compared to hospital food group (unadjusted OR 0.28, 95% CI 0.16-0.52) but this effect was not significant after adjustment for length of stay before nD and PANDORA score (adjusted OR 0.62, 95% CI 0.3-1.34). Cox regression showed a trend to decreased rate of discharge within 30 days in the ONS group. CONCLUSIONS: This cross-sectional study showed a trend of worse outcomes associated with ONS prescription which might be related with higher mortality risk according to PANDORA score and longer previous hospital stay of the patients in the ONS group. Since the 2 studied groups were not comparable, further studies in this specific population should be performed.

Barriers to the conduct of randomised clinical trials within all disease areas.

BACKGROUND: Randomised clinical trials are key to advancing medical knowledge and to enhancing patient care, but major barriers to their conduct exist. The present paper presents some of these barriers. METHODS: We performed systematic literature searches and internal European Clinical Research Infrastructure Network (ECRIN) communications during face-to-face meetings and telephone conferences from 2013 to 2017 within the context of the ECRIN Integrating Activity (ECRIN-IA) project. RESULTS: The following barriers to randomised clinical trials were identified: inadequate knowledge of clinical research and trial methodology; lack of funding; excessive monitoring; restrictive privacy law and lack of transparency; complex regulatory requirements; and inadequate infrastructures. There is a need for more pragmatic randomised clinical trials conducted with low risks of systematic and random errors, and multinational cooperation is essential. CONCLUSIONS: The present paper presents major barriers to randomised clinical trials. It also underlines the value of using a pan-European-distributed infrastructure to help investigators overcome barriers for multi-country trials in any disease area.

The Patient- And Nutrition-Derived Outcome Risk Assessment Score (PANDORA): Development of a Simple Predictive Risk Score for 30-Day In-Hospital Mortality Based on Demographics, Clinical Observation, and Nutrition.

OBJECTIVE: To develop a simple scoring system to predict 30 day in-hospital mortality of in-patients excluding those from intensive care units based on easily obtainable demographic, disease and nutrition related patient data. METHODS: Score development with general estimation equation methodology and model selection by P-value thresholding based on a cross-sectional sample of 52 risk indicators with 123 item classes collected with questionnaires and stored in an multilingual online database. SETTING: Worldwide prospective cross-sectional cohort with 30 day in-hospital mortality from the nutritionDay 2006-2009 and an external validation sample from 2012. RESULTS: We included 43894 patients from 2480 units in 32 countries. 1631(3.72%) patients died within 30 days in hospital. The Patient- And Nutrition-Derived Outcome Risk Assessment (PANDORA) score predicts 30-day hospital mortality based on 7 indicators with 31 item classes on a scale from 0 to 75 points. The indicators are age (0 to 17 points), nutrient intake on nutritionDay (0 to 12 points), mobility (0 to 11 points), fluid status (0 to 10 points), BMI (0 to 9 points), cancer (9 points) and main patient group (0 to 7 points). An appropriate model fit has been achieved. The area under the receiver operating characteristic curve for mortality prediction was 0.82 in the development sample and 0.79 in the external validation sample. CONCLUSIONS: The PANDORA score is a simple, robust scoring system for a general population of hospitalised patients to be used for risk stratification and benchmarking.

Preventable proportion of severe infections acquired in intensive care units: case-mix adjusted estimations from patient-based surveillance data.

BACKGROUND: More than 10% of patients admitted to intensive care units (ICUs) experience a severe, healthcare-associated infection, such as ventilator-associated pneumonia (VAP) or bloodstream infection (BSI). What could be a public health target for prevention is hotly debated, because properly adjusting for intrinsic risk factors in the patient population is difficult. We aimed to estimate the proportion of ICU-acquired VAP and BSI cases that are amenable to prevention in routine conditions. METHODS: We analyzed routine data collected prospectively according to the European standard protocol for patient-based surveillance of healthcare-acquired infections in ICUs. We computed the number of infections to be expected if, after adjustment for case mix, the infection incidence in ICUs with higher infection rates could be reduced to that of the top-tenth-percentile-ranked ICU. Computations came from model-based simulation of individual patient profiles over time in the ICU. The preventable proportion was computed as the number of observed cases minus the number of expected cases divided by the number of observed cases. RESULTS: Data for 78,222 patients admitted for more than 2 days to 525 ICUs in 6 European countries from 2005 to 2008 were available for analysis. We calculated that 52% of VAP and 69% of BSI was preventable. CONCLUSIONS: Our pragmatic, if highly conservative, estimates quantify the potential for prevention of VAP and BSI in routine conditions, assuming that variation in infection incidence between ICUs can be eliminated with improved quality of care, apart from variation attributable to differential case mix.

Nutrition risk assessment in the ICU.

PURPOSE OF REVIEW: Nutrition risk assessment is of great importance to identify patients who may benefit from nutritional intervention to prevent ICU starvation and avoid side-effects of nutrition care. The full spectrum of nutrition risk assessment in ICU has not been defined in guidelines. RECENT FINDINGS: Many patients are admitted to ICUs with nutritional deficits related to acute and chronic disease. The vast majority of patients who cannot resume sufficient oral feeding within a few days will lose body cell mass due to the severe and prolonged inflammatory process and insufficient nutrient intake. All patients staying longer than 1-2 days in the ICU need nutrition support, close monitoring and risk assessment. Risk assessment has to be constantly maintained throughout the ICU stay to manage properly risks associated with critical illness and nutrition care. Many patients are at risk to develop a refeeding syndrome, to experience serious motility disorders and finally dysphagia after extubation. The dramatic consequences of intra-abdominal hypertension may be decreased by early detection and treatment. There is a close interaction between evolution of critical illness, the associated inflammatory reaction, ICU treatments and nutrition care. SUMMARY: Safe and efficient nutrition care may only be obtained when gastrointestinal function and metabolic tolerance of nutrients are regularly assessed.

The first nutritionDay in nursing homes: participation may improve malnutrition awareness.

BACKGROUND & AIMS: A modified version of the nutritionDay project was developed for nursing homes (NHs) to increase malnutrition awareness in this area. This report aims to describe the first results from the NH setting. METHODS: On February 22, 2007, 8 Austrian and 30 German NHs with a total of 79 units and 2137 residents (84+/-9 years of age, 79% female) participated in the NH-adapted pilot test. The NHs participated voluntarily using standardized questionnaires. The actual nutritional intake at lunch time was documented for each resident. Six-month follow-up data were received from 1483 residents (69%). RESULTS: Overall, 9.2% and 16.7% of residents were classified as malnourished subjectively by NH staff and by BMI criteria (<20 kg/m(2)), respectively. Independent risk factors for malnutrition included age>90 years, immobility, dementia, and dysphagia (all p<0.001). In total, 89% of residents ate at least half of the lunch meal, and 46% of residents received eating assistance for an average of 15 min. Six-month mortality was higher in residents with low nutritionDay BMI (<20 kg/m(2): 22%, 20-21.9 kg/m(2): 17%) compared to residents with BMI >or= 22 kg/m(2) (10%, p<0.001). Six-month weight loss >or= 6 kg was less common in residents with nutritionDay BMI<22 kg/m(2) compared to residents with higher nutritionDay BMI (3.4% vs 12.4%, p<0.001). CONCLUSIONS: The first nutritionDay in NH provided valuable data on the nutritional status of NH residents and called attention to the remarkable time investment required by NH staff to adequately provide eating assistance to residents. Participation in the nutritionDay project appears to increase malnutrition awareness as reflected in the outcome weight results.

Gender-related differences in intensive care: a multiple-center cohort study of therapeutic interventions and outcome in critically ill patients.

OBJECTIVE: To determine whether gender-related differences exist in the provided level of care and outcome in a large cohort of critically ill patients. DESIGN: Prospective, observational cohort study with data collection from January 1, 1998, to December 31, 2000. SETTING: Thirty-one intensive care units in Austria. PATIENTS: A total of 25,998 adult patients, consecutively admitted to 31 intensive care units in Austria. INTERVENTIONS: We assessed severity of illness, level of provided care, and vital status at hospital discharge. MEASUREMENTS AND MAIN RESULTS: Of 25,998 patients, 58.3% were male and 41.7% were female. Hospital mortality rate was slightly higher in women (18.1%) than in men (17.2%), but severity of illness-adjusted mortality rate was not different. Men received an overall increased level of care and had a significantly higher probability of receiving invasive procedures, such as mechanical ventilation (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.16-1.28), single vasoactive medication (OR, 1.18; 95% CI, 1.12-1.24), multiple vasoactive medication (OR, 1.21; 95% CI, 1.15-1.28), intravenous replacement of large fluid losses (OR, 1.14; 95% CI, 1.08-1.20), central venous catheter (OR, 1.06; 95% CI, 1.01-1.12), peripheral arterial catheter (OR, 1.15; 95% CI, 1.10-1.22), pulmonary artery catheter (OR, 1.48; 95% CI, 1.34-1.62), renal replacement therapy (OR, 1.28; 95% CI, 1.16-1.42), and intracranial pressure measurement (OR, 1.34; 95% CI, 1.18-1.53). CONCLUSIONS: In a large cohort of critically ill patients, no differences in severity of illness-adjusted mortality rate between men and women were found. Despite a higher severity of illness in women, men received an increased level of care and underwent more invasive procedures. This different therapeutic approach in men did not translate into a better outcome.