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.

Quality appraisal of clinical nutrition practice guidelines for critically ill adult patients: a systematic review using the Advancing Guideline Development, Reporting and Evaluation in Health Care instrument II (AGREE-II) and AGREE-Recommendation Excellence (AGREE-REX).

Nutritional therapy should follow evidence-based practice, thus several societies regarding nutrition and critical care have developed specific Clinical Practice Guidelines (CPG). However, to be regarded as trustworthy, the quality of the CPG for critically ill patients and its recommendations need to be high. This systematic review aimed to appraise the methodology and recommendations of nutrition CPG for critically ill patients. We performed a systematic review (protocol number CRD42020184199) with literature search conducted on PubMed, Embase, Cochrane Library and other four specific databases of guidelines up to October 2021. Two reviewers, independently, assessed titles and abstracts and potentially eligible full-text reports to determine eligibility and subsequently four reviewers appraised the guidelines quality using the Advancing Guideline Development, Reporting and Evaluation in Health Care instrument II (AGREE-II) and AGREE-Recommendation Excellence (AGREE-REX). Ten CPG for nutrition in critically ill patients were identified. Only Academy of Nutrition and Dietetics and European Society of Intensive Care Medicine had a total acceptable quality and were recommended for daily practice according AGREE-II. None of the CPG recommendations had an overall quality score above 70 %, thus being classified as moderate quality according AGREE-REX. The methodological evaluation of the critically ill adult patient CPG revealed significant discrepancies and showed a need for improvement in its development and/or reporting. In addition, recommendations about nutrition care process presented a moderate quality.

Independent and joint association of sarcopenia and frailty with mortality in older patients with gastrointestinal cancer: a cohort study with prospective data collection.

PURPOSE: Sarcopenia and frailty are associated with mortality in older patients with gastrointestinal cancer. However, it is unclear if there is an additional risk when both are present. This study aimed to investigate the independent and overlapping of sarcopenia and frailty with mortality in this population. METHODS: A prospective cohort study including older patients (≥ 60 years old) with gastrointestinal cancer. Sarcopenia was defined by the EWGSP2 criteria: (i) low muscle strength (handgrip test), (ii) low muscle mass (skeletal muscle index), and/or low muscle quality (skeletal muscle radiodensity) by computed tomography. Frailty was defined according to Fried phenotype (at least three of the five components): (i) low muscle strength (handgrip test), (ii) unintentional weight loss, (iii) self-reported exhaustion, (iv) low physical activity, and (v) low gait speed. Cox proportional hazards model was used to assess overall survival rates and risk of mortality. RESULTS: We evaluated 179 patients with gastrointestinal cancer [68.0 (61.0-75.0) years old; 45% women]. The prevalence of sarcopenia, frailty, and sarcopenia-frailty was 32.9% (n = 59), 59.2% (n = 106), and 24.6% (n = 44), respectively. The incidence of mortality was 27.9% (n = 50) over a 23-month (IQR, 10, 28) period. There was an association of sarcopenia (HR = 1.78, 95% CI 1.03-3.06) with mortality, but no association was found of frailty and the outcome. Sarcopenia-frailty was associated with the highest risk of mortality (HR = 2.23, 95% CI 1.27-3.92). CONCLUSION: Sarcopenic-frail older patients with gastrointestinal cancer have a higher risk of mortality than those with sarcopenia or frailty alone, which reinforces the importance of assessing both conditions in oncology clinical care.

Increased energy and/or protein intake improves anthropometry and muscle strength in chronic obstructive pulmonary disease patients: a systematic review with meta-analysis on randomised controlled clinical trials.

Compromised nutritional status is associated with a poor prognosis in chronic obstructive pulmonary disease (COPD) patients. However, the impact of nutritional support in this group of patients is controversial. The present study systematically reviewed the effect of energy and or protein supplements or food fortification on anthropometry and muscle strength of COPD patients. We searched MEDLINE (PubMed), EMBASE, Cochrane Library and Scopus for all published randomised clinical trials without language restriction up to May 2021. Three reviewers performed study selection and data extraction independently. We judged the risk of bias by RoB 2 and the certainty of evidence by the GRADE approach. We included thirty-two randomised controlled trials and compiled thirty-one of them (1414 participants) in the random-effects model meta-analyses. Interventions were energy and/or protein oral nutritional supplements or food fortification added to the diet for at least one week. Pooled analysis revealed that nutritional interventions increased body weight (muscle circumference (MD) = 1·44 kg, 95 % CI 0·81, 2·08, I2 = 73 %), lean body mass (standardised mean difference (SMD) = 0·37; 95 % CI 0·15, 0·59, I2 = 46 %), midarm muscle circumference (MD = 0·29 mm2, 95 % CI 0·02, 0·57, I2 = 0 %), triceps skinfold (MD = 1·09 mm, 95 % CI 0·01, 2·16, I2 = 0 %) and handgrip strength (SMD = 0·39, 95 % CI 0·07, 0·71, I2 = 62 %) compared with control diets. Certainty of evidence ranged from very low to low, and most studies were judged with some concerns or at high risk of bias. This meta-analysis revealed, with limited evidence, that increased protein and/or energy intake positively impacts anthropometric measures and handgrip strength of COPD patients.

Decline of nutritional status in the first week of hospitalisation predicts longer length of stay and hospital readmission during 6-month follow-up.

Nutritional status (NS) monitoring is an essential step of the nutrition care process. To assess changes in NS throughout hospitalisation and its ability to predict clinical outcomes, a prospective cohort study with patients over 18 years of age was conducted. The Subjective Global Assessment (SGA) was performed within 48 h of admission and 7 d later. For each patient, decline in NS was assessed by two different methods: changes in SGA category and severe weight loss alone (≥2 % during the first week of hospitalisation). Patients were followed up until discharge to assess length of hospital stay (LOS) and in-hospital mortality and contacted 6 months post-discharge to assess hospital readmission and death. Out of the 601 patients assessed at admission, 299 remained hospitalised for at least 7 d; of those, 16·1 % had a decline in SGA category and 22·8 % had severe weight loss alone. In multivariable analysis, decline in SGA category was associated with 2-fold (95 % CI 1·06, 4·21) increased odds of prolonged LOS and 3·6 (95 % CI 1·05, 12·26) increased odds of hospital readmission at 6 months. Severe weight loss alone was associated with 2·5-increased odds (95 % CI 1·40, 4·64) of prolonged LOS. In conclusion, deterioration of NS was more often identified by severe weight loss than by decline in SGA category. While both methods were associated with prolonged LOS, only changes in the SGA predicted hospital readmission. These findings reinforce the importance of nutritional monitoring and provide guidance for further research to prevent short-term NS deterioration from being left undetected.

Accuracy of three tools for malnutrition diagnosis in hospitalised patients: Comparison to subjective global assessment.

BACKGROUND: Malnutrition is prevalent in hospital, and the Subjective Global Assessment (SGA) has been widely used for its identification. However, in the last decade, new tools were proposed by the Academy of Nutrition and Dietetics-American Society for Parenteral and Enteral Nutrition (AND-ASPEN), European Society for Clinical Nutrition and Metabolism (ESPEN) and Global Leadership Initiative on Malnutrition (GLIM). The diagnostic test accuracy of these tools has been scarcely investigated. Thus, we aimed to compare the accuracy of AND-ASPEN, ESPEN and GLIM for malnutrition diagnosis in hospitalised patients. METHODS: A cross-sectional study was conducted with hospitalised patients aged ≥ 18 years from a five-unit complex hospital. Malnutrition was diagnosed within 48 h of admission using SGA, AND-ASPEN, ESPEN and GLIM. The accuracy of these tools was evaluated by the area under the receiver operating characteristic (AUROC) curve, considering SGA as reference, which was compared by the DeLong test. RESULTS: Six hundred patients (55.7 ± 14.8 years, 51.3% male) were evaluated. AND-ASPEN [AUROC 0.846; 95% confidence interval (CI) = 0.810-0.883] and GLIM presented a satisfactory accuracy (AUROC 0.842; 95% CI, 0.807-0.877), whereas ESPEN had a substantially lower accuracy (AUROC, 0.572; 95% CI, 0.522-0.622). The AUROC of AND-ASPEN and GLIM were not different from each other (p = 0.785) and both had significantly higher accuracy than ESPEN (p < 0.001). AND-ASPEN and GLIM presented sensitivity, specificity and negative predictive value > 80%, whereas ESPEN sensitivity was < 20%. CONCLUSIONS: AND-ASPEN and GLIM were accurate methods for diagnosing malnutrition and could be applied in hospitalised patients. By contrast, the ESPEN criteria had unsatisfactory accuracy.

Calf Circumference Is a Good Predictor of Longer Hospital Stay and Nutritional Risk in Emergency Patients: A Prospective Cohort Study.

Objective: This study aimed to evaluate the validity of calf circumference (CC) in identifying malnourished patients and patients at nutritional risk and determine the association between CC and clinical outcomes of hospitalized patients.Methods: A prospective cohort study was conducted involving patients admitted to the emergency department of a tertiary hospital in the first 48 hours of admission. Nutritional risk was determined using Nutritional Risk Screening, malnutrition was diagnosed using subjective global assessment, and CC was manually measured. Brazilian cutoff points for CC were used to identify low muscle mass. The outcomes of interest were length of emergency care and hospital stay, occurrence of infection, and death, besides nutritional risk and malnutrition.Results: In total, 528 patients (52.76 ± 16.18 years; 54.6% females) were followed up for 9.0 (3.0-19.0) days; 39.6% of them had reduced CC values. The accuracy of CC in identifying patients at nutritional risk and malnourished patients was 67.7% and 54.1%, respectively. The cutoff value of 36.5 cm was highly accurate in identifying nutritional risk [AUC-ROC curve = 0.764 (95% CI: 0.704-0.825) for men, and AUC-ROC curve = 0.716 (95% CI: 0.659-0.774) for women]. Patients with low CC had a 1.59-fold (95% CI: 1.07-2.36) greater likelihood of a long hospital stay than patients with normal CC.Conclusions: Low CC values have satisfactory validity in identifying nutritional risk and are associated with long hospital stay.

Determination of glycemic index of enteral formulas used in clinical practice.

Glycemic Index (GI) is a measure of carbohydrate quality and is recognised as a valid and reproducible method of classifying carbohydrate foods according to its effects on postprandial glycaemia. In this randomised crossover trial (RBR-7rjx3k) we determined the GI of nine enteral formulas, following the Food and Agriculture Organisation/World Health Organisation method. Forty healthy participants were included in the study (85% female mean age 27.1 ± 6.7 years). GI of the enteral formulas ranged from 40.5 to 85.2; four formulas had high GI (Nutrienteral 1.5®, Novasource GI Control®, Diamax®, Isosource Soya®), two intermediate GI (Fresubin 1.2 HP Fibre®, Nutrison Energy Multifiber 1.5®) and three low GI (Trophic 1.5®, Glucerna®, Novasource GC HP®). The GI coefficient of variation ranged from 22.9% to 83.6%. The effect of the enteral formulas with low GI in glycemic control of patients with enteral nutrition prescription needs to be test in future studies.

Needed Improvements in Diabetes Prevention and Management in Brazil.

INTRODUCTION: Diabetes mellitus is one of the most common chronic diseases worldwide and its prevalence continues to increase. Adherence to good health behaviors provides better control of the disease. This study analyzed trends in the prevalence of diabetes among Brazilian adults between 2006 and 2016 and compared the frequency of key health behaviors between people with and without diabetes. METHODS: We analyzed data from 572,437 Brazilian adults interviewed between 2006 and 2016 by using the Surveillance System of Risk and Protection Factors for Chronic Diseases by Telephone Survey (Vigitel). We used regression models to investigate significant trends in the prevalence of diabetes and differences in adherence to health behaviors between people with and without diabetes. RESULTS: The prevalence of diabetes increased significantly from 5.5% to 8.9% (P <.001), being higher among women, older adults, and those with less than a high school education. The greatest increase was observed among these groups with higher prevalence. People with diabetes had a lower frequency of risk behaviors and a higher frequency of protective behaviors when compared to people without diabetes. The greatest differences were observed in the consumption of soft drinks and sugar-sweetened beverages (9.5% vs 25.0%) and alcoholic beverages (9.0% vs 17.9%), and the smallest differences were related to regular consumption of fruits and vegetables (40.7% vs 34.0%) and meats with excess fat (24.3% vs 32.2%). People with diabetes reported less leisure-time physical activity (PRa, 0.92 [P < .001]) and less transport-related physical activity (PRa, 0.84 [P <.001]) than those without diabetes. CONCLUSION: Diabetes prevalence increased between 2006 and 2016. People with diabetes had better dietary habits than those without diabetes, but still had risk behaviors such as insufficient physical activity.

Derivation of the Screening of Nutritional Risk in Intensive Care risk prediction score: A secondary analysis of a prospective cohort study.

BACKGROUND: For patients who are critically ill, the recommended nutrition risk screening tools are the Nutrition Risk in the Critically Ill (NUTRIC) and the Nutritional Risk Screening 2002 (NRS-2002) have limitations. OBJECTIVE: To develop a new screening tool, the Screening of Nutritional Risk in Intensive Care (SCREENIC score), and assess its predictive validity. METHODS: A secondary analysis of a prospective cohort study was conducted. Variables from several nutritional screening and assessment tools were considered. The high nutrition risk cutoff point was defined using mNUTRIC as a reference. Predictive validity was evaluated using logistic regression and Cox regression. RESULTS: The study included 450 patients (64 [54-71] years, 52.2% men). The SCREENIC score comprised six questions: (1) does the patient have ≥2 comorbidities (1.3 points); (2) was the patient hospitalized for ≥2 days before intensive care unit (ICU) admission (0.9 points); (3) does the patient have sepsis (1.0 point); (4) was the patient on mechanical ventilation upon ICU admission (1.2 points); (5) is the patient aged >65 years (1.2 points); and (6) does the patient exhibit signs of moderate/severe muscle mass loss according to the physical exam (0.6 points). The high nutrition risk cutoff point was set at 4.0. SCREENIC demonstrated moderate agreement (κ = 0.564) and high accuracy (0.896 [95% CI, 0.867-0.925]) with mNUTRIC. It predicted prolonged ICU (odds ratio [OR] = 1.81 [95% CI, 1.14-2.85]) and hospital stay (OR = 2.15 [95% CI, 1.37-3.38]). CONCLUSION: The SCREENIC score comprises questions with variables that do not require nutrition history. Further evaluation of its applicability, reproducibility, and validity in guiding nutrition therapy is needed using large external cohorts.

Remote nutrition care during the first wave of COVID-19 pandemic: Did it impact nutrition therapy goals?

BACKGROUND AND AIMS: Nutrition societies recommended remote hospital nutrition care during the coronavirus disease 2019 (COVID-19) pandemic. However, the pandemic's impact on nutrition care quality is unknown. We aimed to evaluate the association between remote nutrition care during the first COVID-19 wave and the time to start and achieve the nutrition therapy (NT) goals of critically ill patients. METHODS: A cohort study was conducted in an intensive care unit (ICU) that assisted patients with COVID-19 between May 2020 and April 2021. The remote nutrition care lasted approximately 6 months, and dietitians prescribed the nutrition care based on medical records and daily telephone contact with nurses who were in direct contact with patients. Data were retrospectively collected, patients were grouped according to the nutrition care delivered (remote or in person), and we compared the time to start NT and achieve the nutrition goals. RESULTS: One hundred fifty-eight patients (61.5 ± 14.8 years, 57% male) were evaluated, and 54.4% received remote nutrition care. The median time to start NT was 1 (1-3) day and to achieve the nutrition goals was 4 (3-6) days for both groups. The percentage of energy and protein prescribed on day 7 of the ICU stay concerning the requirements did not differ between patients with remote and patients with in-person nutrition care [95.5% ± 20.4% × 92.1% ± 26.4% (energy) and 92.9% ± 21.9% × 86.9% ± 29.2% (protein); P > 0.05 for both analyses]. CONCLUSION: Remote nutrition care in patients critically ill with COVID-19 did not impact the time to start and achieve the NT goals.

Refeeding syndrome risk at ICU admission is an independent predictor of ICU readmission but it was not associated with mortality or length of stay in critically ill patients.

OBJECTIVES: This study evaluated the association between refeeding syndrome (RFS) risk and intensive care unit (ICU)/in-hospital mortality and length of stay (LOS) and ICU readmission in critically ill patients. METHODS: This secondary analysis of a cohort study included patients aged ≥ 18 years admitted at ICU 24 h before data collection. We evaluated RFS risk based on the National Institute for Health and Clinical Excellence (NICE), stratifying it into four categories (no, low, high, and very-high risk). SETTING: Five adult ICUs in Brazil. MAIN OUTCOME MEASURES: ICU/in-hospital mortality and LOS and ICU readmission data were obtained from electronic medical records analysis, following patients until discharge (alive or not). RESULTS: The study involved 447 patients, categorized into no (19.2 %), low (28.6 %), high (48.8 %), and very-high (3.4 %) RFS risk groups. No significant differences emerged between the two groups (at RFS risk and no RFS risk) regarding the ICU death ratio (34.3 % versus 23.4 %) and LOS (5 versus 4 days), respectively. In contrast, patients at RFS risk experienced higher in-hospital mortality rates (34.3 % versus 23.4 %) prolonged hospital LOS (21 days versus 17 days), and increased ICU readmission rates (15 % versus 8.4 %) than patients without RFS risk. After adjusting for age and Sequential Organ Failure Assessment (SOFA) Score, we found no association between RFS risk and increased mortality in the ICU or hospital. Also, there was no significant association between RFS risk and prolonged LOS in the ICU or hospital setting. However, patients identified as at risk of RFS showed nearly double the odds of ICU readmission (Odds ratio, 1.90; 95 % CI 1.02-3.43). CONCLUSIONS: This study found no significant association between RFS risk and increased mortality in both the ICU and hospital settings, nor was there a significant association with prolonged LOS in the ICU or hospital among critically ill patients. However, patients at risk of RFS exhibited nearly double the odds of ICU readmission. IMPLICATIONS FOR CLINICAL PRACTICE: Our findings may contribute to understanding risks associated with ICU readmissions, highlighting the complexity of discharge decision-making through comprehensive assessments.

Absence of association between low calf circumference, adjusted or not for adiposity, and ICU mortality in critically ill adults: A secondary analysis of a cohort study.

BACKGROUND: Despite its correlation with skeletal muscle mass and its predictive value for adverse outcomes in clinical settings, calf circumference is a metric underexplored in intensive care. We aimed to determine whether adjusting low calf circumference for adiposity provides prognostic value superior to its unadjusted measurement for intensive care unit (ICU) mortality and other clinical outcomes in critically ill patients. METHODS: In a secondary analysis of a cohort study across five ICUs, we assessed critically ill patients within 24 h of ICU admission. We adjusted calf circumference for body mass index (BMI) (25-29.9, 30-39.9, and ≥40) by subtracting 3, 7, or 12 cm from it, respectively. Values ≤34 cm for men and ≤33 cm for women identified low calf circumference. RESULTS: We analyzed 325 patients. In the primary risk-adjusted analysis, the ICU death risk was similar between the low and preserved calf circumference (BMI-adjusted) groups (hazard ratio, 0.90; 95% CI, 0.47-1.73). Low calf circumference (unadjusted) increased the odds of ICU readmission 2.91 times (95% CI, 1.40-6.05). Every 1-cm increase in calf circumference as a continuous variable reduced ICU readmission odds by 12%. Calf circumference showed no significant association with other clinical outcomes. CONCLUSION: BMI-adjusted calf circumference did not exhibit independent associations with ICU and in-hospital death, nor with ICU and in-hospital length of stay, compared with its unadjusted measurement. However, low calf circumference (unadjusted and BMI-adjusted) was independently associated with ICU readmission, mainly when analyzed as a continuous variable.

Complementarity of nutrition screening with Global Leadership Initiative on Malnutrition criteria for diagnosing malnutrition in critically ill patients: A comparison study of Nutritional Risk Screening 2002 and modified Nutrition Risk in the Critically Ill Score.

BACKGROUND AND AIM: Critical illness induces hypermetabolism and hypercatabolism, increasing nutrition risk (NR). Early NR identification is crucial for improving outcomes. We assessed four nutrition screening tools (NSTs) complementarity with the Global Leadership Initiative on Malnutrition (GLIM) criteria in critically ill patients. METHODS: We conducted a comparative study using data from a cohort involving five intensive care units (ICUs), screening patients for NR using NRS-2002 and modified-NUTRIC tools, with three cutoffs (≥3, ≥4, ≥5), and malnutrition diagnosed by GLIM criteria. Our outcomes of interest included ICU and in-hospital mortality, ICU and hospital length of stay (LOS), and ICU readmission. We examined accuracy metrics and complementarity between NSTs and GLIM criteria about clinical outcomes through logistic regression and Cox regression. We established a four-category independent variable: NR(-)/GLIM(-) as the reference, NR(-)/GLIM(+), NR(+)/GLIM(-), and NR(+)/GLIM(+). RESULTS: Of the 377 patients analyzed (median age 64 years [interquartile range: 54-71] and 53.8% male), NR prevalence varied from 87% to 40.6%, whereas 64% presented malnutrition (GLIM criteria). NRS-2002 (score ≥4) showed superior accuracy for GLIM-based malnutrition. Multivariate analysis revealed mNUTRIC(+)/GLIM(+) increased >2 times in the likelihood of ICU and in-hospital mortality, ICU and hospital LOS, and ICU readmission compared with the reference group. CONCLUSION: No NST exhibited satisfactory complementarity to the GLIM criteria in our study, emphasizing the necessity for comprehensive nutrition assessment for all patients, irrespective of NR status. We recommend using mNUTRIC if the ICU team opts for nutrition screening, as it demonstrated superior prognostic value compared with NRS-2002, and applying GLIM criteria in all patients.

Association between isolated or combined malnutrition and sarcopenia and quality of life in heart failure outpatients: A cross-sectional study.

BACKGROUND: Heart failure (HF) is a chronic condition with symptoms linked to worse quality of life. Malnutrition and sarcopenia are conditions frequently found in patients with HF. This study aims to evaluate the association between isolated or combined malnutrition and sarcopenia and quality of life in outpatients with HF. METHODS: This is a cross-sectional study with a sample of outpatients with HF aged ≥18 years. Malnutrition was assessed according to the criteria of the Global Leadership Initiative on Malnutrition, and sarcopenia was evaluated by the European Working Group on Sarcopenia in Older People. Quality of life was assessed using the Minnesota Living with HF questionnaire (MLHFQ). Clinical and sociodemographic data were collected. RESULTS: One hundred and fifty-one patients were included in this study, with a median (interquartile range) age of 58 (48-65) years, 58.9% were adults, and 68.9% were male. A total of 29.5% of the patients were malnourished, and 28.5% and 2.6% were identified with probable sarcopenia and sarcopenia, respectively. Of the total, 15.9% of patients were identified with both conditions. Sarcopenia was associated with higher odds of increase in the MLHFQ total score, indicating worse quality of life (odds ratio [OR] = 3.61; 95% CI, 1.65-7.89). The same was found in the presence of two conditions (OR 3.97; 95% CI, 1.32-11.54), whereas isolated malnutrition was not related to life quality (OR = 1.62; 95% CI, 0.73-3.60). CONCLUSION: The presence of malnutrition and sarcopenia simultaneously were associated with worse quality of life scores when compared with these isolated conditions.

Identifying nutrition risk in emergency patients: What is the most appropriate screening tool?

BACKGROUND: The emergency department (ED) is the most frequent access route to the hospital. Nutrition risk (NR) screening allows the early identification of patients at risk of malnutrition. This study aimed to evaluate the feasibility and predictive validity of five different tools in EDs: Nutritional Risk Screening 2002 (NRS-2002), Nutritional Risk Emergency 2017 (NRE-2017), Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT), Malnutrition Universal Screening (MUST), and Malnutrition Screening Tool (MST). METHODS: Patients with scores ≥3 according to the NRS-2002, ≥1.5 according to the NRE-2017, and ≥2 according to the MUST, RFH-NPT, or MST were classified with NR. Prolonged length of stay (LOS) and 1-year mortality were evaluated. RESULTS: 431 patients were evaluated (57.31 ± 15.6 years of age; 54.4% women) in a public hospital in southern Brazil. The prevalence of NR was: 35% according to the NRS-2002, 43% according to the MST, 45% according to the NRE-2017 and MUST, and 49% according to the RFH-NPT. Patients with NR, had a greater risk of prolonged LOS (P < 0.001). The presence of NR was associated with an increased risk of 1-year mortality according to the NRS-2002 (hazard ratio [HR]: 4.04; 95% CI, 2.513-6.503), MST (HR: 2.60; 95% CI, 1.701-3.996), NRE-2017 (HR: 4.82; 95% CI, 2.753-8.443), MUST (HR: 4.00; 95% CI, 2.385-6.710), and RFH-NPT (HR: 5.43; 95% CI, 2.984-9.907). CONCLUSIONS: NRE-2017 does not require objective data and presented predictive validity for all outcomes assessed, regardless of the severity of the disease, and thus appears to be the most appropriate tool for carrying out NR screening in the ED.

Validity of the GLIM criteria for the diagnosis of malnutrition in patients with colorectal cancer: A multicenter study on the diagnostic performance of different indicators of reduced muscle mass and disease severity.

OBJECTIVES: To assess the concurrent and predictive validity of different combinations of Global Leadership Initiative on Malnutrition (GLIM) criteria in patients with colorectal cancer considering different indicators of reduced muscle mass (MM) and the effects of the disease. METHODS: A secondary analysis with patients with colorectal cancer. The reduced MM was assessed by arm muscle area, arm muscle circumference, calf circumference, fat-free mass index, skeletal muscle index (SMI) and skeletal muscle. Cancer diagnosis or disease staging (TNM) was considered for the etiologic criterion referred to as the effect of the disease. The other phenotypic and etiologic criteria were also evaluated, and we analyzed 13 GLIM combinations. Concurrent validity between GLIM criteria and Patient-Generated Subjective Global Assessment was evaluated. Logistic and Cox regression were used in the predictive validation. RESULTS: For concurrent validity (n = 208), most GLIM combinations (n = 6; 54.5%) presented a moderate agreement with Patient-Generated Subjective Global Assessment and none showed satisfactory sensitivity and specificity (>80%). Reduced MM evaluated by SMI and SMI were present in the GLIM combinations associated with postoperative complications (odds ratio, ≥2.0), independent of other phenotypic and etiologic criteria. The combinations with reduced MM considering any method and fixed phenotypic criteria and TNM were associated with mortality (hazard ratio, ≥2.0). CONCLUSIONS: Satisfactory concurrent validity was not verified. The GLIM diagnosis of malnutrition was associated with postoperative complications and mortality.

Association Between Diabetes and Risk of Prostate Cancer: A Systematic Review and Meta-Analysis of Observational Studies.

PURPOSE: Metabolic diseases such as diabetes mellitus may play a role in the development and progression of prostate cancer (PC); however, this association remains to be explored in the context of specific PC stages. The objective of this study was to systematically review the evidence for an association between diabetes and overall, early, or advanced PC risk. MATERIALS AND METHODS: A systematic review with meta-analysis was performed (MEDLINE, EMBASE, and CINAHL) from inception until September 2023. Cohort and case-control studies that assessed PC risk in adult males (≥18 years) associated with type 2 diabetes mellitus or diabetes (if there was no distinction between diabetes type) were included. The Newcastle-Ottawa Scale (NOS) was used to assess study bias; those with NOS<7 were excluded. Evidence certainty was assessed with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method. RESULTS: Thirty-four studies (n=26 cohorts and n=8 case-controls) were included. Of these, 32 assessed diabetes and all PC stages combined, 12 included early PC stages, and 15 included advanced PC stages. Our meta-analysis showed diabetes had a protective effect against early PC development (n=11, risk ratio [RR]=0.71; 95% confidence interval [CI]=0.61-0.83, I²=84%) but no association was found for combined (n=21, RR=0.95; 95% CI=0.79-1.13, I²=99%) or advanced PC stages (n=15, RR=0.96; 95% CI=0.77-1.18, I²=98%) at diagnosis. According to GRADE, the evidence certainty was very low. CONCLUSIONS: Diabetes may be protective against early PC stages, yet evidence linking diabetes to risk across all stages, and advanced PC specifically, is less conclusive. High heterogeneity may partially explain discrepancy in findings and was mostly associated with study design, method used for PC diagnosis, and risk measures. Our results may aid risk stratification of males with diabetes and inform new approaches for PC screening in this group, especially considering the reduced sensitivity of prostate-specific antigen values for those with diabetes.

Association of handgrip strength with nutritional status and clinical outcomes in hospitalized pediatric patients.

BACKGROUND & AIMS: Malnutrition in children and adolescents is prevalent at hospital admission and the incidence increases with length of stay. Malnourished patients have loss of muscle mass and strength, compromising their functionality. Handgrip strength (HGS) is a nutritional marker understudied in pediatrics although it is capable of detecting nutritional deprivation before changes in body composition are observed. Therefore, this study aimed to evaluate the association between reduced HGS at hospital admission, compromised nutritional status and worse clinical outcomes of pediatric patients. METHODS: Cohort study conducted with patients aged 6-18 years admitted to a pediatric ward. Nutritional status was assessed in the first 48 h of hospital admission using the z-score of height for age (H/A) and body mass index for age (BMI/A), percentile of mid-arm muscle circumference for age (MAMC/A) and the pediatric global subjective nutritional assessment (SGNA). HGS was measured using a digital dynamometer and considered reduced when the maximum value of three measurements was below the 5th percentile for sex and age. The clinical outcomes analyzed were length of hospital stay and frequency of readmission within 3 months after hospital discharge. RESULTS: A total of 135 patients were evaluated (median age 10.9 years, 55.6% male) and 17.8% had reduced HGS. Patients with reduced HGS had lower H/A z-score (-0.50 vs 0.22, p = 0.012) and a higher frequency of reduced MAMC when compared to those with normal HGS (8% vs 13%, p = 0.007). Reduced HGS was not associated with malnutrition (OR = 0.63; 95%CI 0.23-1.77), prolonged hospital stay (OR = 1.89; 95%CI 0.72-4.92) or readmission to hospital 3 months after hospital discharge (OR = 1.82; 95%CI 0.67-4.93), in a model adjusted for the clinical condition. CONCLUSION: Reduced HGS was not a predictor of malnutrition and clinical outcomes. However, it was associated with lower H/A Z-score and MAMC/A percentile values and can be used as a complementary measure in the nutritional status assessment of hospitalized pediatric patients.