Oral Nutrition as a Form of Pre-Operative Enhancement in Patients Undergoing Surgery for Colorectal Cancer: A Systematic Review.

BACKGROUND: Nutritional status has major impacts on the outcome of surgery, in particular in patients with cancer. The aim of this review was to assess the merit of oral pre-operative nutritional support as a part of prehabilitation in patients undergoing surgery for colorectal cancer. METHODS: A systematic literature search and meta-analysis was performed according to the Preferred Reporting of Systematic Reviews and Meta-Analyses (PRISMA) recommendations in order to review all trials investigating the effect of oral pre-operative nutritional support in patients undergoing colorectal surgery. The primary outcome was overall complication rate. Secondary outcomes were incision infection rate, anastomotic leakage rate, and length of hospital stay. RESULTS: Five randomized controlled trials and one controlled trial were included. The studies contained a total of 583 patients with an average age of 63 y (range 23-88 y), of whom 87% had colorectal cancer. Malnourishment rates ranged from 8%-68%. All investigators provided an oral protein supplement. Overall patient compliance rates ranged from 72%-100%. There was no significant reduction in the overall complication rate in the interventional groups (odds ratio 0.82; 95% confidence interval 0.52 - 1.25). CONCLUSION: Current studies are too heterogeneous to conclude that pre-operative oral nutritional support could enhance the condition of patients undergoing colorectal surgery. Patients at risk have a relatively lean body mass deficit (sarcopenia) rather than an absolute malnourished status. Compliance is an important element of prehabilitation. Targeting patients at risk, combining protein supplements with strength training, and defining standardized patient-related outcomes will be essential to obtain satisfactory results.

Discriminative value of frailty screening instruments in end-stage renal disease.

BACKGROUND: Numerous frailty screening instruments are available, but their applicability for identifying frailty in patients with end-stage renal disease (ESRD) is unknown. We aimed to investigate the diagnostic accuracy of three instruments used for frailty screening in an ESRD population. METHODS: The study was conducted in 2013 in a teaching hospital in The Netherlands and included patients receiving haemodialysis, peritoneal dialysis and pre-dialysis care. We determined the sensitivity and specificity of three screening instruments: the Groningen Frailty Indicator (GFI), the Identification of Seniors at Risk-Hospitalized Patients (ISAR-HP) and the Veiligheidsmanagementsysteem (VMS), which is a safety management system for vulnerable elderly patients. The Frailty Index was the gold standard used. RESULTS: The prevalence of frailty was 37% in a total of 95 participants with ESRD [mean age 65.2 years (SD 12.0), 57% male]. Frailty prevalence in participants ≥65 years of age and <65 years of age was 44% and 28%, respectively (P = 0.11). Sensitivity and specificity for frailty of the GFI were 89% and 57%, respectively; ISAR-HP 83% and 77%, respectively; and VMS 77% and 67%, respectively. CONCLUSIONS: Although the GFI showed the highest sensitivity, it is not yet possible to propose a firm choice for one of these screening instruments or specific items due to the small scale of the study. Since there is a high prevalence of frailty in ESRD patients, translation and testing of the effectiveness of screening using the GFI in the prognostication and prevention of development or deterioration of frailty in this population should be the next step.

High prevalence of frailty in end-stage renal disease.

PURPOSE: Prognosis of the increasing number of elderly patients with end-stage renal disease (ESRD) is poor with high risk of functional decline and mortality. Frailty seems to be a good predictor for those patients that will not benefit from dialysis. Varying prevalences between populations are probably related to the instrument used. The aim of this study was to measure the prevalence of frailty among ESRD patients with two different validated instruments. METHODS: This cross-sectional study was conducted among patients, aged ≥18 years, receiving hemodialysis, peritoneal dialysis and pre-dialysis care between September 2013 and December 2013 in a single dialysis center in Apeldoorn, the Netherlands. Frailty was measured with the frailty index (FI) and frailty phenotype (FP). RESULTS: Prevalence of frailty by the FI was 36.8 % among 95 participants with ESRD (age: 65.2 years, SD ± 12.0). Frailty prevalence among participants aged ≥65 and <65 years was 43.6 and 27.5 %, respectively. Female sex [odds ratio (OR) 3.3, 95 % confidence interval (CI) 1.3-8.0] and a Charlson comorbidity index score of ≥5 (OR 2.6, 95 % CI 1.0-6.6) were associated with frailty. The FI identified different but overlapping participants as frail compared with the FP; 62.5 % of frail participants according to FI were also frail according to the FP. CONCLUSIONS: Prevalence of frailty among young and elderly ESRD patients is high; being female and having more comorbidity was associated with frailty. Use of a broader definition of frailty, like the FI, gives a higher estimation of prevalence among ESRD patients compared with a physical frailty assessment.

Routine use of the confusion assessment method for the intensive care unit: a multicenter study.

RATIONALE: Delirium is often unrecognized in ICU patients and associated with poor outcome. Screening for ICU delirium is recommended by several medical organizations to improve early diagnosis and treatment. The Confusion Assessment Method for the ICU (CAM-ICU) has high sensitivity and specificity for delirium when administered by research nurses. However, test characteristics of the CAM-ICU as performed in routine practice are unclear. OBJECTIVES: To investigate the diagnostic value of the CAM-ICU in daily practice. METHODS: Teams of three delirium experts including psychiatrists, geriatricians, and neurologists visited 10 ICUs twice. Based on cognitive examination, inspection of medical files, and Diagnostic and Statistic Manual of Mental Disorders, 4th edition, Text Revision criteria for delirium, the expert teams classified patients as awake and not delirious, delirious, or comatose. This served as a gold standard to which the CAM-ICU as performed by the bedside ICU-nurses was compared. Assessors were unaware of each other's conclusions. MEASUREMENTS AND MAIN RESULTS: Fifteen delirium experts assessed 282 patients of whom 101 (36%) were comatose and excluded. In the remaining 181 (64%) patients, the CAM-ICU had a sensitivity of 47% (95% confidence interval [CI], 35%-58%); specificity of 98% (95% CI, 93%-100%); positive predictive value of 95% (95% CI, 80%-99%); and negative predictive value of 72% (95% CI, 64%-79%). The positive likelihood ratio was 24.7 (95% CI, 6.1-100) and the negative likelihood ratio was 0.5 (95% CI, 0.4-0.8). CONCLUSIONS: Specificity of the CAM-ICU as performed in routine practice seems to be high but sensitivity is low. This hampers early detection of delirium by the CAM-ICU.