Nutrition provided during the final weeks to patients with non-gastrointestinal solid malignancies.

BACKGROUND & AIMS: Data regarding the delivery of nutrition and nutritional infusions to patients with terminal cancer remain limited; therefore, this real-world analysis investigated differences in nutrition delivery and infusion statuses for patients with terminal-stage cancers. METHODS: Patients who had died following hospitalization for more than seven days due to neoplasms between April 2014 and December 2018 were identified using the medical claims database of Japan. Data regarding oral diets, enteral feeding, infusion volumes, and infusion energies were extracted. The maximum observation period was 28 days prior to patient death. RESULTS: A total of 12,908 patients were included in our analysis. The proportion of patients without dietary or enteral nutrition increased closer to their dates of death. Observations were recorded at 28 (18.9%), 21 (20.9%), 14 (24.6%), 7 (33.0%), and 0 (80.2%) days prior to death. The infusion volumes given to the patients, as well as their energy contents, decreased near death (P-value for the trend <0.001). CONCLUSIONS: Our study revealed the current status of nutritional therapy for patients with terminal cancer in Japan. The number of patients receiving only parenteral nutrition increased near death, while the amount of nutritional intake was low.

Cachexia staging score predicts survival in patients with cancer who receive palliative care.

OBJECTIVE: The aim of this study was to validate the cachexia staging score (CSS), a multidimensional, item-based diagnostic method of cachexia severity, for patients with advanced cancer receiving palliative care. METHODS: Eligible patients were those with cancer who received palliative care during hospitalization between May 2019 and April 2020. All data were collected retrospectively from medical records. Cachexia was graded into four levels according to the CSS. Kaplan-Meier curves were constructed with or without death as the outcome, comparing prognoses among different levels of cachexia with Bonferroni correction. Cox proportional hazards regression analysis was performed to identify factors affecting mortality. RESULTS: The mean age of the 196 patients was 65.8 ± 14 y. Men made up 42% of the study population. Lower body mass index, increased rate of weight loss, increased strength, assistance walking, rising from a chair, climbing stairs, and falls (SARC-F) points, decline in activities of daily living, appetite loss, and abnormal blood biomarkers were significantly more common with increasing severity of cachexia, and survival was shorter (P < 0.001). The hazard ratio (HR) increased with worsening severity of cachexia according to CSS classification (precachexia: HR, 2.78; 95% confidence interval [CI], 0.62-12.46, P = 0.182; cachexia: HR, 4.77; 95% CI, 1.09-20.80; P = 0.038; and refractory cachexia: HR, 11.00; 95% CI, 2.37-51.07; P = 0.002). CONCLUSIONS: The CSS predicted life expectancy in a population of patients receiving palliative care and had excellent prognostic discriminative power to classify patients at different stages of cachexia.

Prognostic implications of the global leadership initiative on malnutrition criteria as a routine assessment modality for malnutrition in hospitalized patients at a university hospital.

BACKGROUND & AIMS: Few studies have examined the association between mortality and malnutrition diagnosed using the Global Leadership Initiative on Malnutrition (GLIM) criteria for routine nutritional assessment; thus, this association is not well known. We aimed to clarify the association between GLIM-defined malnutrition and mortality in a large population of hospitalized patients. METHODS: In this retrospective cohort study, we enrolled adult patients admitted to Aichi Medical University Hospital between April 2019 and March 2021, who underwent nutritional assessment using the GLIM criteria. In November 2021, we collected the following data from electronic medical records: demographic, clinical, and laboratory data upon admission; nutritional data assessed using GLIM criteria; and data on final patient outcomes. RESULTS: In this study, we included 9372 hospitalized patients who were identified to be at risk by the validated nutritional screening tools (50.6% men, median age 75.0 [67.0-82.0] years, 69.2% patients aged ≥70 years). The number of patients with no, moderate, and severe GLIM-defined malnutrition was 4145 (44.2%), 2799 (29.9%), and 2428 (25.9%), respectively. Kaplan-Meier survival curve analysis showed a significant increase in mortality with worsening nutritional status (log-rank test, P < 0.001). After adjusting for age and sex, multivariable Cox regression analysis revealed that both moderate (Hazard ratio [HR] 2.0, 95% confidence interval [CI] 1.79-2.23, P < 0.001) and severe malnutrition (HR 3.06, 95% CI 2.74-3.40, P < 0.001) were independent risk factors for mortality. Moreover, multivariable analysis showed that four of the five GLIM sub-criteria (except low body mass index) were independently associated with prognosis. CONCLUSION: Malnutrition and its severity, routinely assessed using the GLIM criteria, are associated with high mortality in hospitalized patients at nutritional risk. Further research is needed to evaluate the usefulness of the GLIM sub-criteria, including low body mass index, in these patients.

High SARC-F score predicts poor survival of patients with cancer receiving palliative care.

PURPOSE: A high score determined by SARC-F, a simple screening questionnaire for sarcopenia, has been reportedly associated with worse medical outcomes. However, information regarding whether high SARC-F scores are associated with a poor prognosis in patients with advanced cancer remains limited. We clarified whether a SARC-F score ≥ 4 predicts poor prognosis in patients with cancer receiving palliative care. METHODS: We conducted a retrospective cohort study of patients with cancer who received palliative care at a university hospital between May 2019 and April 2020. Patient characteristics including age, sex, height, weight, cancer type, serum albumin level, C-reactive protein level, presence of edema, Eastern Cooperative Oncology Group-Performance Status (ECOG-PS), SARC-F score, history of anticancer therapy, and clinical outcomes were collected from electronic medical records. RESULTS: Of 304 patients, 188 had a SARC-F score < 4, and 116 patients had a SARC-F score ≥ 4. The overall survival of patients with a SARC-F score ≥ 4 was 40 days (95% CI 29-47), which was significantly worse than 121 days (95% CI 95-156) for patients with a SARC-F score < 4 (p < 0.001). SARC-F score ≥ 4 (hazard ratio: HR 1.56), edema (HR 1.94), head and neck cancer (HR 0.51), C-reactive protein (HR 1.05), ECOG-PS ≥ 3 (HR 1.47), and radiotherapy (HR 0.52) were associated with overall survival. The ability to climb stairs was a SARC-F sub-item significantly associated with mortality (HR 1.59). CONCLUSION: The SARC-F questionnaire is a useful predictor of prognosis for patients with cancer receiving palliative care because a SARC-F ≥ 4 score predicts worse overall survival.

Evaluation of skeletal muscle mass using prediction formulas at the level of the 12th thoracic vertebra.

OBJECTIVES: People with cancer have a high risk of cachexia and sarcopenia, which are associated with worse clinical outcomes. We evaluated the prediction accuracy of the Matsuyama et al. and Ishida et al. formulas using computed tomography (CT) slices from the twelfth thoracic vertebra (Th12) level in people with cancer. METHODS: This retrospective study included patients with advanced cancer who underwent thoracic and abdominal CT scans (n = 173). The cross-sectional area (CSA) on CT images was measured at the levels of Th12 and the third lumbar vertebra (L3). The Matsuyama et al. formula used the Th12 CSA, whereas the Ishida et al. formula used only the Th12 CSA of the spinal erectors; thus, the measurements were performed separately. The correlation between predicted and actual L3 CSA was assessed using r and the intraclass correlation coefficient. A prediction-accuracy analysis of the predicted values was also performed. RESULTS: The mean participant age was 66.2 ± 12.8 y; 50.3% of participants were women and 49.7% were men. Strong correlations were observed between the predicted and measured L3 values calculated from the two prediction formulas. The prediction-accuracy analysis using previously reported cutoff values showed that the Ishida et al. method had high sensitivity and the Matsuyama et al. method had high specificity for low skeletal muscle index determined by the predicted and measured L3 skeletal muscle index. CONCLUSIONS: Both the Matsuyama et al. and Ishida et al. formulas had good reliability on CT slices at the Th12 level in people with advanced cancer, indicating that these formulas can be applied in clinical practice.

Addendum: Ishida et al. Formula for the Cross-Sectional Area of the Muscles of the Third Lumbar Vertebra Level from the Twelfth Thoracic Vertebra Level Slice on Computed Tomography. Geriatrics 2020, 5, 47.

The authors would like to make an addendum to their published paper [...].

Assessing skeletal muscle mass based on the cross-sectional area of muscles at the 12th thoracic vertebra level on computed tomography in patients with oral squamous cell carcinoma.

OBJECTIVES: This study aimed to create a formula to estimate the third lumbar vertebra (L3)1 level skeletal muscle cross-sectional area (CSA), known as a standard value to evaluate skeletal muscle mass on computed tomography (CT), using the twelfth thoracic vertebra (Th12) level skeletal muscle CSA on chest CT. MATERIALS AND METHODS: This retrospective observational study included patients aged 40 + years with a diagnosis of oral squamous cell carcinoma (n = 164). Skeletal muscle CSA on CT images was measured using the Th12 and the L3 levels of pretreatment CT scans. The predictive formula was created based on the five-fold cross-validation method with a linear regression model. Correlations between the predicted L3-level CSA and the actual L3-level CSA were evaluated using r and Intraclass Correlation Coefficients (ICC). RESULTS: The predictive formula for L3-level CSA from Th12-level CSA was: CSA at L3 (cm2) = 14.143 + 0.779 * CSA at Th12 (cm2) - 0.212 * Age (y) + 0.502 * Weight (kg) + 13.763 * Sex. Correlations between the predicted and measured L3-level CSA were r = 0.915 [0.886-0.937] and ICC = 0.911 [0.881-0.934]. CONCLUSION: We developed a formula for predicting skeletal muscle mass from the Th12-level CT slice. The predicted L3-level CSA correlated with the measured L3-level CSA.

Determining the optimal value of the Geriatric Nutritional Risk Index to screen older patients with malnutrition risk: A study at a university hospital in Japan.

AIM: The Geriatric Nutritional Risk Index (GNRI) can predict nutritional risk. However, just a few studies have validated the optimal cut-off value of GNRI for nutrition screening in older patients. Hence, this study aimed to determine the optimal value of GNRI to screen the risk of malnutrition among older patients. METHODS: This retrospective cross-sectional study was carried out with 5867 consecutive older adult patients who were admitted to an academic hospital in Japan. Receiver operating characteristic curve analyses were carried out to obtain the optimal cut-off value of GNRI, and the results were compared against the Mini Nutritional Assessment - Short Form and Malnutrition Universal Screening Tool. The validation of the obtained cut-off value was examined on the concordance rate of malnutrition diagnosis based on the European Society of Clinical Nutrition and Metabolism criteria. RESULTS: The mean age of the patients was 76.0 ± 7.0 years. The optimal cut-off value of GNRI for Mini Nutritional Assessment - Short Form ≤11 points was 95.92 (area under the curve 0.827 [0.817-0.838], P < 0.001), and that for Malnutrition Universal Screening Tool ≥1 point was 95.95 (area under the curve 0.788 [0.776-0.799], P < 0.001). By adapting GNRI <96 points as an initial screening cut-off in the European Society of Clinical Nutrition and Metabolism-defined malnutrition process, the concordance rates of comparisons were 98.5% and 98.5% for Mini Nutritional Assessment - Short Form-based and MUST-based diagnosis, respectively. CONCLUSIONS: The study showed GNRI <96 points as the optimal cut-off value for nutritional screening. GNRI might be one of the easy-to-use tools for nutritional screening and for diagnosing malnutrition in older adults. Geriatr Gerontol Int 2020; 20: 811-816.

Formula for the Cross-Sectional Area of the Muscles of the Third Lumbar Vertebra Level from the Twelfth Thoracic Vertebra Level Slice on Computed Tomography.

The purpose of this study was to investigate a means by which to reflect muscle mass using chest computed tomography (CT). A cross-sectional study was conducted with patients aged ≥ 65 years having abdominal and chest CT scans. The formula to predict third lumbar vertebra (L3) cross-sectional area (CSA) of the muscles from the erector muscles of the spine at the twelfth thoracic vertebra (Th12) level slice on CT was created using the five-fold cross-validation method. Correlation between predicted L3 CSA and measured L3 CSA of the muscles was assessed by intraclass correlation coefficients (ICC) and correlation coefficients (r) in the data of the development, and predictability was examined with accuracy and F-values in the validation study. The development study included 161 patients. The developed formula was as follows: -1006.38 + 16.29 × age + 1161.80 × sex (if female, 0; if male, 1) + 55.91 × body weight + 2.22 × CSA of the erector muscles at Th12. The formula demonstrated strong concordance and correlation (ICC = 0.849 [0.800-0.887] and r = 0.858 [0.811-0.894]). The validation study included 34 patients. The accuracy and F-value between predicted CSA and measured CSA were high (accuracy = 0.889-0.944, F-value = 0.931-0.968). We developed a formula predicting CSA at L3 using Th12 CT slice. This formula could be used to assess decreased muscle mass even with chest CT alone.

Malnutrition at Admission Predicts In-Hospital Falls in Hospitalized Older Adults.

Malnutrition leads to poor prognoses, including a predisposition to falls. Few studies have investigated the relationship between malnutrition and falls during hospitalization. This study aimed to determine malnutrition's association with falls during hospitalization. A retrospective observational study was conducted. Patients aged ≥65 years that were admitted to and discharged from a university hospital between April 2018 and March 2019 were examined. Patients with independent basic activities of daily living were included. Diagnosis of malnutrition was based on the European Society for Clinical Nutrition and Metabolism (ESPEN) criteria at admission. Disease information such as the Charlson Comorbidity Index (CCI) and reasons for hospitalization were reviewed. Kaplan-Meier curve and multivariate Cox regression analyses were performed. Data from 6081 patients (mean age: 74.4 ± 6.1 years; males: 58.1%) were analyzed. The mean CCI was 2.3 ± 2.8 points. Malnutrition was detected in 668 (11.0%) and falls occurred in 55 (0.9%) patients. Malnourished patients experienced a higher fall rate than those without malnutrition (2.4% vs. 0.7%, log-rank test p < 0.001). In multivariate analysis, malnutrition had the highest hazard ratio for falls among covariates (hazard ratio 2.78, 95% confidence interval 1.51-5.00, p = 0.001). In conclusion, malnutrition at the time of admission to hospital predicts in-hospital falls.

Reference body mass index values and the prevalence of malnutrition according to the Global Leadership Initiative on Malnutrition criteria.

BACKGROUND & AIMS: The Global Leadership Initiative on Malnutrition (GLIM) released new criteria for diagnosing and grading malnutrition. This study aimed to investigate the optimal reference values of body mass index (BMI) for discriminating severe malnutrition according to the GLIM criteria, as well as the prevalence of GLIM-defined malnutrition in the clinical setting. METHODS: This study included 6783 patients aged ≥40 years, who were admitted to an academic hospital. Of the 1987 patients who presented with low BMI in period 1, optimal BMI cut-off values were determined using receiver operating characteristic analyses against in-hospital mortality in younger (aged <70 years) and older age groups. Next, 4796 patients from period 2 were screened using a validated nutritional screening tool. Patients had their nutritional condition assessed after screenings were analyzed using the GLIM criteria, which included body weight changes, BMI, reduced muscle mass, nutritional intake, and disease burden. Additionally, patients diagnosed with malnutrition were classified as having moderate or severe malnutrition, according to the obtained BMI values from the period 1 data. RESULTS: The optimal cut-off BMI values were 17.0 kg/m2 for younger patients and 17.8 kg/m2 for older patients. Patients at risk of malnutrition included 14.5% and 42.0% of admitted younger and older patients in period 2, respectively. GLIM-defined malnutrition was diagnosed in 18.0% of all patients (10.6% and 25.7% in younger and older patients, respectively). After adapting the BMI cut-off values according to the period 1 results, 9.0% and 9.0% of all patients were diagnosed as having moderate and severe malnutrition, respectively. Patients with GLIM-defined malnutrition showed significantly higher in-hospital mortality compared to those without malnutrition. CONCLUSIONS: The Asian reference values of BMI to grade malnutrition severity according to the GLIM criteria, as well as the prevalence of GLIM-defined malnutrition were determined. These reference values will contribute to implementing the GLIM criteria in Asian populations.

Impact of edema on length of calf circumference in older adults.

AIM: Calf circumference, which is a known simple indicator of muscle mass, increases during edema. However, the extent to which edema increases calf circumference in older adults is unclear. METHODS: This retrospective cross-sectional study included patients aged ≥65 years whose nutritional status was assessed by nutrition support teams. Two different types of matching models in each sex were created according to the presence of edema on the right lower limb. All models were adjusted by age, body height, handgrip strength and performance status. Sarcopenia was diagnosed based on both reduced calf circumference and decline of handgrip strength. The prevalence of sarcopenia was estimated before and after adjustment for increment of calf circumference. RESULTS: In total, 2101 patients were included. Multifactor matching models showed that the mean difference in calf circumference between pairs was 1.6 cm (95% confidence interval [CI] 1.1-2.1, P < 0.001) for women and 2.1 cm (95% CI 1.6-2.7, P < 0.001) for men. The propensity score matching model similarly showed a mean difference of 1.6 cm (95% CI 1.1-2.1, P < 0.001) for women and 2.0 cm (95% CI 1.5-2.6, P < 0.001) for men. The prevalence of sarcopenia before and after adjusting for an edema-related increase in calf circumference was 42.6%/48.6% for women and 35.3%/38.5%-38.7% for men. CONCLUSIONS: Edema in the lower limb increased the calf circumference by approximately 2 cm. When using calf circumference to assess muscle mass in patients with edema, the increase in circumference should be subtracted from the baseline circumference for an accurate assessment. Geriatr Gerontol Int 2019; 19: 993-998.

Development and Predictors of Sarcopenic Dysphagia during Hospitalization of Older Adults.

The study aimed to investigate the impact of sarcopenia and sarcopenia-related conditions on the development of swallowing disorders during hospitalization. Older adult inpatients (n = 8768) without swallowing disorders in the premorbid period were studied. Sarcopenia-related conditions were evaluated in terms of nutritional status, physical status, and ambulatory conditions as well as hand-grip strength and muscle mass assessed by calf circumference. Development of swallowing disorders was defined based on food texture at discharge from the hospital. The patients' mean age was 76.1 ± 6.9 years. A total of 374 (4.3%) patients developed swallowing disorders during hospitalization. They were older, with poorer nutritional status, and had more decline of physical performance than those without swallowing disorders. Performance Status score (odds ratio (OR) = 1.28 (1.12-1.46) p < 0.001), ambulatory dependency (OR = 1.72 (1.09-2.71), p = 0.020), malnutrition score (OR = 0.92 (0.87-0.97), p = 0.002), insufficient nutritional intake (OR = 2.33 (1.60-3.40), p < 0.001), and length of stay (OR = 1.01 (1.00-1.01), p = 0.001) were independent contributing factors for swallowing disorder development in the multivariate analysis. The presence of possible sarcopenia was also a contributor to swallowing disorder development. In conclusion, swallowing disorders could develop in patients with possible sarcopenia and sarcopenia-related conditions during hospitalization. Clinicians should be aware of this risk and provide appropriate interventions to prevent sarcopenic dysphagia.

Testosterone-lowering activity of canola and hydrogenated soybean oil in the stroke-prone spontaneously hypertensive rat.

Canola and some other types of oil unusually shorten the survival of stroke-prone spontaneously hypertensive rats (SHRSP), compared with soybean oil, perilla oil and animal fats. Since differential effects of canola and soybean oil on steroid hormone metabolism were suggested by a preliminary DNA microarray analysis as a reason for this, the steroid hormone levels in the serum and tissues of SHRSP fed different oils were investigated. The testosterone levels in the serum and the testes were found to be significantly lower in the canola oil group than in the soybean oil group, while no significant differences were detected in the corticosterone and estradiol levels in tissues. In a second experiment, it was found that hydrogenated soybean oil, with a survival-shortening activity comparable to that of canola oil, also decreased the testosterone level in testes to a similar degree. The testosterone-lowering activity of canola and hydrogenated soybean oil observed in SHRSP was considered in relation to other factors possibly affecting the physiology of SHRSP.