Validity of the Global Leadership Initiative on Malnutrition criteria using calf circumference in the prediction of in-hospital mortality in older surgical patients: A secondary analysis of a cohort study.

BACKGROUND: Malnutrition is a prevalent condition among older patients and is associated with worse clinical outcomes. Methods such as the Subjective Global Assessment (SGA), the Mini Nutritional Assessment Long Form (MNA-LF), and the Global Leadership Initiative on Malnutrition (GLIM) diagnose malnutrition early. This study aimed to evaluate the performance and validity of these instruments to predict the length of hospital stay (LOS) and in-hospital mortality in older surgical patients. METHODS: This prospective cohort study was performed in hospitalized older surgical patients. In the first 48 h of admission, general data were collected, and patients were evaluated by SGA, MNA-LF, and GLIM using calf circumference (CC) and mid-upper arm circumference (MUAC) as phenotypic criteria for nutrition diagnoses. Accuracy tests and regression analysis adjusted for sex, type of surgery, and the Charlson Comorbidity Index adjusted for age were performed to assess the criterion validity of instruments to predict LOS and mortality. RESULTS: A total of 214 patients (age 75.4 ± 6.6 years, 57.3% men, and 71.1% admitted to elective surgery) were evaluated. Malnutrition was diagnosed in 39.7% (SGA), 63% (MNA-LF), 41.6% (GLIMCC ), and 32.1% (GLIMMUAC ) of patients. GLIMCC had the best accuracy (AUC = 0.70; 95% CI, 0.63-0.79) and sensitivity (95.8%) to predict in-hospital mortality. In the adjusted analysis, malnutrition, according to SGA, MNA-LF, and GLIMCC , increased the risk of in-hospital mortality by 3.12 (95% CI, 1.08-11.34), 4.51 (95% CI, 1.29-17.61), and 4.83 (95% CI, 1.52-15.22), respectively. CONCLUSION: GLIMCC had the best performance and satisfactory criterion validity to predict in-hospital mortality in older surgical patients.

Orthostatic hypotension, falls and in-hospital mortality among elderly patients with and without type 2 diabetes.

OBJECTIVES: To evaluate the association of falls and in-hospital mortality with the presence of orthostatic hypotension and type 2 diabetes mellitus (T2D). The study also aims to identify whether the orthostatic hypotension assessed at 1 min or at 3 min can predict falls and mortality, as a secondary objective to identify the predictors of fall during hospitalization. METHODS: We performed a prospective study with patients admitted to a university hospital. The risk of falls was assessed using the Morse questionnaire and the presence of falls was verified by the patient's medical records during hospitalization. The orthostatic hypotension was determined by measuring blood pressure at three times, considering as orthostatic hypotension the reduction of at least 20 mmHg in SBP or 10 mmHg in DBP. In-hospital mortality was consulted in the medical records. RESULTS: Patients with orthostatic hypotension were slower on Timed Up and Go test (TUG) (12.26 ±â€Š3.16 vs. 16.08 ±â€Š5.96 s, P = 20 s) and presence of orthostatic hypotension. After adjustments, patients with T2D and orthostatic hypotension had a 2.7 times greater risk of in-hospital falls and 1.54 times greater odds of in-hospital mortality when compared with patients without T2D and orthostatic hypotension. CONCLUSION: In this sample, sedentary patients and those with lower TUG had a higher risk of falls. The prevalence of falls was higher in patients with T2D. The association of T2D with orthostatic hypotension significantly increased both the risk of falls and the risk of in-hospital mortality.

Patient-centered Management of Type 2 Diabetes Mellitus Based on Specific Clinical Scenarios: Systematic Review, Meta-analysis and Trial Sequential Analysis.

INTRODUCTION: New antihyperglycemic medications have been proven to have cardiovascular (CV) and renal benefits in type 2 diabetes mellitus (T2DM); however, an evidence-based decision tree in specific clinical scenarios is lacking. MATERIALS AND METHODS: Systematic review and meta-analysis of randomized controlled trials (RCTs), with trial sequential analysis (TSA). Randomized controlled trial inclusion criteria were patients with T2DM from 1 of these subgroups: elderly, obese, previous atherosclerotic CV disease (ASCVD), previous coronary heart disease (CHD), previous heart failure (HF), or previous chronic kidney disease (CKD). Randomized controlled trials describing those subgroups with at least 48 weeks of follow-up were included. Outcomes: 3-point major adverse cardiovascular events (MACE), CV death, hospitalization due to HF, and renal outcomes. We performed direct meta-analysis with the number of events in the intervention and control groups in each subset, and the relative risk of the events was calculated. RESULTS: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1 RA) were the only antihyperglycemic agents related to a reduction in CV events in different populations. For obese and elderly populations, GLP-1 RA were associated with benefits in 3-point MACE; for patients with ASCVD, both SGLT2i and GLP-1 RA had benefits in 3-point MACE, while for patients with CHD, only SGLT2i were beneficial. CONCLUSIONS: SGLT2i and GLP-1 RA reduced CV events in selected populations: SGLT2i led to a reduction in events in patients with previous CHD, ASCVD, and HF. GLP-1 RA led to a reduction in CV events in patients with ASCVD, elderly patients, and patients with obesity. Trial sequential analysis shows that these findings are conclusive. This review opens a pathway towards evidence-based, personalized treatment of T2DM. REGISTRATION: PROSPERO CRD42019132807.

Sarcopenia and Type 2 diabetes mellitus as predictors of 2-year mortality after hospital discharge in a cohort of hospitalized older adults.

INTRODUCTION: Sarcopenia has been discussed as a possible predictor of mortality in the older people, but there are few studies evaluating the relationship between mortality and sarcopenia in the population of patients with type 2 diabetes (T2D), especially after hospital discharge. OBJECTIVE: To evaluate whether coexistence of sarcopenia and T2D predicts mortality after two years of hospital discharge in older patients compared to a control group without diabetes. METHODOLOGY: A prospective study that included patients hospitalized between July 2015 and December 2017. To assess sarcopenia, a Timed Up and Go (TUG) test was performed, muscle strength was measured by handgrip, and muscle mass was measured across the largest calf circumference region. This project was approved by the HCPA Ethics Committee under number 150068. RESULTS: 610 patients were included. The group was stratified according to the presence of diabetes, 306 (51%) patients had TD2. Patients with T2D had lower muscle strength (19.62 ± 7.53 vs. 21.19 ± 7.31p = 0.009), were slower in TUG test (23 vs. 16 s; p < 0.001) than those without T2D, 46.3% being classified as sarcopenic. The mortality rate among T2D was 28%. After adjustment, the coexistence of T2D and sarcopenia was independently associated with mortality after hospital discharge (HR: 1.78; 95% CI: 1.06-2.30). CONCLUSION: Older patients with T2D and sarcopenia had a higher risk of mortality after hospital discharge compared to a control group.

Saturated fatty acid intake decreases serum adiponectin levels in subjects with type 1 diabetes.

BACKGROUND: Adiponectin is a protein secreted by adipose tissue. It plays a key role in insulin resistance and has anti-inflammatory and anti-atherogenic functions. Changes in diet can influence adiponectin levels. Different dietary interventions, especially those altering fatty acid intake, have been reported as possible mediators of adiponectin levels. METHODS: We conducted a cross-sectional study of 122 subjects with type 1 diabetes (T1DM). Dietary intake was evaluated by 3-day weighed-diet records. Adiponectin levels were categorized into tertiles (T1, <10.260µg/mL; T2, 10.261-18.280µg/mL; T3, >18.281µg/mL). RESULTS: Mean age was 38±11years, and mean duration of diabetes was 17±9years. After multiple regression analysis, waist-to-hip ratio (WHR) (r=-0.19, p = 0.03), age (r=-0.22, p=0.01), systolic blood pressure (SBP) (r=-0.27, p=0.002), diastolic blood pressure (DBP) (r=-0.19, p=0.30), total lipid intake (g) (r=-0.20, p=0.02), saturated fatty acid (SFA) intake (r=-0.25, p=0.004), monounsaturated fatty acid (MUFA) intake (r=-0.21, p=0.02), cholesterol intake (mg) (r=-0.20, p=0.021), sodium intake (g) (r=-0.19, p=0.03), and urinary albumin excretion rate (UAE) (µg/24h) (r=0.26, p=0.02) correlated with adiponectin levels. Even after adjustment for age, SBP or DBP, UAE, and WHR in all models, inverse associations between adiponectin levels and intake of total SFA and MUFA and polyunsaturated fatty acid fractions were observed. Subjects in the first and third tertiles of adiponectin exhibited the greatest differences between adiponectin levels, with a trend toward increasing levels with higher SFA intake. CONCLUSIONS: The present study suggests that high SFA intake may be associated with lower adiponectin levels in patients with T1DM.