Elevated Plasma Vitamin B12 Concentrations Are Independent Predictors of In-Hospital Mortality in Adult Patients at Nutritional Risk.

Background: Elevated plasma vitamin B12 concentrations were identified as predictors of mortality in patients with oncologic, hepatic and renal diseases, and in elderly and critically ill medical patients. The association between vitamin B12 concentrations and in-hospital mortality in adult patients at nutritional risk has not been assessed. Methods: In this five-year prospective study, we investigated whether high vitamin B12 concentrations (>1000 pg/mL) are associated with in-hospital mortality in 1373 not-bed-ridden adult patients at nutritional risk (Nutrition Risk Index <97.5), admitted to medical and surgical departments. Results: Three hundred and ninety-six (28.8%) patients presented vitamin B12 > 1000 pg/mL. Two hundred and four patients died in the hospital (14.9%). The adjusted odds ratio of in-hospital mortality in patients with high vitamin B12 was 2.20 (95% CI, 1.56-3.08; p < 0.001); it was independent of age, gender, body mass index, six-month previous unintentional weight loss, admission ward, presence of malignancy, renal function, C-reactive protein and prealbumin. Patients with high vitamin B12 also had a longer length of stay (LOS) than those with normal concentrations (median 25 days, (IQR 15-41) versus 23 days (IQR 14-36); p = 0.014), and elevated vitamin B12 was an independent predictor of LOS (p = 0.027). Conclusions: An independent association between elevated vitamin B12 concentrations, mortality and LOS was found in our sample of hospitalized adult patients at nutritional risk. Although the underlying mechanisms are still unknown and any cause-effect relation cannot be inferred, clinicians should be aware of the potential negative impact of high vitamin B12 concentrations in hospitalized patients at nutritional risk and avoid inappropriate vitamin supplementation.

Nutritional counseling improves quality of life and preserves body weight in systemic immunoglobulin light-chain (AL) amyloidosis.

OBJECTIVE: Malnutrition is associated with mortality and impaired quality of life (QoL) in systemic immunoglobulin light-chain (AL) amyloidosis. The aim of this study was to determine whether nutritional counseling is beneficial to patients with AL. METHODS: In this intervention study (ClinicalTrials.gov Identifier: NCT02055534), 144 treatment-naïve outpatients with AL were randomized to usual care (UC; n = 72) and nutritional counseling (NC; n = 72). RESULTS: In the randomized population, although patients in the NC group maintained a stable body weight (weight loss [WL] = 0.6 kg; 95% confidence interval [CI], -1.0 to 2.1; P = 0.214), those in the UC group demonstrated a significant decrease (WL = 2.1 kg; 95% CI, 0.2-4.1; P = 0.003). However, the difference in weight between groups was not significant (mean WL difference = 1.6 kg; 95% CI, -0.7 to 3.9; P = 0.179). Patients in the NC group demonstrated more satisfactory energy intake (≥75% of estimated requirements, odds ratio, 2.18; 95% CI, 1.04-4.57; P = 0.048) and a significant increase in the mental component summary of QoL (Short form-36) at 12 mo (mean difference, 8.1; 95% CI, 2.3-13.9; P = 0.007), which was restored to a mean score of 53 (95% CI, 50-53), over the healthy population norms. NC was also associated with better survival (crude hazard ratio, 0.57; 95% CI, 0.35-0.94; P = 0.028). CONCLUSIONS: In outpatients with AL, NC was helpful in preserving body weight, effective in improving mental QoL, and associated with better survival.

The Geriatric Nutritional Risk Index predicts hospital length of stay and in-hospital weight loss in elderly patients.

BACKGROUND & AIMS: Nutritional derangements are common in elderly patients, but how nutritional risk affects outcome in this subset of hospital inpatients deserves further investigation. We evaluated the impact of nutritional risk on length of stay (LOS) and in-hospital weight loss (WL) in elderly patients (>65 yrs). METHODS: Nutritional risk was assessed by the Geriatric Nutritional Risk Index (GNRI) in a prospective multicentre hospital-based cohort study. The outcomes were LOS and in-hospital WL. RESULTS: In the whole sample (N = 667), the prevalence of high (GNRI < 92) and mild (GNRI: 92-98) nutritional risk were 33% and 25%, respectively. Patients with a high nutritional risk were more likely (OR = 1.89; 95%CI: 1.22-2.92) to stay longer in hospital (fourth quartile, LOS ≥ 20 days) compared to those without. Other factors associated with prolonged LOS were cancer diagnosis (OR = 2.52; 95%CI: 1.69-3.75), the presence of comorbidities (OR = 1.24; 95%CI: 1.11-1.40) and surgical setting (OR = 1.65; 95%CI: 1.10-2.47). In-hospital WL ≥ 5% was recorded in 75 ambulant patients from a representative subgroup (N = 583). It was independently associated with prolonged LOS (OR = 1.80; 95%CI: 1.03-3.06) and was more frequent among cancer patients (OR = 1.88; 95%CI: 1.09-3.24), in patients with a high nutritional risk (OR = 2.23; 95%CI: 1.20-4.14) or those admitted to surgical units (OR = 1.77; 95%CI: 1.02-3.05). CONCLUSIONS: Nutritional risk assessed by the GNRI on admission, predicts LOS and in-hospital WL in elderly patients.

Malnutrition at diagnosis predicts mortality in patients with systemic immunoglobulin light-chain amyloidosis independently of cardiac stage and response to treatment.

BACKGROUND: Nutrition status was shown to be a prognostic factor in patients with immunoglobulin light-chain amyloidosis (AL). However, malnutrition was associated with cardiac involvement, thus suggesting potential interactions. This study aim was to clarify the association among nutrition status, cardiac stage, and mortality in AL. METHODS: One hundred twenty-eight consecutive newly diagnosed, treatment-naïve patients with histologically confirmed AL were enrolled. Anthropometric, biochemical, and clinical variables were assessed. RESULTS: At multivariable Cox proportional hazard analysis, body mass index (BMI) < 22 kg/m(2) (HR = 1.98, 95% CI = 1.09-3.56) and unintentional 6-month weight loss (WL) ≥ 10% (HR = 1.94, 95% CI = 1.00-3.74) resulted in independent predictors of survival after controlling for hematologic response to treatment (HR = 0.27, 95% CI = 0.14-0.53) and cardiac stage (Mayo Clinic stage III, HR = 4.42, 95% CI = 2.61-7.51). There was no effect modification of malnutrition on mortality by cardiac stage (P for interaction = .27). Moderate and severe malnutrition (prevalence: 21.9% and 7.8%, respectively) similarly increased the risk of death (HR = 3.09, 95% CI = 1.75-5.46; 2.88, 95% CI = 1.23-6.72, respectively). CONCLUSIONS: In AL, malnutrition at diagnosis is a frequent comorbidity that affects the prognosis independently of hematologic response to treatment and cardiac stage. Nutrition status should be systematically considered in future intervention trials in AL. Nutrition support trials are warranted.

Effects of preoperative oral carbohydrate supplementation on postoperative metabolic stress response of patients undergoing elective abdominal surgery.

BACKGROUND: The goal of the present study was to evaluate the effects of preoperative oral carbohydrate supplementation (OCH) on the postoperative metabolic stress response of patients undergoing elective abdominal surgery. METHODS: The study was designed as a controlled, prospective, cohort study including 38 patients treated with OCH (800 mL the day before surgery and 400 mL within 3 h before the induction of anesthesia) and 38 controls matched for surgical procedure. Fasting glucose, insulin, insulin resistance (HOMA-IR index), cortisol, and interleukin 6 (IL-6) were assessed before and after surgery (postoperative day (POD) 1, 2, and 3). RESULTS: The administration of OCH resulted in lower fasting glucose, HOMA-IR index, cortisol, and IL-6 on both POD 1 and POD 2. At multivariable regression analyses, the reduction of these parameters was independent of sex, age, body mass index, and major abdominal surgery. Particularly, models including OCH treatment explained 70, 63, and 66 % of the variance of the increase in IL-6 levels at POD 1, POD 2, and POD 3, respectively. The effect of OCH on changes in glucose, insulin resistance, and cortisol on POD 1 and POD 2 disappeared after the inclusion of IL-6 in the models. CONCLUSIONS: Treatment with OCH was associated with attenuation of the postoperative metabolic stress response. We hypothesize that modulation of the inflammatory response is one of the mechanisms involved.

Disease-related malnutrition in outpatients with systemic sclerosis.

BACKGROUND & AIM: Disease-related malnutrition is known to negatively affect clinical outcomes. The aim of the present study was to evaluate the prevalence of malnutrition in a cohort of outpatients affected by Systemic Sclerosis (SSc) and its association with clinical variables. METHODS: One hundred sixty SSc patients were consecutively evaluated. The following clinical variables were assessed: disease duration, activity and severity, treatments, functional status, gastrointestinal involvement. Nutritional assessment included: body mass index (BMI), weight loss (WL) history, nutritional intakes and serum prealbumin. Malnutrition was defined as BMI <20 kg/m² and/or previous 6-month WL ≥ 10%. RESULTS: Prevalence of malnutrition was 15% (10-21%). Logistic regression showed that malnutrition was independently associated with disease activity (OR 3.72; p < 0.001) and low serum prealbumin (OR 8.58; p < 0.001). The association with gastrointestinal involvement was not statistically significant, although a trend was detected (OR 1.88). CONCLUSION: Malnutrition is common in SSc outpatients. It appears associated with disease activity and not influenced by nutritional intakes; gastrointestinal involvement might contribute to its development over time. Serum prealbumin could be an early marker of malnutrition in SSc, whose role should be confirmed by further longitudinal investigations. Prospective studies are also required to clarify the clinical significance of the association between malnutrition and disease activity in SSc.

Nutritional status independently affects quality of life of patients with systemic immunoglobulin light-chain (AL) amyloidosis.

Nutritional status is an independent prognostic factor in immunoglobulin light-chain amyloidosis (AL), but its influence on quality of life (QoL) is unknown. The aim of this cross-sectional study was to investigate the association between nutritional status and QoL in AL patients at diagnosis. One hundred and fifty consecutive patients with biopsy-proven AL were assessed for nutritional status by anthropometry [body mass index, unintentional weight loss (WL) in the previous 6 months and mid-arm muscle circumference (MAMC)], biochemistry (serum prealbumin), and semiquantitative food intake at referral. QoL was assessed by the Medical Outcomes Study 36-item Short Form General Health Survey. The composite physical component summary (PCS) and the mental component summary (MCS) for AL outpatients were 36.2 ± 10.1 and 44.9 ± 11.3, respectively (p < 0.001 for both vs the population norms of 50). In multivariate linear regression models adjusted for gender, age, Eastern Cooperative Oncology Group performance status, the number of organs involved, the severity of cardiac damage, C-reactive protein, energy intake, and WL, PCS was significantly lower for serum prealbumin <200 mg/L and MAMC <10th percentile (adjusted difference 3.8, 95% CI 0.18-7.5, p = 0.040 and 5.3, 95% CI 2.0-8.7, p = 0.002, respectively). MCS was decreased by 0.47 (95% CI 0.18-0.75, p = 0.002) for each kilogram of body weight lost in the previous 6 months. Nutritional status independently affects QoL in AL patients since diagnosis. Nutritional evaluation should be integral part of the clinical assessment of AL patients. Nutritional support intervention trials are warranted in such patients' population.

Nutritional parameters associated with prolonged hospital stay among ambulatory adult patients.

BACKGROUND: Comprehensive evaluations of the nutritional parameters associated with length of hospital stay are lacking. We investigated the association between malnutrition and length of hospital stay in a cohort of ambulatory adult patients. METHODS: From September 2006 to June 2009, we systematically evaluated 1274 ambulatory adult patients admitted to hospital for medical or surgical treatment. We evaluated the associations between malnutrition and prolonged hospital stay (> 17 days [> 75th percentile of distribution]) using multivariable log-linear models adjusted for several potential nutritional and clinical confounders recorded at admission and collected during and at the end of the hospital stay. RESULTS: Nutritional factors associated with a prolonged hospital stay were a Nutritional Risk Index score of less than 97.5 (relative risk [RR] 1.64, 95% confidence interval [CI] 1.31-2.06) and an in-hospital weight loss of 5% or greater (RR 1.60, 95% CI 1.30-1.97). Sensitivity analysis of data for patients discharged alive and who had a length of stay of at least three days (n = 1073) produced similar findings (adjusted RR 1.51, 95% CI 1.20-1.89, for Nutritional Risk Index score < 97.5). A significant association was also found with in-hospital starvation of three or more days (RR 1.14, 95% CI 1.01-1.28). INTERPRETATION: Nutritional risk at admission was strongly associated with a prolonged hospital stay among ambulatory adult patients. Another factor associated with length of stay was worsening nutritional status during the hospital stay, whose cause-effect relationship with length of stay should be clarified in intervention trials. Clinicians need to be aware of the impact of malnutrition and of the potential role of worsening nutritional status in prolonging hospital stay.

A 4-year survey of the activity of a malnutrition task force in an Italian research hospital.

OBJECTIVE: The proper management of nutritional support remains a challenging task in many Western hospitals. This study aimed at reporting a 4-y survey on the centralized management of nutritional support by a malnutrition task force in an Italian research hospital. METHODS: The requests for nutritional supports, the number of patients treated with enteral nutrition in the medical and surgical units, and the number of home artificial nutritional support activated were recorded from 2005 to 2008. RESULTS: The median number of first and follow-up visits per month significantly increased from 16 (25th-75th percentiles 13-26) in 2005 to 74 (25th-75th percentiles 69-82) in 2008 (P < 0.001) and from 56 (25th-75th percentiles 42-82) in 2005 to 101 (25th-75th percentiles 90-120) in 2008 (P = 0.001), respectively. This trend was observed also in the number of patients treated with enteral nutrition (from 95 in 2004 to 190 in 2008) and in those on home artificial nutritional support (from 25 in 2004 to 65 in 2008), whereas the number of parenteral nutrition bags produced remained substantially stable. CONCLUSION: The centralized management of nutritional support is a successful strategy, which provides the appropriate prescription of artificial nutrition during hospitalization and at discharge. Multidisciplinary nutrition support teams or task forces should be created in every hospital.

Nutritional Intake of Young Italian High-Level Soccer Players: Under-Reporting is the Essential Outcome.

It is recognized that much of the dietary data on adolescents and athletes is prone to reporting error, mostly through under-reporting. Nevertheless, in the majority of studies assessing the nutritional intake of young soccer players under-reporting has not been taken into consideration. The purpose of this study was to assess the dietary intake of a sample of young male Italian high-level soccer players on two time points to evaluate the degree of under- reporting. Seventy-five male high level soccer players (age range: 15-17 years) completed 4-day food records on two separate occasions (T0; T1, 3 months after T0). Under-reporting was assessed by the ratio of reported estimated energy intake (EEI) to estimated energy expenditure (EEE). Forty- three subjects, whose food records were judged accurate enough both at T0 and T1, were included in the data analysis (inclusion rate 57.3%). No significant weight changes were documented between T0 and T1 and in the two weeks preceding both T0 and T1. Reported mean daily energy intake was significantly lower than mean estimated daily energy expenditure both at T0 and T1 (p < 0.001). The average EEI/EEE ratio was 0.75 + 0.2 both at T0 and T1. It was ≤ 80% in 27 subjects (62.8%) at T0 and in 23 (53.4%) at T1; it reached 50% in 4 subjects both at T0 and T1. The degree of under- reporting of the young soccer players was in line with the available data on this age group. This study emphasizes that under-reporting is a critical issue in the evaluation of young athletes dietary intake, which should be considered in the interpretation of data, particularly when energy inadequacies are reported. Further studies with uniformed methods are needed, in order to reduce the degree of under-reporting, obtain reliable data on the dietary intake of young soccer players and evaluate the efficacy of targeted nutrition education programs. Key pointsUnder-reporting is a critical issue in the evaluation of young athletes' dietary intake, which should be always considered in the interpretation of data.The young athletes' motivation and parents' co-operation are key points that should be enhanced in this kind of studies.The nutritional intakes of young Italian high-level soccer players are likely to be qualitative inadequate, due to excessive cholesterol and very poor fiber intakes.

Nutritional status of outpatients with systemic immunoglobulin light-chain amyloidosis 1.

BACKGROUND: Maintenance of a good nutritional status is associated with prolonged survival in many chronic diseases. To date, the nutritional status of outpatients with immunoglobulin light-chain (AL) amyloidosis has not been evaluated. OBJECTIVE: The aims of this study were to obtain information regarding the nutritional status of AL amyloidosis outpatients and to investigate its prognostic role. DESIGN: One hundred six consecutive patients with histologically confirmed AL amyloidosis were enrolled. Anthropometric, biochemical, and clinical variables were measured. The Kaplan-Meier method was used to calculate survival. A Cox proportional hazard model was constructed to evaluate the prognostic effect of the nutritional variables. RESULTS: Unintentional weight loss (median: 11.3%; range: 2.6-34% of usual nonedematous body weight) was documented in 58 subjects (54.7%). Body mass index (BMI; in kg/m2) was <22 in 25 subjects (23.6%). Serum prealbumin was <200 mg/L (lower reference limit) in 26 patients (24.5%). A multivariate analysis showed that the percentage weight loss was significantly greater in patients with than in those without cardiac involvement (P = 0.03), and it also differed significantly by New York Heart Association class (P = 0.02) and Eastern Cooperative Oncology Group performance status (P = 0.001). Cardiac involvement (P = 0.008), hematologic response to therapy (P = 0.013), BMI (P = 0.001) and serum prealbumin (P = 0.001) were independent predictors of survival. CONCLUSIONS: Malnutrition is a prominent clinical feature of patients with AL amyloidosis. Appropriate nutritional evaluation that comprises the easily measurable nutritional variables associated with survival should be an integral part of the clinical assessment of AL amyloidosis outpatients.