The nutrition impact symptoms (NIS) score detects malnutrition risk in patients admitted to nephrology wards

Background

Nutritional screening tools recommended for the general hospitalised population do not always adequately detect malnutrition risk in patients with kidney disease. The present study assessed the validity and reliability of the Nutrition Impact Symptoms (NIS ) score as a nutrition screening tool for hospitalised inpatients prefer in nephrology wards.

Methods

Nutritional status was classified using Subjective Global Assessment (SGA ). NIS scores were calculated from the total score of responses to questions assessing symptoms impacting upon nutritional status from the patient‐generated SGA . Concurrent validity of NIS score was assessed using a receiver operating characteristic curve to predict malnutrition risk against SGA . Predictive validity was examined against length of hospital stay (LOS ) and 30‐day re‐admission using Poisson and logistic regression, respectively. Inter‐rater reliability of NIS scoring between assessors was determined using intraclass correlation.

Results

In 143 patients [90 males; mean (SD ) age 57.8 (15.8) years], malnutrition prevalence was 38% (54/143) using SGA (rating B/C). Predicting malnutrition risk with an NIS score of ≥3 had a sensitivity of 0.89 and a specificity of 0.65 (area under the curve = 0.81 [95% confidence interval (CI ) = 0.74–0.88]). For each 1‐point increase in NIS score, the model predicted a 1.9% rise in the risk of an increased LOS (P = 0.002). Thirty‐day re‐admission was not associated with NIS score. Inter‐rater reliability was moderate (mean difference = 0.53; intraclass correlation coefficient = 0.74; 95% CI = 0.57–0.85).

Conclusions

Nutrition impact symptoms score is a valid stand‐alone nutrition screening tool for identifying malnutrition risk in nephrology inpatients and is associated with LOS.

     

Terminal transferase in patients hospitalized for malnutrition

Terminal deoxynucleotidyl transferase (TdT) is a DNa polymerase which is used as a marker for immature T lymphocytes. Elevated levels of TdT have previously been demonstrated in the peripheral blood of malnourished Indian children. In this study, 50% of a group of adult patients, referred for total parenteral nutrition had elevated levels of TdT in their lymphocytes compared to a group of normal healthy volunteers. Elevated TdT levels were associated with the presence of malnutrition and were partially related to the presence of sepsis and cancer. The level of TdT correlated significantly with a composite index of nutritional status, the Hospital Nutritional Index, that predicts hospital morbidity and mortality. TdT may be useful as a rapid test of critical protein malnutrition.     

Malnutrition at Hospital Admission—Contributors and Effect on Length of Stay

Background: In hospitals, length of stay (LOS) is a priority but it may be prolonged by malnutrition. This study seeks to determine the contributors to malnutrition at admission and evaluate its effect on LOS. Materials and Methods: This is a prospective cohort study conducted in 18 Canadian hospitals from July 2010 to February 2013 in patients ≥ 18 years admitted for ≥ 2 days. Excluded were those admitted directly to the intensive care unit; obstetric, psychiatry, or palliative wards; or medical day units. At admission, the main nutrition evaluation was subjective global assessment (SGA). Body mass index (BMI) and handgrip strength (HGS) were also performed to assess other aspects of nutrition. Additional information was collected from patients and charts review during hospitalization. Results: One thousand fifteen patients were enrolled: based on SGA, 45% (95% confidence interval [CI], 42%–48%) were malnourished, and based on BMI, 32% (95% CI, 29%–35%) were obese. Independent contributors to malnutrition at admission were Charlson comorbidity index > 2, having 3 diagnostic categories, relying on adult children for grocery shopping, and living alone. The median (range) LOS was 6 (1–117) days. After controlling for demographic, socioeconomic, and disease‐related factors and treatment, malnutrition at admission was independently associated with prolonged LOS (hazard ratio, 0.73; 95% CI, 0.62–0.86). Other nutrition‐related factors associated with prolonged LOS were lower HGS at admission, receiving nutrition support, and food intake < 50%. Obesity was not a predictor. Conclusion: Malnutrition at admission is prevalent and associated with prolonged LOS. Complex disease and age‐related social factors are contributors.     

Nutrition status and risk factors associated with length of hospital stay for surgical patients

Objective: To diagnose the nutrition status of hospitalized patients and identify the risk factors associated with hospital length of stay (LOS). Methods: The subjective approach and the body mass index (BMI) were used to classify the nutrition status, and other indicators (anthropometry, biochemistry, and energy intake) were analyzed regarding their association with length of hospital stay of 350 patients. The chi‐square test was used to compare proportions, and the Mann‐Whitney or Kruskal‐Wallis test was used to compare continuous measures. Linear association was verified using Spearman's rank correlation coefficient. Cox's regression model was used to investigate factors associated with LOS. Results: Disease was the factor that influenced LOS the most in the studied population. Longer LOS prevailed in males (P < .0001), patients aged ≥60 years (P = .0008), patients with neoplasms (P < .0001), patients who lost weight during their hospital stay (P < .0001), and malnourished patients (P = .0034). There was a negative and significant, but weak, correlation between LOS and nutrition indicators (calf circumference, arm circumference, triceps skinfold thickness, subscapular skinfold thickness, arm fat area, lymphocyte count, and hemoglobin). Among adults, well‐nourished patients were 3 times more likely to be discharged sooner (P = .0002, RR = 3.3 [1.7–6.2]) than those who had some degree of malnutrition. Well‐nourished patients with digestive tract diseases (DTD) were also discharged sooner than malnourished patients with the same condition (P = .02, RR = 2.5 [1.1–5.8]). In patients with neoplasms, arm circumference was an independent risk factor to assess LOS (P = .009, RR = 1.1 [1.0–1.1]). Conclusions: LOS was associated with disease and nutrition status. Among the more common diseases, nutrition status according to the subjective approach determined the LOS for patients with DTD and nutrition status according to arm circumference determined the LOS for patients with neoplasms.     

Recognition by medical and nursing professionals of malnutrition and risk of malnutrition in elderly hospitalised patients

Objective:  To determine the prevalence of malnutrition in a population of elderly hospitalised patients and to explore health professionals' perceptions and awareness of signs and risks of malnutrition and treatment options available.
Subjects and design:  One hundred elderly patients and 57 health professionals from medical wards of a tertiary teaching hospital. Quantitative and qualitative study design using a validated malnutrition assessment tool (Mini Nutritional Assessment) and researcher-designed questionnaire to assess health professionals' knowledge of nutrition risk factors.
Main outcome measures:  Mini Nutritional Assessment score, nutrition risk category and themes in health professionals' knowledge and awareness of malnutrition and its risk factors.
Results:  Thirty per cent of patients were identified as malnourished while 61% were at risk of malnutrition. Documentation by health professionals of two major risk factors for malnutrition—recent loss of weight and appetite—were poor with only 19% and 53% of patients with actual loss of weight or appetite, respectively, identified by staff and only 7% and 9% of these patients, respectively, referred for dietetic assessment. While health professionals' knowledge of important medical risk factors for malnutrition was good, their knowledge of malnutrition risk factors such as recent loss of weight and loss of appetite was poor. Medical staff focused on biochemical factors when assessing nutrition status, while nursing staff focused on skin integrity and turgor.
Conclusion:  Malnutrition in elderly hospitalised patients remains a significant problem with low rates of recognition and referral by medical and nursing staff. Considerable scope exists to develop training and education tools and to implement an appropriate nutrition screening policy to improve referral rates to dietitians.     

Nutritional status,nutrition practices and post‐operative complications in patients with gastrointestinal cancer

Background: Malnutrition and its associated complications are a considerable issue for surgical patients with upper gastrointestinal and colorectal cancer. The present study aimed to determine whether specific perioperative nutritional practices and protocols are associated with improved patient outcomes in this group. Methods: Patients admitted for elective upper gastrointestinal or colorectal cancer surgery (n = 95) over a 19‐month period underwent a medical history audit assessing weight changes, nutritional intake, biochemistry, post‐operative complications and length of stay. A subset of patients (n = 25) underwent nutritional assessment by subjective global assessment prior to surgery in addition to assessment of post‐operative medical outcomes, nutritional intake and timing of dietetic intervention. Results: Mean (SD) length of stay for patients was 14.0 (12.2) days, with complication rates at 35%. Length of stay was significantly longer in patients who experienced significant preoperative weight loss compared to those who did not [17.0 (15.8) days versus 10.0 (6.8) days, respectively; P < 0.05]. Low albumin and post‐operative weight loss were also predictive of increased length of stay. Of patients who underwent nutritional assessment, 32% were classified as mild–moderately malnourished and 16% severely malnourished. Malnourished patients were hospitalised twice as long as well‐nourished patients [15.8 (12.8) days versus 7.6 (3.5) days; P < 0.05]. Time taken [6.9 (3.6) days] to achieve adequate nutrition post surgery was a factor in post‐operative outcomes, with a positive correlation with length of stay (r = 0.493; P < 0.01), a negative correlation with post‐operative weight change (r = ?0.417; P < 0.05) and a greater risk of complications (52% versus 13%; P < 0.01). Conclusions: Malnutrition is prevalent among surgical patients with gastrointestinal cancer. Poor nutritional status coupled with delayed and inadequate post‐operative nutrition practices are associated with worse clinical outcomes.     

The effects of air pollution on length of hospital stay for adult patients with asthma

Length of hospital stay (LOS) of asthma can be a reflection of the disease burden faced by patients, and it is also sensitive to air pollution. This study aims at estimating and validating the effects of air pollution and readmission on the LOS for those who have asthma, considering their readmission history, minimum temperature, and threshold effects of air pollutants. In addition, sex, age, and season were also constructed for stratification to achieve more precise and specific results. The results show that no significant effects of PM_2.5 and NO₂ on LOS were observed in any of the patients, but there were significant effects of PM_2.5 and NO₂ on LOS when a stratifying subgroup analysis was performed. The effect of PM₁₀ on LOS was found to be lower than that of PM_2.5 and higher than that of NO₂. SO₂ did not have a significant effect on LOS for patients with asthma in our study. Our study confirmed that the adverse effects of air pollutants (such as PM₁₀) on LOS for patients with asthma existed; in addition, these effects vary for different stratifications. We measured the effects of air pollutants on the LOS for patients with asthma, and this study offers policy makers quantitative evidence that can support relevant policies for health care resource management and ambient air pollutants control.     

Prognostic Value of Isolated Sarcopenia or Malnutrition–Sarcopenia Syndrome for Clinical Outcomes in Hospitalized Patients

Malnutrition–sarcopenia syndrome (MSS) is frequent in the hospital setting. However, data on the predictive validity of sarcopenia and MSS are scarce. We evaluated the association between sarcopenia and MSS and clinical adverse outcomes (prolonged length of hospital stay—LOS, six-month readmission, and death) using a prospective cohort study involving adult hospitalized patients (n = 550, 55.3 ± 14.9 years, 53.1% males). Sarcopenia was diagnosed according to the EWGSOP2, and malnutrition according to the Subjective Global Assessment (SGA). Around 34% were malnourished, 7% probable sarcopenic, 15% sarcopenic, and 2.5% severe sarcopenic. In-hospital death occurred in 12 patients, and the median LOS was 10.0 days. Within six months from discharge, 7.9% of patients died, and 33.8% were readmitted to the hospital. Probable sarcopenia/sarcopenia had increased 3.95 times (95% CI 1.11–13.91) the risk of in-hospital death and in 3.25 times (95% CI 1.56–6.62) the chance of mortality in six months. MSS had increased the odds of prolonged LOS (OR = 2.73; 95% CI 1.42–5.25), readmission (OR = 7.64; 95% CI 3.06–19.06), and death (OR = 1.15; 95% CI 1.08–1.21) within six months after discharge. Sarcopenia and MSS were predictors of worse clinical outcomes in hospitalized patients.     

nutritionDay: An Australian hospital's participation in international benchmarking on malnutrition

Aim: Malnutrition is a significant issue for hospitals worldwide. This project examined malnutrition prevalence and associated factors including meal consumption in an Australian hospital. Methods: The cross‐sectional study was undertaken at a private hospital in Brisbane, Australia, for ‘nutritionDay in Europe’ 2009. Nutritional status (subjective global assessment), demographic, medical condition and intake data were collected from 147 inpatients across five medical specialties. Results: The present study found 19.7% (29) of patients were malnourished (17.7% mild to moderately malnourished, 2% severely malnourished). Unintentional weight loss was reported by 39.5% of patients (58) and 49% of patients (72) reported eating less than normal. There were 41.5% of patients (61) who reported not having their usual appetite, with 46.3% (68) eating half or less of a hospital meal. The likelihood of being malnourished increased 4.0 times (CI 1.4–11.6, P= 0.01) for patients who ate less than normal during the previous week and 15 times (CI 4.2–53.5, P < 0.001) for those patients who reported eating less than one quarter to nearly nothing. The likelihood of being malnourished increased 2.9 (CI 1.1–7.6, P= 0.026) and 4.8 (CI 1.6–14.3, P= 0.005) times for patients consuming less than half of breakfast and dinner respectively. Binary logistic regression modelling found a malnutrition screening tool score of ≥2 and average meal consumption of 50% or less were predictors of malnutrition. Conclusions: The present study provides evidence of the increased likelihood of malnutrition in relation to decreased meal consumption and provides insights for future interventions in the acute care setting.