Nevin Manimala

Clin Nutr ESPEN. 2024 Jun;61:266-273. doi: 10.1016/j.clnesp.2024.03.014. Epub 2024 Mar 13.

ABSTRACT

BACKGROUND & AIMS: Insufficient screening and management of malnutrition leads to increase morbidity and mortality.

AIMS: to evaluate the characteristics and clinical outcomes of malnourished patients referred to a specialized outpatient clinic for the management of malnutrition (primary); to compare the latter according to malnutrition severity; to determine the factors associated with severe malnutrition and mortality; to compare the consistency of the decided medical nutrition therapy with the European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines (secondary).

METHODS: This retrospective, observational study included malnourished adults referred for the first time to the specialized nutrition consultation of a teaching University Hospital during 50 months. Malnutrition was diagnosed according to the Global Leadership Initiative on Malnutrition criteria, including body composition assessment by bioimpedance analysis.

STATISTICS: Chi2 or Fisher, Student or Wilcoxon rank-sum tests; multivariable logistic regression to assess the factors associated with severe malnutrition and mortality.

RESULTS: 108 malnourished adults were included: 74% had severe malnutrition. The main secondary diagnosis was digestive cancer (48.2%). During the follow-up (median = 70 days) after the first nutritional consultation, 11% of patients were admitted at hospital, 19% had infections and 23.1% died, without any difference according to malnutrition severity. Severely malnourished patients had lower body mass index, a smaller fat mass index (FMI) (4.6 ± 1.8 vs 6.0 ± 2.5 kg/m²; p = 0.01), and a higher level of total body water (64.7 ± 7.1 vs 60.6 ± 5.4%; p = 0.02), compared to moderately malnourished individuals. A low FMI (odds ratio = 0.72 [0.54-0.96]) was the only factor significantly associated with severe malnutrition. We did not find any factor associated with mortality. There was a moderate consistency (47.1%) between the decided medical nutrition therapy and the ESPEN guidelines of nutritional care.

CONCLUSIONS: Adults referred for the first time to a specialized nutritional consultation present mostly with severe malnutrition and are at risk for significant complications, leading to a high mortality rate. In this population, a low FMI is associated with severe malnutrition. An earlier diagnosis and care of malnutrition and an earlier referral to clinical nutrition units would improve outcomes.

PMID:38777442 | DOI:10.1016/j.clnesp.2024.03.014

Clin Nutr ESPEN. 2024 Jun;61:203-211. doi: 10.1016/j.clnesp.2024.03.012. Epub 2024 Mar 28.

ABSTRACT

BACKGROUND: Taurine is considered an immunomodulatory agent. From current reports on clinical studies, we conducted a systematic review and meta-analysis to investigate the effects of taurine-enhanced enteral nutrition (EN) on the outcomes of critically ill patients to resolve conflicting evidence in literature.

METHODS: Literature from PubMed, EMBASE, Web of Science, Cochrane Library, CNKI, SINOMED, and WanFang databases were retrieved, and randomized controlled trials (RCTs) were identified. The time range spanned from January 1, 2000, to January 31, 2024. The Cochrane Collaboration Tool was used to evaluate the risk of bias. We used the GRADE approach to rate the quality of evidence and the I2 test to assess the statistical heterogeneity of the results. Risk ratio (RR), mean difference (MD), and 95% confidence interval (95% CI) were used to analyze measurement data.

RESULTS: Four trials involving 236 patients were finally included. The meta-analysis results indicated that taurine-enhanced EN did not reduce mortality (RR = 0.70, p = 0.45, 95% CI [0.28, 1.80], two trials, 176 participants, low quality). There was also no significant difference in length of stay in the intensive care unit (ICU) between the taurine-enhanced EN and control groups. Taurine-enhanced EN may reduce pro-inflammatory factor interleukin-6 (IL-6) levels in critically ill patients（the result about IL-6 cannot be pooled）. However, taurine-enhanced EN had no significant impact on high-sensitivity-C-reactive protein levels (MD = -0.41, p = 0.40, 95% CI [-1.35, 0.54], two trials, 60 participants, low quality).

DISCUSSION: Taurine-enhanced EN may reduce IL-6 levels and is not associated with improved clinical outcomes in critically ill patients, which may have potential immunoregulatory effects in critically ill patients. Given that published studies have small samples, the above conclusions need to be verified by more rigorously designed large-sample clinical trials.

PMID:38777434 | DOI:10.1016/j.clnesp.2024.03.012

Clin Nutr ESPEN. 2024 Jun;61:181-188. doi: 10.1016/j.clnesp.2024.03.023. Epub 2024 Mar 27.

ABSTRACT

BACKGROUND & AIMS: Exploration whether Motivational Interviewing (MI) could be learned and implemented with ease within a surgical in-hospital setting and whether participation in the intervention led to significantly higher compliance with ERAS®-recommended protein intake goals. The individual healing process of many patients is delayed because they fail to cover their calorie requirement, which could be counteracted by a patient-centered conversational intervention that is new in perioperative practice.

METHODS: This patient-blinded pilot-RCT included 60 patients (≥18 years) following the certified ERAS® bowel protocol for colorectal surgery between March and August 2022. Five perioperative MI interventions were conducted by two health employees certified to perform MI. Key endpoints were the number of protein shakes drunk, calories of proteins ingested and overall calorie intake.

RESULTS: A total of 60 patients (34 men [56.7%]; mean [SD] age, 60.7 [13.3] years) were randomized. MI patient-group had significantly higher protein shake intake on all postoperative days except day 3. For days 0-3 MI group drank significantly more shakes overall (median 5.5 vs. 2.0; P = 0.004) and consumed more calories (median 1650.0 vs. 600.0 kcal; P = 0.004) and proteins (median 110.0 vs. 40.0 g; P = 0.005). Total calorie intake for each day by shakes and dietary intake was significantly higher in the MI-intervention group on day 2 (mean 1772.3 vs. 1358.9 kcal; P = 0.03).

CONCLUSIONS: MI may contribute to improve compliance with nutritional goals in the certified ERAS® protocol by increasing protein and calorie intake. The findings suggest further investigation of MI to help patients achieve their perioperative nutrition goals in different clinical settings.

TRIAL REGISTRATION: DRKS – Deutsches Register Klinischer Studien; DRKS-ID: DRKS00027863; https://drks.de/search/de/trial/DRKS00027863.

PMID:38777431 | DOI:10.1016/j.clnesp.2024.03.023

Clin Nutr ESPEN. 2024 Jun;61:158-167. doi: 10.1016/j.clnesp.2024.03.013. Epub 2024 Mar 24.

ABSTRACT

BACKGROUND: Diabetic retinopathy (DR) and limb amputation are frequent complications of diabetes that cannot always be explained by blood glucose control. Metabolomics is a science that is currently being explored in the search for biomarkers or profiles that identify clinical conditions of interest.

OBJECTIVE: This study aimed to analyze, using a metabolomic approach, peripheral blood samples from type 2 diabetes mellitus (DM2) individuals, compared with those with diabetic retinopathy and limb amputation.

METHODS: The sample consisted of 128 participants, divided into groups: control, DM2 without DR (DM2), non-proliferative DR (DRNP), proliferative DR (DRP), and DM2 amputated (AMP). Metabolites from blood plasma were classified by spectra using nuclear magnetic resonance (NMR), and the metabolic routes of each group using metaboanalyst.

RESULTS: We identified that the metabolism of phenylalanine, tyrosine, and tryptophan was discriminant for the DRP group. Histidine biosynthesis, on the other hand, was statistically associated with the AMP group. The results of this work consolidate metabolites such as glutamine and citrulline as discriminating for DRP, and the branched-chain amino acids as important for DR.

CONCLUSIONS: The results demonstrate the relationship between the metabolism of ketone bodies, with acetoacetate metabolite being discriminating for the DRP group and histidine being a significant metabolite in the AMP group, when compared to the DM2 group.

PMID:38777429 | DOI:10.1016/j.clnesp.2024.03.013

Clin Nutr ESPEN. 2024 Jun;61:140-144. doi: 10.1016/j.clnesp.2024.03.008. Epub 2024 Mar 13.

ABSTRACT

INTRODUCTION: Patients with intestinal failure (IF) are often dependent on PN for provision of calories and nutrients for survival. Similar to chronic intestinal failure (CIF) patients, those who have AIF are also at risk of IFALD, which is a poorly understood but potentially fatal condition. The local incidence of IFALD amongst AIF patients is not known.

OBJECTIVES: The primary objective of this study was to determine the incidence of IFALD in AIF patients on short-term PN. Secondary objectives were to analyse patient and PN risk factors of IFALD, and clinical outcomes of length of stay (LOS) and inpatient mortality.

DESIGN: This was a retrospective cross-sectional cohort study of hospitalised adult patients with AIF prescribed with short-term PN. All adult patients aged 21 years and above who received PN for at least 5 consecutive days and had normal liver function tests (LFTs) at the time of PN initiation were included in this study.

RESULTS: A total of 171 patients were enrolled in this study, with 77 (45%) having deranged LFTs at the end of PN therapy and categorised under the IFLAD group. The patient cohort was predominantly male (92 [54%]) and had a median age of 68 years (IQR 59-76). Patients with IFALD at the end of PN therapy had higher diabetes prevalence (36% vs 26%, p = 0.2) and were on PN for a longer duration (median [IQR]: 12 [8-17] vs 8 [6-15] days, p = 0.003) than those without IFALD. There were no significant differences in patient and PN characteristics between the IFLAD and non-IFALD group. The multivariable models showed that the IFALD cohort had longer hospital stays (HR 0.90, 95% CI 0.65-1.23) and lower odds of inpatient death (OR 0.75, 95% CI 0.12-4.60), though both findings are not statistically significant (p = 0.5, 0.7).

CONCLUSION: In this study, IFALD is a common phenomenon in AIF and the incidence was found to be an estimated 50% amongst patients on short-term PN with similar clinical outcomes between the two groups.

PMID:38777425 | DOI:10.1016/j.clnesp.2024.03.008

Clin Nutr ESPEN. 2024 Jun;61:101-107. doi: 10.1016/j.clnesp.2024.03.006. Epub 2024 Mar 15.

ABSTRACT

BACKGROUND & AIMS: Refeeding syndrome (RFS) lacks both a global definition and diagnostic criteria. Different diagnostic criteria are used; serum phosphate (traditional criterion (TC)), the Friedli consensus recommendations, and the ASPEN. We investigated the incidence of RFS in older hospitalized patients and the mortality rates in patients with or without RFS using these three different diagnostic criteria.

METHODS: This is a longitudinal study with data originating from a randomized controlled trial conducted between March 2017 and August 2019. A total of 85 malnourished hospitalized patients at risk of RFS according to the National Institute for Health and Clinical Excellence tool for detecting patients at risk of RFS, were included. All patients were provided with enteral tube feeding, and electrolytes were measured daily during the intervention period. Friedli and ASPEN included phosphate, magnesium, and potassium in their definitions, but used different cut-off values. Incidences were recorded, and Kaplan-Meier estimates were used to determine whether mortality was more prevalent in patients with RFS. Regression analysis was used to test for confounders regarding the association between RFS and death, and Kappa was used to test for agreement between the three diagnostic criteria.

RESULTS: The mean (SD) age of the patients was 79.8 (7.4) years, and the mean (SD) BMI was 18.5 (3.4) kg/m². The mean (SD) kcal/kg/day was 19 (11) on day one and 26 (15) on day seven. The incidences of RFS differed with the criteria used; 12.9% (TC), 31.8% (Friedli), and 65.9% (ASPEN). Mortality was high, with 36.5% (n = 31) and 56.5% (n = 48) of patients dead at three-month and one-year follow-up, respectively. In the TC, 8/11 (72.7%) with RFS vs. 40/74 (54.1%) without RFS died within one-year, in Friedli 15/27 (55.5%) with RFS vs. 33/58 (56.9%) without RFS died, and in ASPEN 32/56 (65.9%) with RFS, vs. 16/29 (55.2%) without RFS died within one-year. There was no statistically significant difference in mortality between patients with or without RFS regardless of which criteria were used. Age was the only variable associated with death at one-year. The Kappa analysis showed very low agreement between the categories.

CONCLUSION: Our results show that using different diagnostic criteria significantly impacts incidence rates. However, regardless of criteria used, the mortality was not significantly higher in the group of patients with RFS compared to the patients without RFS. Furthermore, none of the criteria showed a significant association with death at one-year. This supports the need for a global unified diagnostic criterion for RFS. This study was registered in ClinicalTrials.gov (identifier NCT03141489).

PMID:38777421 | DOI:10.1016/j.clnesp.2024.03.006

BMJ Glob Health. 2024 May 22;9(5):e015053. doi: 10.1136/bmjgh-2024-015053.

ABSTRACT

INTRODUCTION: Non-communicable diseases (NCDs) have surpassed infectious diseases as the leading global cause of death, with the Southeast Asian region experiencing a significant rise in NCD prevalence over the past decades. Despite the escalating burden, screening for NCDs remains at very low levels, resulting in undetected cases, premature mortality and high public healthcare costs. We investigate whether community-based NCD prevention and management programmes are an effective solution.

METHODS: In Indonesia, we compare participants in the community-based NCD screening and management programme Pos Pembinaan Terpadu-Penyakit Tidak Menular with matched non-participants with respect to their uptake of screening activities, health-related behaviour and knowledge and metabolic risk factors. We use statistical matching to redress a possible selection bias (n=1669). In Viet Nam, we compare members of Intergenerational Self-Help Clubs, which were offered similar NCD health services, with members of other community groups, where such services were not offered. We can rely on two waves of data and use a double-difference approach to redress a possible selection bias and to measure the impacts of participation (n=1710). We discuss strengths and weaknesses of the two approaches in Indonesia and Viet Nam.

RESULTS: In Indonesia, participants have significantly higher uptake of screening for hypertension and diabetes (+13% from a control mean of 88% (95% CI 9% to 17%); +93% from a control mean of 48% (95% CI 79% to 108%)). In both countries, participants show a higher knowledge about risk factors, symptoms and complications of NCDs (Indonesia: +0.29 SD (0.13-0.45), Viet Nam: +0.17 SD (0.03-0.30)). Yet, the improved knowledge is only partly reflected in improved health behaviour (Viet Nam: fruit consumption +0.33 SD (0.15-0.51), vegetable consumption +0.27 SD (0.04-0.50)), body mass index (BMI) (Viet Nam: BMI -0.07 SD (-0.13 to -0.00)) or metabolic risk factors (Indonesia: systolic blood pressure: -0.13 SD (-0.26 to -0.00)).

CONCLUSION: Community-based NCD programmes are well suited to increase screening and to transmit health knowledge. Due to their extensive outreach within the community, they can serve as a valuable complement to the screening services provided at the primary healthcare level. Yet, limited coverage, insufficient resources and a high staff turnover remain a problem.

TRIAL REGISTRATION NUMBER: NCT05239572.

PMID:38777393 | DOI:10.1136/bmjgh-2024-015053

J Surg Res. 2024 May 21;299:224-236. doi: 10.1016/j.jss.2024.04.026. Online ahead of print.

ABSTRACT

INTRODUCTION: Acute kidney injury (AKI) is a serious postoperative complication associated with increased morbidity and mortality. Identifying patients at risk for AKI is important for risk stratification and management. This study aimed to develop an AKI risk prediction model for colectomy and determine if the operative approach (laparoscopic versus open) alters the influence of predictive factors through an interaction term analysis.

METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was analyzed from 2005 to 2019. Patients undergoing laparoscopic and open colectomy were identified and propensity score matched. Multivariable logistic regression identified significant preoperative demographic, comorbidity, and laboratory value predictors of AKI. The predictive ability of a baseline model consisting of these variables was compared to a proposed model incorporating interaction terms between operative approach and predictor variables using the likelihood ratio test, c-statistic, and Brier score. Shapley Additive Explanations values assessed relative importance of significant predictors.

RESULTS: 252,372 patients were included in the analysis. Significant AKI predictors were hypertension, age, sex, race, body mass index, smoking, diabetes, preoperative sepsis, Congestive heart failure, preoperative creatinine, preoperative albumin, and operative approach (P < 0.001). The proposed model with interaction terms had improved predictive ability per the likelihood ratio test (P < 0.05) but had no statistically significant interaction terms. C-statistic and Brier scores did not improve. Shapley Additive Explanations analysis showed hypertension had the highest importance. The importance of age and diabetes showed some variation between operative approaches.

CONCLUSIONS: While the inclusion of interaction terms collectively improved AKI prediction, no individual operative approach interaction terms were significant. Including operative approach interactions may enhance predictive ability of AKI risk models for colectomy.

PMID:38776578 | DOI:10.1016/j.jss.2024.04.026

J Contam Hydrol. 2024 May 18;264:104368. doi: 10.1016/j.jconhyd.2024.104368. Online ahead of print.

ABSTRACT

In this study, twenty-two water samples were collected from boreholes (BH), and streams to evaluate drinking water quality, its distribution, identification of contamination sources and apportionment for Moti village, northern Pakistan. An atomic absorption spectrophotometer (AAS) is utilized to determine the level of heavy metals in water such as arsenic (As), zinc (Zn), lead (Pb), copper (Cu), cadmium (Cd), manganese (Mn), and ferrous (Fe). Groundwater chemistry and its quantitative driving factors were further explored using multivariate statistical methods, Principal Component Analysis (PCA) and Positive Matrix Factorization (PMF) models. Finally, a total of eight electrical resistivity tomographs (ERTs) were acquired across i) the highly contaminated streams; ii) the villages far away from contaminated streams; and iii) across the freshwater stream. In the Moti village, the mean levels (mg/l) of heavy metals in water samples were 7.2465 (As), 0.4971 (Zn), 0.5056 (Pb), 0.0422 (Cu), 0.0279 (Cd), 0.1579 (Mn), and 0.9253 (Fe) that exceeded the permissible limit for drinking water (such as 0.010 for As and Pb, 3.0 for Zn, 0.003 for Cd and 0.3 for Fe) established by the World Health Organization (WHO, 2008). The average entropy weighted water quality index (EWQI) of 200, heavy metal pollution index (HPI) of 175, heavy metal evaluation index (HEI) of 1.6 values reveal inferior water quality in the study area. Human health risk assessment, consisting of hazard quotient (HQ) and hazard index (HI), exceeded the risk threshold (>1),indicating prevention of groundwater usage. Results obtained from the PCA and PMF models indicated anthropogenic sources (i.e. industrial and solid waste) responsible for the high concentration of heavy metals in the surface and groundwater. The ERTs imaged the subsurface down to about 40 m depths and show the least resistivity values (<11 Ωm) for subsurface layers that are highly contaminated. However, the ERTs revealed relatively high resistivity values for subsurface layers containing fresh or less contaminated water. Filtering and continuous monitoring of the quality of drinking water in the village are highly recommended.

PMID:38776561 | DOI:10.1016/j.jconhyd.2024.104368

Oncologist. 2024 May 22:oyae099. doi: 10.1093/oncolo/oyae099. Online ahead of print.

ABSTRACT

BACKGROUND: Venous thromboembolism (VTE) is a leading cause of death in patients with cancer. Limited data exist about VTE in patients with adrenocortical carcinoma (ACC). The primary objective of this study was to identify the prevalence of VTE in a cohort of patients with ACC. Secondary objectives were to determine the impact of VTE events on overall survival (OS) and to describe the characteristics of VTE in patients with ACC.

PATIENTS AND METHODS: We retrospectively reviewed data from 289 patients with ACC cared for at a major referral center from February 2010 to June 2022.

RESULTS: VTE prevalence was 18.7% (54 events). Thirty patients (55.6%) had pulmonary embolism (PE); 12 patients (22.2%) had deep vein thrombosis (DVT); and 12 patients (22.2%) had both PE and DVT. VTE occurred after ACC diagnosis in 50 patients (92.6%) including 44 patients (88%) with stage 3 or 4 ACC. VTEs were CTCAE grade ≤2 in 32 cases (59.3%), grade 3 in 17 (31.5%), and grade 4 in 2 (3.7%). Thirteen patients (24%) died within 6 months after VTE diagnosis, although there was no statistically significant association between VTE and overall survival.

CONCLUSION: Despite the potential to underestimate the prevalence of VTEs, we found a high frequency of VTE events in patients with ACC. A majority of VTEs occurred in the context of advanced ACC and we observed high short-term mortality. Further studies are needed to validate our findings and investigate mechanisms associated with VTE in ACC.

PMID:38776552 | DOI:10.1093/oncolo/oyae099