Martina Bally

Nutritional Support and Outcomes in Malnourished Medical Inpatients: A Systematic Review and Meta-analysis

IMPORTANCE During acute illness, nutritional therapy is widely used for medical inpatients with malnutrition or at risk for malnutrition. Yet, to our knowledge, no comprehensive trial has demonstrated that this approach is effective and beneficial for patients. OBJECTIVE To assess the effects of nutritional support on outcomes of medical inpatients with malnutrition or at risk for malnutrition in a systematic review of randomized clinical trials (RCTs). DATA SOURCES The Cochrane Library, MEDLINE, and EMBASE. The study dates were October 5, 1982, to April 30, 2014, in various (mostly European) countries. The dates of our analysis were March 10, 2015, to September 16, 2015. STUDY SELECTION Based on a prespecified Cochrane protocol, we systematically searched RCTs investigating the effects of nutritional support (including counseling and oral and enteral feeding) in medical inpatients compared with a control group. DATA EXTRACTION Two reviewers extracted data on study characteristics, methods, and outcomes. Disagreement was resolved by consensus. MAIN OUTCOMES AND MEASURES The primary study outcome was mortality. Secondary outcomes included hospital-acquired infections, nonelective readmissions, functional outcome, length of hospital stay, daily caloric and protein intake, and weight change. RESULTS We included 22 RCTs with a total of 3736 participants. Heterogeneity across RCTs was high, with overall low study quality and mostly unclear risk of bias. Intervention group patients significantly increased their weight (mean difference, 0.72 kg; 95% CI, 0.23-1.21 kg), caloric intake (mean difference, 397 kcal; 95% CI, 279-515 kcal), and protein intake (mean difference, 20.0 g/d; 95% CI, 12.5-27.1 g/d) compared with control group patients. No differences between intervention group patients and control group patients were found with respect to mortality (9.8% vs 10.3%; odds ratio [OR], 0.96; 95% CI, 0.72-1.27), hospital-acquired infections (overall, 6.0% vs 7.6%; OR, 0.75; 95% CI, 0.50-1.11), functional outcome (mean Barthel index difference, 0.33 point; 95% CI, -0.88 to 1.55 points), or length of hospital stay (mean difference, -0.42 days; 95% CI, -1.09 to 0.24 days). Nonelective readmissions were significantly decreased by the intervention (20.5% vs 29.6%; risk ratio, 0.71; 95% CI, 0.57-0.87). CONCLUSIONS AND RELEVANCE In medical inpatients, nutritional support increases caloric and protein intake and body weight. However, there is little effect on clinical outcomes overall except for nonelective readmissions. High-quality RCTs are needed to fill this gap.

Loss of appetite in acutely ill medical inpatients: physiological response or therapeutic target?

Loss of appetite and ensuing weight loss is a key feature of severe illnesses. Protein-energy malnutrition (PEM) contributes significantly to the adverse outcome of these conditions. Pharmacological interventions to target appetite stimulation have little efficacy but considerable side effects. Therefore nutritional therapy appears to be the logical step to combat inadequate nutrition. However, clinical trial data demonstrating benefits are sparse and there is no current established standard algorithm for use of nutritional support in malnourished, acutely ill medical inpatients. Recent high-quality evidence from critical care demonstrating harmful effects when parenteral nutritional support is used indiscriminately has led to speculation that loss of appetite in the acute phase of illness is indeed an adaptive, protective response that improves cell recycling (autophagy) and detoxification. Outside critical care, there is an important gap in high quality clinical trial data shedding further light on these important issues. The selection, timing, and doses of nutrition should be evaluated as carefully as with any other therapeutic intervention, with the aim of maximising efficacy and minimising adverse effects and costs. In light of the current controversy, a reappraisal of how nutritional support should be used in acutely ill medical inpatients outside critical care is urgently required. The aim of this review is to discuss current pathophysiological concepts of PEM and to review the current evidence for the efficacy of nutritional support regarding patient outcomes when used in an acutely ill medical patient population outside critical care.

Symptoms and Characteristics of Individuals with Profound Hyponatremia: A Prospective Multicenter Observational Study

To assess symptoms and characteristics of hyponatremia, the most common electrolyte disturbance in hospitalized individuals and a condition that is associated with substantial morbidity and mortality.

Postoperative Copeptin Concentration Predicts Diabetes Insipidus After Pituitary Surgery

CONTEXT Copeptin is a stable surrogate marker of vasopressin release; the peptides are stoichiometrically secreted from the neurohypophysis due to elevated plasma osmolality or nonosmotic stress. We hypothesized that following stress from pituitary surgery, patients with neurohypophyseal damage and eventual diabetes insipidus (DI) would not exhibit the expected pronounced copeptin elevation. OBJECTIVE The objective was to evaluate copeptins accuracy to predict DI following pituitary surgery. DESIGN This was a prospective multicenter observational cohort study. SETTING Three Swiss or Canadian referral centers were used. PATIENTS Consecutive pituitary surgery patients were included. MEASUREMENTS Copeptin was measured postoperatively daily until discharge. Logistic regression models and diagnostic performance measures were calculated to assess relationships of postoperative copeptin levels and DI. RESULTS Of 205 patients, 50 (24.4%) developed postoperative DI. Post-surgically, median [25th-75th percentile] copeptin levels were significantly lower in patients developing DI vs those not showing this complication: 2.9 [1.9-7.9] pmol/L vs 10.8 [5.2-30.4] pmol/L; P < .001. Logistic regression analysis revealed strong association between postoperative copeptin concentrations and DI even after considering known predisposing factors for DI: adjusted odds ratio (95% confidence interval) 1.41 (1.16-1.73). DI was seen in 22/27 patients with copeptin <2.5 pmol/L (positive predictive value, 81%; specificity, 97%), but only 1/40 with copeptin >30 pmol/L (negative predictive value, 95%; sensitivity, 94%) on postoperative day 1. LIMITATIONS Lack of standardized DI diagnostic criteria; postoperative blood samples for copeptin obtained during everyday care vs at fixed time points. CONCLUSIONS In patients undergoing pituitary procedures, low copeptin levels despite surgical stress reflect postoperative DI, whereas high levels virtually exclude it. Copeptin therefore may become a novel tool for early goal-directed management of postoperative DI.

Evaluation of copeptin and commonly used laboratory parameters for the differential diagnosis of profound hyponatraemia in hospitalized patients: 'The Co-MED Study'

Hyponatraemia is common and its differential diagnosis is challenging. Commonly used diagnostic algorithms have limited diagnostic accuracy. Copeptin, the c‐terminal portion of the precursor peptide of arginine vasopressin might help in the differential diagnosis of hyponatraemia.

Industry sponsorship and outcomes of nutrition studies: Is there an association when looking at the trial level?

Munk 2014 Nonindustry (public)/Industry (Herlev University Hospit Denmark for protein powder.) Potter 2001 Nonindustry (public)/Industry (grant from the Chief Scie provided the sip feed supplements free of charge) Rüfenacht 2010 Nonindustry (public)/Industry (Independent Research Fu Kantonsspital Winterthur. Additional support by the Fed Ryan 2004 Nonindustry (public/private)/Industry (“Contrat de plan association with the Soci et e francaise de Nutrition Ent er Saudny-Unterberger 1997 Nonindustry (public/private)/Industry (supported by a g Centre of the Montreal Chest institute. Supplements are Starke 2011 Nonindustry (public)/Industry (Exchange Organisation St Service (DAAD)/Germany. Nestl e Nutrition/Switzerland Vermeeren 2004 Industry (Numico Research BV, The Netherlands) Vlaming 2001 Nonindustry (public)/Industry (Grant from Responsive F Authority NHS R&D. Abbott Laboratories Ltd supplied s financial support. Seton Heath Care provided the vita Trials reporting no industry sponsoring Broqvist 1994 Nonindustry (public/private) “Forenade liv” Mutual Grou Research Foundation, Sweden, Pharmacia AB, Sweden. T Research Foundation of the University Hospital of Links€ o Bunout 1989

Characteristics and Outcomes of Patients with Profound Hyponatremia due to Primary Polydipsia

Hyponatraemia due to excessive fluid intake (ie primary polydipsia [PP]) is common. It may culminate in profound hyponatraemia—carrying considerable risk of morbidity. However, data on patients with PP leading to hyponatraemia are lacking. Herein, we describe the characteristics of polydiptic patients hospitalized with profound hyponatraemia and assess 1‐year outcomes.

Copeptin levels and commonly used laboratory parameters in hospitalised patients with severe hypernatraemia - the “Co-MED study”

BackgroundHypernatraemia is common in inpatients and is associated with substantial morbidity. Its differential diagnosis is challenging, and delayed treatment may have devastating consequences. The most important hormone for the regulation of water homeostasis is arginine vasopressin, and copeptin, the C-terminal portion of the precursor peptide of arginine vasopressin, might be a reliable new parameter with which to assess the underlying cause of hypernatraemia.MethodsIn this prospective, multicentre, observational study conducted in two tertiary referral centres in Switzerland, 92 patients with severe hyperosmolar hypernatraemia (Na+ > 155 mmol/L) were included. After a standardised diagnostic evaluation, the underlying cause of hypernatraemia was identified and copeptin levels were measured.ResultsThe most common aetiology of hypernatraemia was dehydration (DH) (n = 65 [71%]), followed by salt overload (SO) (n = 20 [22%]), central diabetes insipidus (CDI) (n = 5 [5%]) and nephrogenic diabetes insipidus (NDI) (n = 2 [2%]). Low urine osmolality was indicative for patients with CDI and NDI (P < 0.01). Patients with CDI had lower copeptin levels than patients with DH or SO (both P < 0.01) or those with NDI. Copeptin identified CDI with an AUC of 0.99 (95% CI 0.97–1.00), and a cut-off value ≤ 4.4pmol/L showed a sensitivity of 100% and a specificity of 99% to predict CDI. Similarly, urea values were lower in CDI than in DH or SO (P < 0.05 and P < 0.01, respectively) or NDI. The AUC for diagnosing CDI was 0.98 (95% CI 0.96–1.00), and a cut-off value < 5.05 mmol/L showed high specificity and sensitivity for the diagnosis of CDI (98% and 100%, respectively). Copeptin and urea could not differentiate hypernatraemia induced by DH from that induced by SO (P = 0.66 and P = 0.30, respectively).ConclusionsCopeptin and urea reliably identify patients with CDI and are therefore helpful tools for therapeutic management in patients with severe hypernatraemia.Trials registrationClinicalTrials.gov, NCT01456533. Registered on 20 October 2011.