Silvia Cappello

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.

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.

Phase Angle and Handgrip Strength Are Sensitive Early Markers of Energy Intake in Hypophagic, Non-Surgical Patients at Nutritional Risk, with Contraindications to Enteral Nutrition

The assessment of nutritional intakes during hospitalization is crucial, as it is known that nutritional status tends to worsen during the hospital stay, and this can lead to the negative consequences of malnutrition. International guidelines recommend the use of parenteral nutrition (PN) in hypophagic, non-surgical patients at nutritional risk, with contraindications to enteral nutrition. However, to date, there are no published data regarding either energy intake or objective measurements associated with it in this patient population. The aim of the present exploratory methodological study was to evaluate whether phase angle (PhA) and handgrip strength normalized for skeletal muscle mass (HG/SMM) are sensitive early markers of energy intake in hypophagic, non-surgical patients at nutritional risk, with contraindications to enteral nutrition. We evaluated 30 eligible patients, who were treated with personalized dietary modifications and supplemental PN for at least one week during hospitalization. In a liner regression model adjusted for age, gender, basal protein intake and the basal value of each variable, a trend toward improvement of PhA and preservation of HG/SMM was observed in patients satisfying the estimated calorie requirements (N = 20), while a significant deterioration of these parameters occurred in those who were not able to reach the target (N = 10). The mean adjusted difference and 95% CI were +1.4° (0.5–2.3) (p = 0.005) for PhA and +0.23 (0.20–0.43) (p = 0.033) for HG/SMM. A significant correlation between PhA and HG/SMM variations was also observed (r = 0.56 (95% CI, 0.23–0.77); p = 0.0023). PhA and HG/SMM were able to distinguish between hypophagic, non-surgical patients at nutritional risk who satisfied their estimated caloric requirements and those who did not after a one-week personalized nutritional support. Clinical studies are warranted, in order to verify these preliminary observations and to validate the role of PhA variations as early markers of anabolic/catabolic fluctuations.

Nutritional counseling with or without systematic use of oral nutritional supplements in head and neck cancer patients undergoing radiotherapy

BACKGROUND To evaluate the benefit of oral nutritional supplements (ONS) in addition to nutritional counseling in head and neck cancer (HNC) patients undergoing radiotherapy (RT). METHODS In a single-center, randomized, pragmatic, parallel-group controlled trial (ClinicalTrials.gov: NCT02055833; February 2014-August 2016), 159 newly diagnosed HNC patients suitable for to RT regardless of previous surgery and induction chemotherapy were randomly assigned to nutritional counseling in combination with ONS (N = 78) or without ONS (N = 81) from the start of RT and continuing for up to 3 months after its end. Primary endpoint was the change in body weight at the end of RT. Secondary endpoints included changes in protein-calorie intake, muscle strength, phase angle and quality of life and anti-cancer treatment tolerance. RESULTS In patients with the primary endpoint assessed (modified intention-to-treat population), counseling plus ONS (N = 67) resulted in smaller loss of body weight than nutritional counseling alone (N = 69; mean difference, 1.6 kg [95%CI, 0.5-2.7]; P = 0.006). Imputation of missing outcomes provided consistent findings. In the ONS-supplemented group, higher protein-calorie intake and improvement in quality of life over time were also observed (P < 0.001 for all). The use of ONS reduced the need for changes in scheduled anti-cancer treatments (i.e. for RT and/or systemic treatment dose reduction or complete suspension, HR=0.40 [95%CI, 0.18-0.91], P = 0.029). CONCLUSION In HNC patients undergoing RT or RT plus systemic treatment, and receiving nutritional counseling, the use of ONS resulted in better weight maintenance, increased protein-calorie intake, improved quality of life and was associated with better anti-cancer treatment tolerance.

PP115-MON SERUM PREALBUMIN IS A PREDICTOR OF MORTALITY IN SYSTEMIC SCLEROSIS OUTPATIENTS

PP115-MON SERUM PREALBUMIN IS A PREDICTOR OF MORTALITY IN SYSTEMIC SCLEROSIS OUTPATIENTS E. Cereda1, V. Codullo2, C. Klersy3, S. Breda2, A. Crippa1, M.L. Rava1, M. Orlandi1, C. Bonardi1, L. Quarleri1, S. Cappello1, R. Caporali2, R. Caccialanza1. 1Nutrition and Dietetics Service, Fondazione IRCCS Policlinico San Matteo, 2Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, 3Biometry and Clinical Epidemiology Service, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy