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Background & Aims: Existing skeletal muscle index (SMI) thresholds for sarcopenia are inconsistent, and do not reflect severity of depletion. In this study we aimed to define criterion values for moderate and severe skeletal muscle depletion based on the risk of mortality in a population of patients with head and neck cancer (HNC). Additionally, we aimed to identify clinical and demographic predictors of skeletal muscle depletion, evaluate the survival impact of skeletal muscle depletion in patients with minimal nutritional risk or good performance status, and finally, benchmarking SMI values of patients with HNC against healthy young adults., Methods: Population cohort of 1231 consecutive patients and external validation cohorts with HNC had lumbar SMI measured by cross-sectional imaging. Optimal stratification determined sex-specific thresholds for 2-levels of SMI depletion (Class I and II) based on overall survival (OS). Adjusted multivariable regression analyses (tumor site, stage, performance status, age, sex, dietary intake, weight loss) determined relationships between 2-levels of SMI depletion and OS., Results: Mean SMI (cm 2 /m 2 ) was 51.7 ± 9.9 (males) and 39.8 ± 7.1 (females). The overall and sex-specific population demonstrated an increased risk of mortality associated with decreasing SMI. Sex-specific SMI (cm 2 /m 2 ) depletion thresholds for 2-levels of muscle depletion determined by optimal stratification for males and females, respectively (male: 45.2-37.5, and <37.5; female: 40.9-34.2, and <34.2). In the overall population, Normal SMI, Class I and II SMI depletion occurred in 65.0%, 24.0%, and 11.0%, respectively. Median OS was: Normal SMI (114 months, 95% CI, 97.1-130.8); Class I SMI Depletion (42 months, 95% CI, 28.5-55.4), and Class II SMI Depletion (15 months, 95% CI, 9.8-20.1). Adjusted multivariable analysis compared with Normal SMI (reference), Class I SMI Depletion (HR, 1.49; 95% CI, 1.18-1.88; P < .001), Class II SMI Depletion (HR, 1.91; 95% CI, 1.42-2.58; P < .001)., Conclusions: Moderate and severe SMI depletion demonstrate discrimination in OS in patients with HNC. Moderate and severe SMI depletion is prevalent in patients with minimal nutrition risk and good performance status. Benchmarking SMI values against healthy young adults exemplifies the magnitude of SMI depletion in patients with HNC and may be a useful method in standardizing SMI assessment., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Multiple systematic reviews and meta-analyses (SRMAs) on various nutritional interventions in hospitalized patients with or at risk of malnutrition are available, but disagreements among findings raise questions about their validity in guiding practice., Objectives: We conducted an umbrella review (a systematic review of systematic reviews in which all appropriate studies included in SRMAs are combined) to assess the quality of reviews, identify the types of interventions available (excluding enteral and parenteral nutrition), and re-analyze the effectiveness of interventions., Methods: The databases MEDLINE/PubMed, CINAHL, Embase, The Cochrane Library, and Google Scholar were searched. AMSTAR-2 was used for quality assessment and GRADE for certainty of evidence. Updated meta-analyses with risk of bias (ROB) by Cochrane ROB 2.0 were performed. Pooled effects were reported as relative risk (RR), with zero-events and publication bias adjustments, and trial sequential analysis (TSA) performed for mortality, readmissions, complications, length of stay, and quality of life., Results: A total of 66 randomized controlled trials were cited by the 19 SRMAs included in this umbrella review, and their data extracted and analyzed. Most clinical outcomes were discordant with variable effect sizes in both directions. In trials with low ROB, interventions targeting nutritional intake reduce mortality at 30 d (15 studies, n: 4156, RR: 0.72, 95% CI: 0.55, 0.94, P: 0.02, I 2 : 6%, Certainty: High), 6 mo (27 studies, n: 6387, RR: 0.81, 95% CI: 0.71, 0.92, P = 0.001, I 2 : 4%, Certainty: Moderate), and 12 mo (27 studies, n: 6387, RR: 0.80, 95% CI: 0.67, 0.95, P: 0.01, I 2 : 33%, Certainty: Moderate), with TSA verifying an adequate sample size and robustness of the meta-analysis., Conclusion: Existing evidence is sufficient to show that nutritional intervention is effective for mortality outcomes at 30 d, 6 mo, and 12 mo. Future clinical trials should focus on the effect of nutritional interventions on other clinical outcomes., Trial Registration Number: The protocol is registered on PROSPERO (CRD42022341031)., (Copyright © 2023 American Society for Nutrition. Published by Elsevier Inc. All rights reserved.)

Background: Computed tomography (CT)-defined sarcopenia is a demonstrated poor prognostic factor in patients with cancer; however, its influence on outcomes for patients with head and neck cancer (HNC) has not been established., Objective: This review synthesizes current knowledge regarding the association between CT-defined sarcopenia and outcomes for adult patients undergoing radiotherapy with or without other treatment modalities of curative intent for HNC., Methods: A systematic review of the literature published between January 2004 and June 2019 was conducted in Medline, Embase, Cumulative Index of Nursing and Allied Health Literature, Allied and Complementary Medicine Database, and PubMed. Empirical studies of CT-defined sarcopenia in adult patients (≥18 years) with HNC who had completed radiotherapy of curative intent with or without other treatment modalities were included. Outcomes reported included survival, prolonged radiotherapy breaks, and chemotherapy toxicity. Study quality was assessed using the American Academy of Nutrition and Dietetics Quality Criteria Checklist. Synthesis of outcomes and clinical relevance was performed using the Grading of Recommendations Assessment, Development, and Evaluation system., Results: Of 11 studies (n = 3,461) identified, 3 were positive and 8 were neutral quality. Studies were heterogeneous in HNC diagnosis, ethnicity, definition of sarcopenia, CT level of evaluation, and skeletal muscle index threshold value. Eight definitions for sarcopenia were identified with pretreatment prevalence of 6.6% to 70.9% and posttreatment prevalence of 12.4% to 65.8%. Pretreatment sarcopenia was independently associated with reduced: overall survival (OS), 3-year OS, disease-free survival, prolonged radiotherapy breaks, and chemotherapy-related toxicities. Posttreatment sarcopenia was independently associated with reduced OS and 5-year OS. The overall certainty of evidence according to Grading of Recommendations Assessment, Development and Evaluation criteria was low for OS; 3-year, 5-year, and 10-year OS; locoregional control; locoregional failure; progression-free survival; metastasis-free survival, disease-specific survival; and disease-free survival and very low for distant metastasis, prolonged radiotherapy breaks, and chemotherapy toxicity-related outcomes., Conclusions: CT-defined sarcopenia is independently associated with reduced OS and treatment completion in patients with HNC and holds a clinically meaningful prognostic value. The certainty of the evidence requires strengthening with further research. Understanding the impact sarcopenia has on outcomes for these patients has implications for informing potential nutrition interventions and facilitating individualized care., (Copyright © 2020 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Background: The optimal method of tube feeding for patients with head and neck cancer remains unclear. A validated protocol is available that identifies high-nutritional-risk patients who would benefit from prophylactic gastrostomy tube placement. Adherence to this protocol is ultimately determined by clinical team discretion or patient decision., Objective: The study aim was to compare outcomes after adherence and nonadherence to this validated protocol, thus comparing a prophylactic and reactive approach to nutrition support in this patient population., Design: We conducted a prospective comparative cohort study. Patients were observed during routine clinical practice over 2 years., Participants/setting: Patients with head and neck cancer having curative-intent treatment between August 2012 and July 2014 at a tertiary hospital in Queensland, Australia, were included if assessed as high nutrition risk according to the validated protocol (n=130). Patients were grouped according to protocol adherence as to whether they received prophylactic gastrostomy (PEG) per protocol recommendation (prophylactic PEG group, n=69) or not (no PEG group, n=61)., Main Outcome Measures: Primary outcome was percentage weight change during treatment. Secondary outcomes were feeding tube use and hospital admissions., Statistical Analysis Performed: Fisher's exact, χ 2 , and two sample t tests were performed to determine differences between the groups. Linear and logistic regression were used to examine weight loss and unplanned admissions, respectively., Results: Patients were 88% male, median age was 59 years, with predominantly stage IV oropharyngeal cancer receiving definitive chemoradiotherapy. Statistically significantly less weight loss in the prophylactic PEG group (7.0% vs 9.0%; P=0.048) and more unplanned admissions in the no PEG group (82% vs 75%; P=0.029). In the no PEG group, 26 patients (43%) required a feeding tube or had ≥10% weight loss., Conclusions: Prophylactic gastrostomy improved nutrition outcomes and reduced unplanned hospital admissions. Additional investigation of characteristics of patients with minimal weight loss or feeding tube use could help refine and improve the protocol., (Copyright © 2018 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Objectives: Studies are lacking in the health economic implications of home enteral nutrition (HEN) in home-residing and long-term care/institutionalized patients. The aims of this review were to determine the total costs, the cost-effectiveness and other economic outcomes for HEN., Design: A systematic search of randomized trials and observational studies available from January 2000 to April 2016 was performed using standard literature and electronic databases. Inclusion criteria were adults receiving HEN with economic outcomes in the long-term care or home settings. There was no restriction to the control groups used in the studies., Results: A total of 10 studies met the inclusion criteria. The majority of the studies were not specifically designed for economic evaluation. Cost per QALY was lower in residents residing in home compared to long-term care facilities, and HEN appeared to be cost-effective for those with pressure ulcers. Higher costs were incurred for patients with dementia on HEN. Lower hospitalization costs and infection rates were reported for patients who switched to commercial feeds from blenderized food. The availability of nutritional support teams may decrease overall costs but these studies were of poor study quality., Conclusions: The lack of good quality economic evaluation studies affected the ability to conclude the overall cost-effectiveness of HEN. There is a trend for cost-saving and improved clinical outcomes in some populations. HEN is unlikely beneficial for patients with dementia. The availability of a nutrition support team may lead to cost savings and improved clinical outcomes for HEN., (Copyright © 2017 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Objectives: Prophylactic gastrostomy tube (PGT) is frequently used in patients with head and neck cancer (HNSCC). There are concerns this leads to tube dependency but this phenomena is not well defined. This study aimed to determine whether early feeding via PGT impacted on longer term tube feeding outcomes., Materials and Methods: Patients with HNSCC with PGT were observed monthly post-treatment regarding tube use and time to removal up to twelve months. Patients were from a randomised controlled trial comparing an early feeding intervention via the PGT (n=57) versus usual care which commenced feeding when clinically indicated (n=67)., Results: Patient characteristics; male (88%), mean age 60±10.1years, oropharyngeal tumours (76%), receiving chemoradiotherapy (82%). Tubes were used by 87% (108/124) on completion of treatment and 66% (83/124) one month post. No differences in tube use between groups at any time point or tube removal rates over 12months (p=0.181). In patients free of disease (n=99), the intervention had higher tube use at 4months (p=0.003) and slower removal rates (p=0.047). Overall ten patients had their tube in-situ at 12months (8%) but five were awaiting removal (4% true dependency rate). Of the five patients legitimately using the tube, only one (<1%) was from severe dysphagia post definitive chemoradiotherapy., Conclusion: PGT use is high in the acute phase post-treatment. Encouraging early use may prolong time to tube removal but it does not increase long term dependency rates beyond four months post treatment. Monitoring tube use is important to prevent over-estimation of dependency rates., Clinical Trial Registration: This trial has been registered in the Australian New Zealand Clinical Trials registry as ACTRN12612000579897. Available at http://www.anzctr.org.au., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background & Aims: Malnutrition is highly prevalent and resistant to intervention following hip fracture. This study investigated the impact of individualised versus multidisciplinary nutritional care on nutrition intake and outcomes in patients admitted to a metropolitan hospital acute hip fracture unit., Methods: A prospective, controlled before and after comparative interventional study aligning to the CONSORT guidelines for pragmatic clinical trials. Randomly selected patients receiving individualised nutritional care (baseline) were compared with post-interventional patients receiving a new model of nutritional care promoting nutrition as a medicine, multidisciplinary nutritional care, foodservice enhancements, and improved nutrition knowledge and awareness. Malnutrition was diagnosed using the Academy of Nutrition and Dietetics criteria., Results: Fifty-eight weighed food records were available for each group across a total of 82 patients (n = 44, n = 38). Group demographics were not significantly different with predominantly community dwelling (72%), elderly (82.2 years), female (70%), malnourished (51.0%) patients prone to co-morbidities (median 5) receiving early surgical intervention (median D1). Multidisciplinary nutritional care reduced intake barriers and increased total 24-h energy (6224 vs. 2957 kJ; p < 0.001) and protein (69.0 vs. 33.8 g; p < 0.001) intakes, reduced nutritional deterioration over admission (5.4 vs. 20.5%; p = 0.049), and increased discharge directly back to the community setting (48.0 vs. 17.6%; p = 0.012). Trends suggested a reduction in median length of stay (D13 vs. D14). Inpatient mortality remained low across groups (5.2%, 2.3%)., Conclusions: Multidisciplinary nutritional care improves nutrition intake and outcomes in acute hip fracture inpatients. Similar pragmatic study designs should be considered in other elderly inpatient populations perceived resistant to nutritional intervention., (Copyright © 2013 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Background: Malnutrition is common in older adults and early and appropriate nutrition intervention can lead to positive quality of life and health outcomes., Objective: The purpose of our study was to determine the concurrent validity of several malnutrition screening tools and anthropometric parameters against validated nutrition assessment tools in the long-term-care setting., Study Design: This work was a cross-sectional, observational study., Participants/setting: Older adults (aged >55 years) from two long-term-care facilities were screened., Main Outcomes: Nutrition screening tools used included the Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST), Mini Nutritional Assessment-Short Form (MNA-SF), and the Simplified Nutritional Assessment Questionnaire. Nutritional status was assessed by Subjective Global Assessment (SGA), Mini Nutritional Assessment (MNA), body mass index (BMI), corrected arm muscle area, and calf circumference. Residents were rated as either well nourished or malnourished according to each nutrition assessment tool., Statistical Analysis: A contingency table was used to determine the sensitivity and specificity of the nutrition screening tools and objective measures in detecting patients at risk of malnutrition compared with the SGA and MNA., Results: One hundred twenty-seven residents (31.5% men; mean age 82.7 ± 9 years, 57.5% high care) consented. According to SGA, 27.6% (n=31) of residents were malnourished and 13.4% were rated as malnourished by MNA. MST had the best sensitivity and specificity compared with the SGA (sensitivity 88.6%, specificity 93.5%, ?=0.806), followed by MNA-SF (85.7%, 62%, ?=0.377), MUST (68.6%, 96.7%, ?=0.703), and Simplified Nutritional Assessment Questionnaire (45.7%, 77.2%, ?=0.225). Compared with MNA, MNA-SF had the highest sensitivity of 100%, but specificity was 56.4% (?=0.257). MST compared with MNA had a sensitivity of 94.1%, specificity 80.9% (?=0.501). The anthropometric screens ranged from ?=0.193 to 0.468 when compared with SGA and MNA., Conclusions: MST, MUST, MNA-SF, and the anthropometric screens corrected arm muscle area and calf circumference have acceptable concurrent validity compared with validated nutrition assessment tools and can be used to triage nutrition care in the long-term-care setting., (Copyright © 2012 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

This article describes an exercise to investigate the utility of modeling and human factors analysis in understanding surgical processes and their vulnerabilities to medical error. A formal method to identify error vulnerabilities was developed and applied to a test case of Veress needle insertion during closed laparoscopy. A team of 2 surgeons, a medical assistant, and 3 engineers used hierarchical task analysis and Integrated DEFinition language 0 (IDEF0) modeling to create rich models of the processes used in initial port creation. Using terminology from a standardized human performance database, detailed task descriptions were written for 4 tasks executed in the process of inserting the Veress needle. Key terms from the descriptions were used to extract from the database generic errors that could occur. Task descriptions with potential errors were translated back into surgical terminology. Referring to the process models and task descriptions, the team used a modified failure modes and effects analysis (FMEA) to consider each potential error for its probability of occurrence, its consequences if it should occur and be undetected, and its probability of detection. The resulting likely and consequential errors were prioritized for intervention. A literature-based validation study confirmed the significance of the top error vulnerabilities identified using the method. Ongoing work includes design and evaluation of procedures to correct the identified vulnerabilities and improvements to the modeling and vulnerability identification methods., (Copyright 2010 AAGL. Published by Elsevier Inc. All rights reserved.)

Background & Aims: To estimate the economic consequences of pressure ulcer attributable to malnutrition., Methods: Statistical models were developed to predict the number of cases of pressure ulcer, associated bed days lost and the dollar value of these losses in public hospitals in 2002/2003 in Queensland, Australia. The following input parameters were specified and appropriate probability distributions fitted.One thousand random re-samples were made and the results expressed as (output) probabilistic distributions., Results: The model predicts a mean 16,060 (SD 5671) bed days lost and corresponding mean economic cost of AU$12,968,668 (SD AU$4,924,148) (EUROS 6,925,268; SD 2,629,495) of pressure ulcer attributable to malnutrition in 2002/2003 in public hospitals in Queensland, Australia., Conclusion: The cost of pressure ulcer attributable to malnutrition in bed days and dollar terms are substantial. The model only considers costs of increased length of stay associated with pressure ulcer and not other factors associated with care., (Crown Copyright 2009. Published by Elsevier Ltd. All rights reserved.)

Background & Aims: Uraemic symptoms as a result of reduced kidney function may impact on an individual's functional and nutritional status. This study aims to investigate whether providing individualised nutritional counselling can improve nutritional status and influence quality of life in pre-dialysis chronic kidney disease patients., Methods: Fifty-three stage IV and V pre-dialysis chronic kidney disease patients underwent assessment of nutritional status (by Patient Generated Subjective Global Assessment) and quality of life (by Kidney Disease Quality of Life). Participants were assessed at baseline and following a 12-week randomised-controlled treatment, allocated to either individualised counselling with regular follow-up (n=24) or standard care treatment (generic education only (n=23))., Results: At baseline, nutritional status was significantly correlated with all general quality of life sub-scales. There was a statistically significant mean difference in change between groups for: symptoms of kidney disease (7.1 (0.1-14.1) p=0.047); cognitive functioning (14.6 (5.4-23.7) p=0.003); and vitality (12.0 (4.6-19.5) p=0.002) favouring intervention treatment., Conclusions: Quality of life is related to nutritional status in pre-dialysis patients. Providing individualised nutritional counselling improves many components of quality of life, compared with standard nutrition care, in the stage prior to dialysis treatment.

Background: A randomized controlled trial previously conducted in radiation oncology patients demonstrated that nutrition intervention had a beneficial impact on body weight, nutritional status, and quality of life compared with standard practice, but it did not report on dietary intake data., Objective: To determine the impact of nutrition intervention compared with standard practice on dietary intake in outpatients receiving radiotherapy., Design: Prospective, randomized, controlled trial., Subjects: Sixty consecutive radiation oncology outpatients (51 men and nine women; age 61.9+/-14 years [mean+/-standard deviation])., Setting: Australian private radiotherapy facility., Intervention: Patients were randomly assigned to receive either nutrition intervention (n=29) (nutrition counseling following the American Dietetic Association [ADA] medical nutrition therapy [MNT] protocol for radiation oncology) or standard practice (n=31) (general nutrition talk and booklet)., Main Outcome Measure: Dietary intake (protein, energy, fiber) assessed at baseline and at 4, 8, and 12 weeks after starting radiotherapy., Statistical Analyses: Repeated-measures analysis of variance done on an intention to treat basis., Results: The nutrition intervention group had a higher mean total energy (P=0.029) and protein intake (P<0.001) compared with the standard practice group. Mean intake per kilogram of body weight for the nutrition intervention group ranged from 28 to 31 kcal/kg/day compared with 25 to 29 kcal/kg/day for the standard practice group (P=0.022). The nutrition intervention group had a higher mean protein intake (1.1 to 1.3 g/kg/day) compared with the standard practice group (1.0 to 1.1 g/kg/day) (P=0.001). Although the change in fiber intake between the groups was not significant, there was a trend in the anticipated direction (P=0.083)., Conclusions: Intensive nutrition intervention following the ADA MNT protocol results in improved dietary intake compared with standard practice and seems to beneficially impact nutrition-related outcomes previously observed in oncology outpatients receiving radiotherapy. The ADA MNT protocol for radiation oncology is a useful guide to the level of nutrition support required.

Background & Aims: The extent of malnutrition in hospitalised stroke patients and its influence on outcomes including hospital complications, length of stay and discharge destination are important issues. The aim of this study was to determine the nutritional status of patients admitted to an acute stroke unit and the association between nutritional status and health outcomes., Methods: Nutritional status was determined prospectively using the scored patient generated subjective global assessment (PG-SGA) in patients (n=73) admitted to an acute stroke unit within 48 h of admission to an Australian private hospital. Outcome data were collected by retrospective audit., Results: On admission, 19.2% of patients were malnourished and this was associated with a significantly greater PG-SGA score (15 vs. 5) and lower body weight (59.8 kg vs. 75.8 kg) compared to well-nourished patients. In terms of health outcomes, malnourished patients had longer length of stay (13 vs. 8 days), increased complications (50% vs. 14%), increased frequency of dysphagia (71% vs. 32%) and enteral feeding (93% vs. 59%). No association was found between nutritional status and serum albumin level or discharge destination., Conclusions: Malnutrition on admission to hospital after acute stroke is associated with poor outcomes including increased length of stay and increased prevalence of dysphagia and complications. The scored PG-SGA is a nutrition assessment tool that allows quick identification of malnourished stroke patients.

If special programs to increase the number of blacks gaining entry into health professional schools can identify whom they best serve, changes in either the selection process or the curriculum can increase their effectiveness. As one part of an evaluation of the effectiveness of the various components of the prehealth professions program at Xavier University of Louisiana (XU), black freshmen entering the university from 1981 to 1983 in the university's premedical program were tracked to determine who gained entry into medical and related mainline health professional schools upon graduation.The analyses indicate that high-ability black freshmen entering Xavier are more than twice as likely to gain admission into medical school than are their black counterparts nationally, and that this difference is statistically significant beyond the 99 percent level. Fifty-seven percent of high-ability black freshmen (those with American College Testing [ACT] composite scores of 24 or above, the top 2 percent of blacks nationally) who entered XU's biology or chemistry programs during the period under study gained entry into medical school upon graduation, whereas a study by the Educational Testing Service indicates that only 24 percent of similar blacks nationally gain entry into any graduate or professional school.The present study suggests that XU's premedical program serves those blacks who are not in the high-ability group (those whose ACT scores are below 24) at least as well (relative to the national average) as it does the top students. It therefore seems reasonable to assume that XU's premedical program is successful because it increases the probability that students gain admission into health professional schools rather than because of any preselection of students. These results are similar to those obtained from a comparable analysis of XU's prepharmacy program, the other component of prehealth at Xavier.