- Email: [email protected]
Comparison of two nutritional screening tools to detect nutritional risk in hematologic inpatients
Accepted Manuscript Comparison of Two Nutritional Screening Tools to Detect Nutritional Risk in Haematological Inpatients Lucía Fiol-Martínez, RD, Alicia Calleja-Fernández, RD PhD, Begoña Pintor de la Maza, RD, Alfonso Vidal-Casariego, MD PhD, Rocío Villar-Taibo, MD PhD, Ana Urioste-Fondo, MD, Marta Cuervo, RD PhD, Isidoro Cano-Rodríguez, MD PhD, María D. Ballesteros-Pomar, MD PhD PII:
S0899-9007(16)30216-7
DOI:
10.1016/j.nut.2016.09.009
Reference:
NUT 9846
To appear in:
Nutrition
Received Date: 23 June 2016 Revised Date:
22 August 2016
Accepted Date: 23 September 2016
Please cite this article as: Fiol-Martínez L, Calleja-Fernández A, Pintor de la Maza B, Vidal-Casariego A, Villar-Taibo R, Urioste-Fondo A, Cuervo M, Cano-Rodríguez I, Ballesteros-Pomar MD, Comparison of Two Nutritional Screening Tools to Detect Nutritional Risk in Haematological Inpatients, Nutrition (2016), doi: 10.1016/j.nut.2016.09.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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TITLE: COMPARISON OF TWO NUTRITIONAL SCREENING TOOLS TO DETECT
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NUTRITIONAL RISK IN HAEMATOLOGICAL INPATIENTS
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RUNNING
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HAEMATOLOGICAL PATIENTS
TITLE:
COMPARING
TWO
SCREENING
TOOLS
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Authors:
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Lucía Fiol-Martínez RD, Department of Nutrition. University of Navarra, Pamplona, Spain. [email protected]
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Alicia Calleja-Fernández RD PhD, Clinical Nutrition and Dietetics Unit, Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de León, León, Spain.
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[email protected]
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Begoña Pintor de la Maza RD, Clinical Nutrition and Dietetics Unit, Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de León, León, Spain.
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[email protected]
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Alfonso Vidal-Casariego MD PhD, Clinical Nutrition and Dietetics Unit, Department of
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Endocrinology and Nutrition, Complejo Asistencial Universitario de León, León, Spain.
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[email protected]
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Rocío Villar-Taibo MD PhD, Clinical Nutrition and Dietetics Unit, Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de León, León, Spain.
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[email protected]
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Ana Urioste-Fondo MD, Clinical Nutrition and Dietetics Unit, Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de León, León, Spain.
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[email protected]
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Marta Cuervo RD PhD, Department of Nutrition. University of Navarra, Pamplona, Spain. [email protected]
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Isidoro Cano-Rodríguez MD PhD, Clinical Nutrition and Dietetics Unit, Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de León, León, Spain. [email protected]
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María D. Ballesteros-Pomar MD PhD, Clinical Nutrition and Dietetics Unit,
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Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de
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León, León, Spain. [email protected]
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Role of authors •
Lucía Fiol-Martínez: Design of the study, acquisition of data, writing of the paper
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Alicia Calleja-Fernández: Design of the study, acquisition of data, statistical analysis writing of the paper
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Begoña Pintor de la Maza: acquisition of data, writing of the paper
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Alfonso Vidal-Casariego: Critically review the paper
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Rocío Villar-Taibo: Critically review the paper
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Ana Urioste-Fondo: Critically review the paper
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Marta Cuervo-Zapatel: Design of the study, critically review the paper
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Isidoro Cano-Rodríguez: Critically review the paper
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María D. Ballesteros-Pomar : Design of the study, Critically review the paper
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Correspondence:
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Lucía Fiol-Martínez
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Avda. Alcalde Miguel Castaño, Nº 36 (bajo) C.P.:24005, León, SPAIN.
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Phone: +34 609 22 03 98
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Fax: +34 987 20 54 61
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Email: [email protected]
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ACCEPTED MANUSCRIPT Abstract
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Objective: The aim of the study was to compare two nutritional screening tools in onco-
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haematological inpatients.
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Methods: A cross-sectional study was performed in a haematology ward from August to
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December 2015. Within the first 24h of admission, the following nutritional screenings
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were performed: Malnutrition Universal Screening Tool (MUST), Malnutrition
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Screening Tool (MST) and Subjective Global Assessment (SGA). Patients who stayed
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in the haematological ward were reevaluated with the three screening tools one and two
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weeks after their admission. The SGA was used as the gold standard in the detection of
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malnutrition.
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Results: A total of 63 patients were included in the study – 61.9% men, aged 64.0 (SD
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17.9) years – with 90.5% having a diagnosis of cancer. The prevalence of patients with
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nutritional risk at admission was 17.5% with SGA, 16.7% at the first week, and 31.6%
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at the second week. According to MST, the prevalence was 41.3% at admission, 13.9%
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at the first week, and 15.8% at the second week. According to MUST, the prevalence
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was 36.5%, 25.0%, and 36.8%, respectively. The results of diagnostic tests on
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admission were an AUC ROC of 0.691 for MST and 0.830 for MUST at admission; at
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the first week, 0.717 for MST and 0.850 for MUST; and at the second week of
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assessment, 0.506 for MST and 0.840 for MUST.
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Conclusion: MUST might be a better screening tool compared to MST for detecting the
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risk of malnutrition in onco-haematological inpatients.
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Keywords: malnutrition, nutritional screening tool, haematologic neoplasm.
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Abbreviations: ASPEN: American Society of Parenteral and Enteral Nutrition;
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BAPEN: British Association of Parenteral and Enteral Nutrition; BMI: Body Mass
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Index; ESPEN: European Society for Clinical Nutrition and Metabolism; LOS: length
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of hospital stay; MST: Malnutrition Screening Tool; MUST: Malnutrition Universal
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Screening Tool
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ACCEPTED MANUSCRIPT Introduction
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Malnutrition is an inadequate nutritional status that is highly prevalent in hospitals, and
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it should be considered in order to provide complete treatment to inpatients. This
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deterioration of nutritional status has negative consequences in almost every organ or
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system of the human body. The increased incidence of pneumonia in malnourished
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patients might be explained by the impaired immune function and poor wound healing
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caused by the deterioration of the muscle function1. Malnutrition in the healthcare
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systems has a significant clinical and economic impact as it can translate into increased
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morbidity and also a long length of stay (LOS). In 2008, the PREDyCES® study was
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conducted in Spain and evaluated the presence of malnutrition in 31 Spanish hospitals,
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obtaining a prevalence of malnutrition that rose up to 23%2. The main causes of
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malnutrition are a decrease in energy intake during the hospital stay and an increase of
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energy requirements due to the illness that altogether can worsen the patient’s status.
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Therefore, several studies have shown that decreased food intake is associated with
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increased morbidity and mortality during a hospital stay3,4. Besides those complications,
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patients with a worse nutritional status are readmitted to the hospital more frequently
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once they are discharged, 15, 30, and 90 days and even six months after the first
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admission5,6,7. It is the health staff’s responsibility to evaluate food intake of inpatients
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in order to decrease the risk of malnutrition, minimise the LOS and costs, and obtain the
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best outcomes for patients.
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Among all of the hospital wards, cancer patients might present a higher risk of a poorer
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nutritional status. They frequently suffer from cachexia-anorexia syndrome, which
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reaches an incidence of 50% and grows to up to 80–90% in advanced phases of the
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disease. The prevalence of this syndrome depends not only on the stage of the disease
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but also on the tumour location as well, and might be responsible for 20–25% of the
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deaths of these patients. The mechanisms that cause malnutrition in cancer can be
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classified in four big groups: low energy and nutrient intake, alterations in the digestion
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and nutrient absorption, higher nutritional needs, and alterations in the metabolism of
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nutrients.
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The ESPEN and the ASPEN recommend an early and systematic screening for under-
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nutrition in all hospitalised patients8. Clinical tools should be used to detect this
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malnutrition in hospitalised patients in order to perform a nutritional diagnosis,
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minimise comorbidity and mortality and decrease the costs associated with it. A
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nutritional screening tool is defined as an evaluation tool that can quickly and easily
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evaluate one’s nutritional status. Its objective is to detect the individuals who present a
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poor nutritional condition or are at risk of suffering malnutrition..
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The aim of the study was to compare two nutritional screening tools, the Malnutrition
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Universal Screening Tool (MUST) and the Malnutrition Screening Tool (MST), to the
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Subjective Global Assessment (SGA), in a haematological hospital ward.
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Methodology
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A cross-sectional study was performed in the haematology ward of the Complejo
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Asistencial Universitario of León (Spain) from August to December 2015. The study
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was approved by the Ethics and Clinical Research Committee of the hospital, which
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confirmed that the study followed the Declaration of Helsinki. All patients were
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informed at bedside about the study and were asked to sign the written consent.
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Patients included were those older than 18 years of age, inpatients from the
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haematological area with a length of stay longer than 24h, patients that could be
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weighed and those that signed the informed consent.
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Two nutritional screening tools (MST and MUST) were performed for each patient and
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the results were compared with the gold standard for nutritional assessment (SGA). The
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MST was completed by the patients at admission. MUST and SGA were both
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performed by the dietitian.
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The Malnutrition Screening Tool (MST) includes two questions about the patients’
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intake and their weight9,10. Each of the questions had a score depending on the answer
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given by the patient. The total score allowed for classifying each patient according to
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their nutritional status: without risk of malnutrition (0 point); at risk of malnutrition (1
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point); malnourished (≥2 points).
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The Malnutrition Universal Screening Tool (MUST) consists of three items that allow
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for establishing the nutritional status of the patient under evaluation. These criteria are
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body mass index (BMI), percentage of weight loss in the last three months, and whether
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or not the acute illness of the patient is likely to impair an adequate intake over the next
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five days11,12,13,14. According to the data registered, the patient obtains a score and can
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be classified in the following groups: low risk (0 points), the patient has to be
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reevaluated weekly; intermediate risk (1 point), the patient has to be monitored; high
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risk (≥2 points), it is necessary to establish nutritional treatment.
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The Subjective Global Assessment (SGA) is a nutritional evaluation where several data
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are registered, such as habitual and actual weight of the patient, changes in the intake
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and physical activity, and a complete physical exam (fat loss, muscle loss and presence
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of oedema)15,16,17. SGA classifies patients in three groups: A: good nutritional status; B:
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at risk of suffering malnutrition; C: bad nutritional status.
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Several anthropometric measures were taken at bedside. All patients were asked about
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their usual weight in the three previous months before their admission in the
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haematological ward. They were weighed standing, wearing underwear and barefoot
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using a Seca 762® mechanical scale with a precision of 0.1 kg. Their height was
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estimated according to the method using ulna length, the use of which was validated by
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BAPEN18. The measurement was made with a flexible tape having a precision of 1 mm.
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Once cubital distance was measured and taking into account the sex and the age of the
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patient, the height was estimated according to the values of the BAPEN. The BMI was
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calculated following the formula: current weight (kg) / [height (m) x height (m)].
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Finally, the percentage of weight loss (%WL) was calculated after the patients were
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asked about their usual weight and were weighed during the nutritional assessment. The
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usual weight used for the formula was the reported weight upon admission. For the first
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and second week assessments, the used weight was the one from the week before.
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The statistical analysis was carried out using SPSS® 15.0 for Windows. A Kolmogorov-
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Smirnov test was performed to determine which data followed a normal distribution. All
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quantitative variables followed a normal distribution. They were summarised with the
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mean and the standard deviation and compared using a Student’s t-test. The qualitative
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variables were summarised and compared with the χ2 test.
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The diagnosis tests were performed for both MST and MUST, using SGA as the gold
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standard15,16,17, with the data collected at admission, and from the first and second week
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assessments. The sensitivity and specificity were analysed, as well as the area under the
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curve ROC, the positive and negative prognostic values, and the positive and negative
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likelihood ratios.
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Results
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Seventy-five patients were recruited, of whom two refused to participate. In all, 61.90%
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of the patients were men, aged 64.01 (SD 17.94) years. Of the sample, 60.30% were
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aged over 65 years old, their height was 162.83 (SD 9.72) cm, their usual weight was
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74.02 (SD 12.82) kg and their usual BMI was 27.69 (SD 3.62) kg/m2. A total of 90.50%
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had a cancer diagnosis and their length of hospital stay was eight (IQR 8.00) days.
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Nineteen patients were hospitalised for three weeks. The values of weight, %WL and
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BMI evolution are included in Table 1. Differences were only found regarding weight
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and BMI in the first week assessment vs. admission; but not between the second week
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assessment vs. admission. The results of the detection of malnutrition risk using the
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screening tools are summarised in Table 2. The results of sensitivity and specificity
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analysis at admission, and after the first and second weeks, are shown in Table 3. ROC
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curves were described and are included as well in Figure 1 (admission, first week and
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second week assessments).
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Discussion
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As previous studies have pointed out, the prevalence of malnutrition is important in
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hospitalisation. In this regard, screening tools are needed to detect malnutrition. The
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PREDyCES® study was performed in Spain and evaluated the presence of malnutrition
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in 31 Spanish hospitals, obtaining a prevalence of malnutrition that rose up to 23%2.
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Although the screening tool used in this multicentre study was the Nutritional Risk
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Screening 2002 (NRS-2002), Calleja et al. saw in their study that with the results they
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achieved, MUST was more indicated than was NRS-2002 or Mini Nutritional
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Assessment (MNA) for detecting the risk of malnutrition in hospitalised patients in our
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hospital15.
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It is acknowledged that cancer malignancies are associated with a higher prevalence of
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malnutrition, which is why nutritional surveillance might be essential throughout the
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hospital stay. The prevalence of malnutrition among oncology patients is 15–40%, and
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47.7% prevalence of malnutrition was found in this centre in a previous study, which is
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similar to the malnutrition rates found in the literature21. In addition, Shaw et al. found a
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rate of 71% of malnourished patients using SGA, which was higher than the results
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obtained by SGA in our study (17.5% at admission and 31.6% during the hospital
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stay)22. These variations might be explained by the differences in the type of cancer
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patients included in both studies.
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Among the wide set of used nutritional screening tools to detect malnutrition, MST is
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one of the best validated for oncology patients23. This nutritional screening tool is
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suitable for clinical practice and is easy to perform, both by caregivers and patients.
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Nowadays, MST is the screening tool in use in the haematological ward of our hospital.
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On the other hand, MUST seems to be an adequate and complete tool for detecting
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malnutrition in onco-haematological inpatients13,15. Previous studies, such as Shaw et
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al.’s, which obtained a sensitivity for the MST of 66%,22 have revealed that the MST
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has a poorer sensitivity when compared to other screening tools. Our results
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demonstrated that the MST, at admission, had a sensitivity of 72.73%, a value that is
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even lower at the first (50.00%) and second week (16.67%) assessments. The 19
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patients that were hospitalised at the time of the second week assessment might be
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sicker and, likely, they were not aware of their weight loss, which was the variable that
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would have determined the MST results. The sensitivity of the MST is lower than that
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obtained using the MUST at admission, and the differences became more consistent
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throughout the LOS. Furthermore, it has been proven that the sensitivity of MUST
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tended to be higher than that obtained for MST. Calleja et al. and Velasco et al., who
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also used SGA as the gold standard, showed in their studies that MUST had a sensitivity
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of 82.40% and 71.60%, respectively, which is lower than the results obtained in the
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current study (90.91% at admission and 83.33% at the first and second week
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assessments)15,16. This difference in sensitivity might be explained because the MST
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includes the weight loss that is self-reported by the patient, who can potentially
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underestimate the changes and fluctuations in their weight. Second, MUST patients are
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weighed by trained healthcare staff, diminishing the subjectivity of the test, which
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enables more reliable results.
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onco-haematological inpatients. The main limitation of the study was the small sample
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size, which is related to the recruitment time and might bias the results obtained.
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Although the MST is quick and easy to perform, as it is a self-reported tool completed
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by the patients at admission, it is also important to recognise that the MUST is much
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more complete and gives us very useful information about the nutritional status of the
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patients. MUST needs trained personnel and is more time consuming than is the MST,
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but the more accurate results are worth that effort.
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In conclusion, the MUST, which should be performed by trained staff, might be a better
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screening tool compared to the MST in order to detect the risk of malnutrition in onco-
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haematological inpatients.
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Conflict of interest
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The authors have no competing financial interests in relation to the work described
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herein.
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FIRST ASSESSMENT
SECOND ASSESSMENT
Figure 1. ROC curve comparing MST and MUST to SGA at admission, and the first week and second week assessments.
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ADMISSION
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Table 1. Evolution of anthropometric data.
69.48 (SD 12.91)
First week assessment 64.46 (SD 11.81)*
Second week assessment 61.79 (SD 14.02)
26.13 (SD 3.81)
25.20 (SD 4.38)*
24.59 (SD 4.42)
Admission Weight (kg) 2
BMI (kg/m ) %WL
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5.96 (SD 7.01) 1.99 (SD 3.51) 0.97 (SD 4.42) BMI: Body mass index; %WL: Percentage of weight loss. * p < 0.05 for the difference with admission.
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assessment
assessment
42.9%
44.4%
31.6%
B
39.7%
38.9%
36.8%
C
17.5%
16.7%
31.6%
MST
Admission
0
38.1%
61.1%
1
20.6%
25.0%
≥2
41.3%
13.9%
15.8%
MUST
Admission
First week
Second week
0
39.7%
1
23.8%
≥2
36.5%
A
First week assessment
Second week assessment 57.9%
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First week
SGA
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26.3%
assessment
assessment
61.1%
52.6%
13.9%
10.5%
25.0%
36.8%
SGA: Subjective Global Assessment; MST: Malnutrition Screening Tool; MUST:
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Malnutrition Universal Screening Tool
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ACCEPTED MANUSCRIPT Table 3. Sensitivity and specificity of MST and MUST with respect to SGA. MST
MUST
Sensitivity
72.73 (41.86–100)
90.91 (69.37–100)
Specificity
65.38 (51.49–79.28)
75.00 (62.27–87.73)
PV+
30.77 (11.11–50.43)
43.48 (21.04–65.91)
PV-
91.89 (81.75–100)
97.50 (91.41–100)
LR+
2.10 (1.25–3.53)
LR-
0.42 (0.16–1.12)
3.64 (2.19–6.03)
0.12 (0.02–0.79)
0.691 (0.519–0.862)
FIRST ASSESSMENT
MST
0.830 (0.705–0.954) MUST
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ROC (AUC)
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Sensitivity
50.00 (1.66–98.34)
83.33 (45.18–100)
Specificity
93.33 (82.74–100)
86.67 (72.84–100)
PV+
60.00 (7.06–100)
55.56 (17.54–93.57)
PV-
90.32 (78.30–100)
96.30 (87.32–100)
LR+
7.50 (1.58–35.68)
6.25 (2.35–16.65)
LR-
0.54 (0.24–1.20)
0.19 (0.03–1.16)
0.717 (0.453–0.980)
0.850 (0.661–1.039)
MST
MUST
ROC (AUC)
Specificity PV+ PVLR+
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SECOND ASSESSMENT
ROC (AUC)
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16.67 (0–54.82)
83.33 (45.18–100)
84.62 (61.16–100)
84.62 (61.16–100)
33.33 (0–100)
71.43 (30.82–100)
68.75 (42.91–94.59)
91.67 (71.86–100)
1.08 (0.12–9.75)
5.42 (1.44–20.36)
0.98 (0.64–1.51)
0.20 (0.03–1.20)
0.506 (0.219–0.794)
0.840 (0.628–1.051)
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MST: Malnutrition Screening Tool; MUST: Malnutrition Universal Screening Tool;
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PV+: Positive Prognostic Value; PV-: Negative Prognostic Value; LR+: Positive
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Likelihood Ratio; LR-: Negative Likelihood Ratio; ROC: Receiver Operating
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Characteristic Curve; AUC: Area Under the Curve.
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ACCEPTED MANUSCRIPT References 1
Correia MA, Waitzberg DL. The impact of malnutrition on morbidity,
mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr 2003;22:235–239. 2
Alvarez-Hernandez J, Planas Vila M, León-Sanz M, García de Lorenzo A,
RI PT
Celava-Pérez S, García-Lorda P et al. Prevalence and costs of malnutrition in hospitalized patients; the PREDyCES study. Nutr Hosp 2012;27:1049–1059. 3
Naber T, Schemer T, de Bree A, Nusteling K, Eggink L, Kruimel W J et al.
Prevalence of malnutrition in nonsurgical hospitalized patients and its association with 4
SC
disease complications. Am J Clin Nutr 1997;66:1232–1239.
de Ulibarri Pérez JI, Picón MJ, García E, Mancha A. Detección precoz y control
5
M AN U
de la desnutrición hospitalaria. Nutr. Hosp 2002;17:139–146.
Planas M, Audivert S, Pérez Portabella C, Burgos R, Puigross C, Casanelles JM
et al. Nutritional status among adult patients admitted to university-affiliated hospital in Spain at the time of the genoma. Clin Nutr 2004;23:1016–1024. 6
Lim SL, Ong K CB, Chan YH, Loke WC, Ferguson M, Daniels L. Malnutrition
and its impact on cost of hospitalization, length of stay, readmission and 3 year 7
TE D
mortality. Clin Nutr 2012;31:345–350.
Calleja Fernández A, Vidal Casariego A, Cano Rodríguez I, Ballesteros Pomar
MD. Malnutrition in hospitalized patients receiving nutritionally complete menus: prevalence and outcomes. Nutr Hosp. 2014;30:1344–1349. White JV, Guenter P, Jensen G, Malone A, Schofield M; Academy of Nutrition
EP
8
and Dietetics Malnutrition Work Group; A.S.P.E.N. Malnutrition Task Force;
AC C
A.S.P.E.N. Board of Directors. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012;112:730–738. Erratum in: J Acad Nutr Diet. Nov 2012:112:1899. 9
Ferguson M, Capra S, Bauer J, Banks M. Development of a valid and reliable
malnutrition screening tool for adult acute hospital patients. Nutrition 1999;15:458–464. 10
Isenring E, Elia M. Which screening method is appropriate for older cancer
patients at risk for malnutrition? Nutrition 2015;31:594–597.
14
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Elia M, Chairman and Editor. Screening for malnutrition: A multidisciplinary
responsibility. Development and use of The “Malnutrition Universal Screening Tool” (“MUST”) for adults. Malnutrition Advisory Group (MAG),a Standing Committee of BAPEN. Redditch, Worcs: BAPEN 2003. 12
Elia M, Chairman and Editor. Guidelines for detection and management of
Committee of BAPEN. Maidenhead,Berks:BAPEN.2000. 13
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malnutrition in the community. Malnutrition Advisory Group (MAG), Standing
Stratton RJ, Hackston A, Longmore D, Dixon R, Price S, Stroud M, King C,
Elia M. Malnutrition in hospital outpatients and inpatients: prevalence, concurrent
SC
validity and ease of use of the ‘Malnutrition Universal Screening Tool’ (‘MUST’) for adults. Br J Nutr 2004;92:755–808.
Boléo-Tomé C(1), Monteiro-Grillo I, Camilo M, Ravasco P. Validation of the
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Malnutrition Universal Screening Tool (MUST) in cancer. Br J Nutr. 2012;108:343–8. 15
Calleja Fernández A, Vidal Casariego A, Cano Rodríguez I, Ballesteros Pomar
MD. Efficacy and effectiveness of different nutritional screening tools in a tertiary hospital. Nutr Hosp. 2015;31:2240–2246. 16
Velasco C, García E, Rodríguez V, Frías I, Garriga R, Álvarez J et al.
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Comparison of four nutritional screening tools to detect nutritional risk in hospitalized patients: a multicentre study. Eur J Clin Nutr 2011;65:269–274. 17
Da Silva Fink J, de Mello PD, de Mello ED. Subjective global assessment of
nutritional status. A systematic review of the literature. Clin Nutr 2015;34:785–792. www.bapen.org.uk/pdfs/must/must_full.pdf (Accessed May 4, 2016).
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Nelson KA, Walsh D, Sheehan FA. The cancer anorexia-cachexia syndrome. J
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Clin Oncol 1994;12:213–225.
Horsley P, Bauer J, Gallagher B. Poor nutritional status prior to peripheral
blood stem cell transplantation is associated with increased length of hospital stay. Bone Marrow Transplant 2005;35:1113–1116. 21
Calleja Fernández A, Pintor de la Maza B, Vidal Casariego A, Villar Taibo R,
López Gómez JJ, Cano Rodríguez I, Ballesteros Pomar MD. Food intake and nutritional status influence outcomes in hospitalized hematology-oncology patients. Nutr Hosp. 2015;31:2598–2605. 22
Shaw C, Fleuret C, Pickard JM, Mohammed K, Black G, Wedlake L.
Comparison of a novel, simple nutrition screening tool for adult oncology inpatients and
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Leunberger M, Kurmann S, Stanga Z. Nutritional screening tools in daily
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ACCEPTED MANUSCRIPT Highlights of the study
When comparing both screening tools, Malnutrition Universal Screening Tool had a higher specificity and sensitivity than Malnutrition Screening Tool.
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The values of sensitivity remained higher in Malnutrition Universal Screening Tool on the second assessment during hospitalization.
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Patients hospitalized worsened their nutritional status during hospitalization.
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S0899-9007(16)30216-7
DOI:
10.1016/j.nut.2016.09.009
Reference:
NUT 9846
To appear in:
Nutrition
Received Date: 23 June 2016 Revised Date:
22 August 2016
Accepted Date: 23 September 2016
Please cite this article as: Fiol-Martínez L, Calleja-Fernández A, Pintor de la Maza B, Vidal-Casariego A, Villar-Taibo R, Urioste-Fondo A, Cuervo M, Cano-Rodríguez I, Ballesteros-Pomar MD, Comparison of Two Nutritional Screening Tools to Detect Nutritional Risk in Haematological Inpatients, Nutrition (2016), doi: 10.1016/j.nut.2016.09.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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TITLE: COMPARISON OF TWO NUTRITIONAL SCREENING TOOLS TO DETECT
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NUTRITIONAL RISK IN HAEMATOLOGICAL INPATIENTS
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RUNNING
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HAEMATOLOGICAL PATIENTS
TITLE:
COMPARING
TWO
SCREENING
TOOLS
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Authors:
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Lucía Fiol-Martínez RD, Department of Nutrition. University of Navarra, Pamplona, Spain. [email protected]
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Alicia Calleja-Fernández RD PhD, Clinical Nutrition and Dietetics Unit, Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de León, León, Spain.
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[email protected]
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Begoña Pintor de la Maza RD, Clinical Nutrition and Dietetics Unit, Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de León, León, Spain.
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[email protected]
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Alfonso Vidal-Casariego MD PhD, Clinical Nutrition and Dietetics Unit, Department of
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Endocrinology and Nutrition, Complejo Asistencial Universitario de León, León, Spain.
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[email protected]
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Rocío Villar-Taibo MD PhD, Clinical Nutrition and Dietetics Unit, Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de León, León, Spain.
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[email protected]
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Ana Urioste-Fondo MD, Clinical Nutrition and Dietetics Unit, Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de León, León, Spain.
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[email protected]
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Marta Cuervo RD PhD, Department of Nutrition. University of Navarra, Pamplona, Spain. [email protected]
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Isidoro Cano-Rodríguez MD PhD, Clinical Nutrition and Dietetics Unit, Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de León, León, Spain. [email protected]
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María D. Ballesteros-Pomar MD PhD, Clinical Nutrition and Dietetics Unit,
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Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de
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León, León, Spain. [email protected]
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Role of authors •
Lucía Fiol-Martínez: Design of the study, acquisition of data, writing of the paper
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•
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Alicia Calleja-Fernández: Design of the study, acquisition of data, statistical analysis writing of the paper
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Begoña Pintor de la Maza: acquisition of data, writing of the paper
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Alfonso Vidal-Casariego: Critically review the paper
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Rocío Villar-Taibo: Critically review the paper
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Ana Urioste-Fondo: Critically review the paper
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Marta Cuervo-Zapatel: Design of the study, critically review the paper
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Isidoro Cano-Rodríguez: Critically review the paper
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María D. Ballesteros-Pomar : Design of the study, Critically review the paper
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Correspondence:
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Lucía Fiol-Martínez
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Avda. Alcalde Miguel Castaño, Nº 36 (bajo) C.P.:24005, León, SPAIN.
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Phone: +34 609 22 03 98
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Fax: +34 987 20 54 61
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Email: [email protected]
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Objective: The aim of the study was to compare two nutritional screening tools in onco-
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haematological inpatients.
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Methods: A cross-sectional study was performed in a haematology ward from August to
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December 2015. Within the first 24h of admission, the following nutritional screenings
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were performed: Malnutrition Universal Screening Tool (MUST), Malnutrition
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Screening Tool (MST) and Subjective Global Assessment (SGA). Patients who stayed
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in the haematological ward were reevaluated with the three screening tools one and two
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weeks after their admission. The SGA was used as the gold standard in the detection of
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malnutrition.
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Results: A total of 63 patients were included in the study – 61.9% men, aged 64.0 (SD
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17.9) years – with 90.5% having a diagnosis of cancer. The prevalence of patients with
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nutritional risk at admission was 17.5% with SGA, 16.7% at the first week, and 31.6%
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at the second week. According to MST, the prevalence was 41.3% at admission, 13.9%
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at the first week, and 15.8% at the second week. According to MUST, the prevalence
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was 36.5%, 25.0%, and 36.8%, respectively. The results of diagnostic tests on
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admission were an AUC ROC of 0.691 for MST and 0.830 for MUST at admission; at
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the first week, 0.717 for MST and 0.850 for MUST; and at the second week of
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assessment, 0.506 for MST and 0.840 for MUST.
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Conclusion: MUST might be a better screening tool compared to MST for detecting the
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risk of malnutrition in onco-haematological inpatients.
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Keywords: malnutrition, nutritional screening tool, haematologic neoplasm.
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Abbreviations: ASPEN: American Society of Parenteral and Enteral Nutrition;
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BAPEN: British Association of Parenteral and Enteral Nutrition; BMI: Body Mass
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Index; ESPEN: European Society for Clinical Nutrition and Metabolism; LOS: length
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of hospital stay; MST: Malnutrition Screening Tool; MUST: Malnutrition Universal
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Screening Tool
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ACCEPTED MANUSCRIPT Introduction
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Malnutrition is an inadequate nutritional status that is highly prevalent in hospitals, and
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it should be considered in order to provide complete treatment to inpatients. This
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deterioration of nutritional status has negative consequences in almost every organ or
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system of the human body. The increased incidence of pneumonia in malnourished
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patients might be explained by the impaired immune function and poor wound healing
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caused by the deterioration of the muscle function1. Malnutrition in the healthcare
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systems has a significant clinical and economic impact as it can translate into increased
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morbidity and also a long length of stay (LOS). In 2008, the PREDyCES® study was
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conducted in Spain and evaluated the presence of malnutrition in 31 Spanish hospitals,
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obtaining a prevalence of malnutrition that rose up to 23%2. The main causes of
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malnutrition are a decrease in energy intake during the hospital stay and an increase of
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energy requirements due to the illness that altogether can worsen the patient’s status.
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Therefore, several studies have shown that decreased food intake is associated with
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increased morbidity and mortality during a hospital stay3,4. Besides those complications,
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patients with a worse nutritional status are readmitted to the hospital more frequently
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once they are discharged, 15, 30, and 90 days and even six months after the first
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admission5,6,7. It is the health staff’s responsibility to evaluate food intake of inpatients
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in order to decrease the risk of malnutrition, minimise the LOS and costs, and obtain the
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best outcomes for patients.
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Among all of the hospital wards, cancer patients might present a higher risk of a poorer
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nutritional status. They frequently suffer from cachexia-anorexia syndrome, which
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reaches an incidence of 50% and grows to up to 80–90% in advanced phases of the
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disease. The prevalence of this syndrome depends not only on the stage of the disease
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but also on the tumour location as well, and might be responsible for 20–25% of the
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deaths of these patients. The mechanisms that cause malnutrition in cancer can be
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classified in four big groups: low energy and nutrient intake, alterations in the digestion
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and nutrient absorption, higher nutritional needs, and alterations in the metabolism of
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nutrients.
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The ESPEN and the ASPEN recommend an early and systematic screening for under-
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nutrition in all hospitalised patients8. Clinical tools should be used to detect this
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malnutrition in hospitalised patients in order to perform a nutritional diagnosis,
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minimise comorbidity and mortality and decrease the costs associated with it. A
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nutritional screening tool is defined as an evaluation tool that can quickly and easily
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evaluate one’s nutritional status. Its objective is to detect the individuals who present a
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poor nutritional condition or are at risk of suffering malnutrition..
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The aim of the study was to compare two nutritional screening tools, the Malnutrition
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Universal Screening Tool (MUST) and the Malnutrition Screening Tool (MST), to the
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Subjective Global Assessment (SGA), in a haematological hospital ward.
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Methodology
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A cross-sectional study was performed in the haematology ward of the Complejo
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Asistencial Universitario of León (Spain) from August to December 2015. The study
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was approved by the Ethics and Clinical Research Committee of the hospital, which
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confirmed that the study followed the Declaration of Helsinki. All patients were
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informed at bedside about the study and were asked to sign the written consent.
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Patients included were those older than 18 years of age, inpatients from the
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haematological area with a length of stay longer than 24h, patients that could be
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weighed and those that signed the informed consent.
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Two nutritional screening tools (MST and MUST) were performed for each patient and
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the results were compared with the gold standard for nutritional assessment (SGA). The
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MST was completed by the patients at admission. MUST and SGA were both
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performed by the dietitian.
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The Malnutrition Screening Tool (MST) includes two questions about the patients’
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intake and their weight9,10. Each of the questions had a score depending on the answer
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given by the patient. The total score allowed for classifying each patient according to
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their nutritional status: without risk of malnutrition (0 point); at risk of malnutrition (1
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point); malnourished (≥2 points).
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The Malnutrition Universal Screening Tool (MUST) consists of three items that allow
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for establishing the nutritional status of the patient under evaluation. These criteria are
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body mass index (BMI), percentage of weight loss in the last three months, and whether
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or not the acute illness of the patient is likely to impair an adequate intake over the next
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five days11,12,13,14. According to the data registered, the patient obtains a score and can
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be classified in the following groups: low risk (0 points), the patient has to be
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reevaluated weekly; intermediate risk (1 point), the patient has to be monitored; high
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risk (≥2 points), it is necessary to establish nutritional treatment.
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The Subjective Global Assessment (SGA) is a nutritional evaluation where several data
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are registered, such as habitual and actual weight of the patient, changes in the intake
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and physical activity, and a complete physical exam (fat loss, muscle loss and presence
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of oedema)15,16,17. SGA classifies patients in three groups: A: good nutritional status; B:
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at risk of suffering malnutrition; C: bad nutritional status.
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Several anthropometric measures were taken at bedside. All patients were asked about
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their usual weight in the three previous months before their admission in the
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haematological ward. They were weighed standing, wearing underwear and barefoot
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using a Seca 762® mechanical scale with a precision of 0.1 kg. Their height was
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estimated according to the method using ulna length, the use of which was validated by
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BAPEN18. The measurement was made with a flexible tape having a precision of 1 mm.
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Once cubital distance was measured and taking into account the sex and the age of the
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patient, the height was estimated according to the values of the BAPEN. The BMI was
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calculated following the formula: current weight (kg) / [height (m) x height (m)].
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Finally, the percentage of weight loss (%WL) was calculated after the patients were
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asked about their usual weight and were weighed during the nutritional assessment. The
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usual weight used for the formula was the reported weight upon admission. For the first
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and second week assessments, the used weight was the one from the week before.
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The statistical analysis was carried out using SPSS® 15.0 for Windows. A Kolmogorov-
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Smirnov test was performed to determine which data followed a normal distribution. All
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quantitative variables followed a normal distribution. They were summarised with the
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mean and the standard deviation and compared using a Student’s t-test. The qualitative
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variables were summarised and compared with the χ2 test.
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The diagnosis tests were performed for both MST and MUST, using SGA as the gold
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standard15,16,17, with the data collected at admission, and from the first and second week
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assessments. The sensitivity and specificity were analysed, as well as the area under the
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curve ROC, the positive and negative prognostic values, and the positive and negative
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likelihood ratios.
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Results
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Seventy-five patients were recruited, of whom two refused to participate. In all, 61.90%
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of the patients were men, aged 64.01 (SD 17.94) years. Of the sample, 60.30% were
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aged over 65 years old, their height was 162.83 (SD 9.72) cm, their usual weight was
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74.02 (SD 12.82) kg and their usual BMI was 27.69 (SD 3.62) kg/m2. A total of 90.50%
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had a cancer diagnosis and their length of hospital stay was eight (IQR 8.00) days.
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Nineteen patients were hospitalised for three weeks. The values of weight, %WL and
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BMI evolution are included in Table 1. Differences were only found regarding weight
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and BMI in the first week assessment vs. admission; but not between the second week
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assessment vs. admission. The results of the detection of malnutrition risk using the
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screening tools are summarised in Table 2. The results of sensitivity and specificity
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analysis at admission, and after the first and second weeks, are shown in Table 3. ROC
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curves were described and are included as well in Figure 1 (admission, first week and
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second week assessments).
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Discussion
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As previous studies have pointed out, the prevalence of malnutrition is important in
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hospitalisation. In this regard, screening tools are needed to detect malnutrition. The
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PREDyCES® study was performed in Spain and evaluated the presence of malnutrition
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in 31 Spanish hospitals, obtaining a prevalence of malnutrition that rose up to 23%2.
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Although the screening tool used in this multicentre study was the Nutritional Risk
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Screening 2002 (NRS-2002), Calleja et al. saw in their study that with the results they
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achieved, MUST was more indicated than was NRS-2002 or Mini Nutritional
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Assessment (MNA) for detecting the risk of malnutrition in hospitalised patients in our
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hospital15.
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It is acknowledged that cancer malignancies are associated with a higher prevalence of
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malnutrition, which is why nutritional surveillance might be essential throughout the
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hospital stay. The prevalence of malnutrition among oncology patients is 15–40%, and
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47.7% prevalence of malnutrition was found in this centre in a previous study, which is
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similar to the malnutrition rates found in the literature21. In addition, Shaw et al. found a
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rate of 71% of malnourished patients using SGA, which was higher than the results
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obtained by SGA in our study (17.5% at admission and 31.6% during the hospital
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stay)22. These variations might be explained by the differences in the type of cancer
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patients included in both studies.
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Among the wide set of used nutritional screening tools to detect malnutrition, MST is
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one of the best validated for oncology patients23. This nutritional screening tool is
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suitable for clinical practice and is easy to perform, both by caregivers and patients.
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Nowadays, MST is the screening tool in use in the haematological ward of our hospital.
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On the other hand, MUST seems to be an adequate and complete tool for detecting
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malnutrition in onco-haematological inpatients13,15. Previous studies, such as Shaw et
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al.’s, which obtained a sensitivity for the MST of 66%,22 have revealed that the MST
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has a poorer sensitivity when compared to other screening tools. Our results
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demonstrated that the MST, at admission, had a sensitivity of 72.73%, a value that is
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even lower at the first (50.00%) and second week (16.67%) assessments. The 19
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patients that were hospitalised at the time of the second week assessment might be
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sicker and, likely, they were not aware of their weight loss, which was the variable that
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would have determined the MST results. The sensitivity of the MST is lower than that
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obtained using the MUST at admission, and the differences became more consistent
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throughout the LOS. Furthermore, it has been proven that the sensitivity of MUST
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tended to be higher than that obtained for MST. Calleja et al. and Velasco et al., who
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also used SGA as the gold standard, showed in their studies that MUST had a sensitivity
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of 82.40% and 71.60%, respectively, which is lower than the results obtained in the
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current study (90.91% at admission and 83.33% at the first and second week
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assessments)15,16. This difference in sensitivity might be explained because the MST
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includes the weight loss that is self-reported by the patient, who can potentially
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underestimate the changes and fluctuations in their weight. Second, MUST patients are
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weighed by trained healthcare staff, diminishing the subjectivity of the test, which
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enables more reliable results.
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onco-haematological inpatients. The main limitation of the study was the small sample
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size, which is related to the recruitment time and might bias the results obtained.
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Although the MST is quick and easy to perform, as it is a self-reported tool completed
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by the patients at admission, it is also important to recognise that the MUST is much
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more complete and gives us very useful information about the nutritional status of the
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patients. MUST needs trained personnel and is more time consuming than is the MST,
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but the more accurate results are worth that effort.
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In conclusion, the MUST, which should be performed by trained staff, might be a better
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screening tool compared to the MST in order to detect the risk of malnutrition in onco-
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haematological inpatients.
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Conflict of interest
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The authors have no competing financial interests in relation to the work described
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herein.
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SECOND ASSESSMENT
Figure 1. ROC curve comparing MST and MUST to SGA at admission, and the first week and second week assessments.
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ADMISSION
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Table 1. Evolution of anthropometric data.
69.48 (SD 12.91)
First week assessment 64.46 (SD 11.81)*
Second week assessment 61.79 (SD 14.02)
26.13 (SD 3.81)
25.20 (SD 4.38)*
24.59 (SD 4.42)
Admission Weight (kg) 2
BMI (kg/m ) %WL
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5.96 (SD 7.01) 1.99 (SD 3.51) 0.97 (SD 4.42) BMI: Body mass index; %WL: Percentage of weight loss. * p < 0.05 for the difference with admission.
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assessment
assessment
42.9%
44.4%
31.6%
B
39.7%
38.9%
36.8%
C
17.5%
16.7%
31.6%
MST
Admission
0
38.1%
61.1%
1
20.6%
25.0%
≥2
41.3%
13.9%
15.8%
MUST
Admission
First week
Second week
0
39.7%
1
23.8%
≥2
36.5%
A
First week assessment
Second week assessment 57.9%
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SGA
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26.3%
assessment
assessment
61.1%
52.6%
13.9%
10.5%
25.0%
36.8%
SGA: Subjective Global Assessment; MST: Malnutrition Screening Tool; MUST:
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Malnutrition Universal Screening Tool
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MUST
Sensitivity
72.73 (41.86–100)
90.91 (69.37–100)
Specificity
65.38 (51.49–79.28)
75.00 (62.27–87.73)
PV+
30.77 (11.11–50.43)
43.48 (21.04–65.91)
PV-
91.89 (81.75–100)
97.50 (91.41–100)
LR+
2.10 (1.25–3.53)
LR-
0.42 (0.16–1.12)
3.64 (2.19–6.03)
0.12 (0.02–0.79)
0.691 (0.519–0.862)
FIRST ASSESSMENT
MST
0.830 (0.705–0.954) MUST
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ROC (AUC)
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Sensitivity
50.00 (1.66–98.34)
83.33 (45.18–100)
Specificity
93.33 (82.74–100)
86.67 (72.84–100)
PV+
60.00 (7.06–100)
55.56 (17.54–93.57)
PV-
90.32 (78.30–100)
96.30 (87.32–100)
LR+
7.50 (1.58–35.68)
6.25 (2.35–16.65)
LR-
0.54 (0.24–1.20)
0.19 (0.03–1.16)
0.717 (0.453–0.980)
0.850 (0.661–1.039)
MST
MUST
ROC (AUC)
Specificity PV+ PVLR+
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ROC (AUC)
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16.67 (0–54.82)
83.33 (45.18–100)
84.62 (61.16–100)
84.62 (61.16–100)
33.33 (0–100)
71.43 (30.82–100)
68.75 (42.91–94.59)
91.67 (71.86–100)
1.08 (0.12–9.75)
5.42 (1.44–20.36)
0.98 (0.64–1.51)
0.20 (0.03–1.20)
0.506 (0.219–0.794)
0.840 (0.628–1.051)
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MST: Malnutrition Screening Tool; MUST: Malnutrition Universal Screening Tool;
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PV+: Positive Prognostic Value; PV-: Negative Prognostic Value; LR+: Positive
282
Likelihood Ratio; LR-: Negative Likelihood Ratio; ROC: Receiver Operating
283
Characteristic Curve; AUC: Area Under the Curve.
13
ACCEPTED MANUSCRIPT References 1
Correia MA, Waitzberg DL. The impact of malnutrition on morbidity,
mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr 2003;22:235–239. 2
Alvarez-Hernandez J, Planas Vila M, León-Sanz M, García de Lorenzo A,
RI PT
Celava-Pérez S, García-Lorda P et al. Prevalence and costs of malnutrition in hospitalized patients; the PREDyCES study. Nutr Hosp 2012;27:1049–1059. 3
Naber T, Schemer T, de Bree A, Nusteling K, Eggink L, Kruimel W J et al.
Prevalence of malnutrition in nonsurgical hospitalized patients and its association with 4
SC
disease complications. Am J Clin Nutr 1997;66:1232–1239.
de Ulibarri Pérez JI, Picón MJ, García E, Mancha A. Detección precoz y control
5
M AN U
de la desnutrición hospitalaria. Nutr. Hosp 2002;17:139–146.
Planas M, Audivert S, Pérez Portabella C, Burgos R, Puigross C, Casanelles JM
et al. Nutritional status among adult patients admitted to university-affiliated hospital in Spain at the time of the genoma. Clin Nutr 2004;23:1016–1024. 6
Lim SL, Ong K CB, Chan YH, Loke WC, Ferguson M, Daniels L. Malnutrition
and its impact on cost of hospitalization, length of stay, readmission and 3 year 7
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mortality. Clin Nutr 2012;31:345–350.
Calleja Fernández A, Vidal Casariego A, Cano Rodríguez I, Ballesteros Pomar
MD. Malnutrition in hospitalized patients receiving nutritionally complete menus: prevalence and outcomes. Nutr Hosp. 2014;30:1344–1349. White JV, Guenter P, Jensen G, Malone A, Schofield M; Academy of Nutrition
EP
8
and Dietetics Malnutrition Work Group; A.S.P.E.N. Malnutrition Task Force;
AC C
A.S.P.E.N. Board of Directors. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012;112:730–738. Erratum in: J Acad Nutr Diet. Nov 2012:112:1899. 9
Ferguson M, Capra S, Bauer J, Banks M. Development of a valid and reliable
malnutrition screening tool for adult acute hospital patients. Nutrition 1999;15:458–464. 10
Isenring E, Elia M. Which screening method is appropriate for older cancer
patients at risk for malnutrition? Nutrition 2015;31:594–597.
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Elia M, Chairman and Editor. Screening for malnutrition: A multidisciplinary
responsibility. Development and use of The “Malnutrition Universal Screening Tool” (“MUST”) for adults. Malnutrition Advisory Group (MAG),a Standing Committee of BAPEN. Redditch, Worcs: BAPEN 2003. 12
Elia M, Chairman and Editor. Guidelines for detection and management of
Committee of BAPEN. Maidenhead,Berks:BAPEN.2000. 13
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malnutrition in the community. Malnutrition Advisory Group (MAG), Standing
Stratton RJ, Hackston A, Longmore D, Dixon R, Price S, Stroud M, King C,
Elia M. Malnutrition in hospital outpatients and inpatients: prevalence, concurrent
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validity and ease of use of the ‘Malnutrition Universal Screening Tool’ (‘MUST’) for adults. Br J Nutr 2004;92:755–808.
Boléo-Tomé C(1), Monteiro-Grillo I, Camilo M, Ravasco P. Validation of the
M AN U
14
Malnutrition Universal Screening Tool (MUST) in cancer. Br J Nutr. 2012;108:343–8. 15
Calleja Fernández A, Vidal Casariego A, Cano Rodríguez I, Ballesteros Pomar
MD. Efficacy and effectiveness of different nutritional screening tools in a tertiary hospital. Nutr Hosp. 2015;31:2240–2246. 16
Velasco C, García E, Rodríguez V, Frías I, Garriga R, Álvarez J et al.
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Comparison of four nutritional screening tools to detect nutritional risk in hospitalized patients: a multicentre study. Eur J Clin Nutr 2011;65:269–274. 17
Da Silva Fink J, de Mello PD, de Mello ED. Subjective global assessment of
nutritional status. A systematic review of the literature. Clin Nutr 2015;34:785–792. www.bapen.org.uk/pdfs/must/must_full.pdf (Accessed May 4, 2016).
19
Nelson KA, Walsh D, Sheehan FA. The cancer anorexia-cachexia syndrome. J
EP
18
20
AC C
Clin Oncol 1994;12:213–225.
Horsley P, Bauer J, Gallagher B. Poor nutritional status prior to peripheral
blood stem cell transplantation is associated with increased length of hospital stay. Bone Marrow Transplant 2005;35:1113–1116. 21
Calleja Fernández A, Pintor de la Maza B, Vidal Casariego A, Villar Taibo R,
López Gómez JJ, Cano Rodríguez I, Ballesteros Pomar MD. Food intake and nutritional status influence outcomes in hospitalized hematology-oncology patients. Nutr Hosp. 2015;31:2598–2605. 22
Shaw C, Fleuret C, Pickard JM, Mohammed K, Black G, Wedlake L.
Comparison of a novel, simple nutrition screening tool for adult oncology inpatients and
15
ACCEPTED MANUSCRIPT the Malnutrition Screening Tool (MST) against the patient-generated Subjective Global Assessment (PG-SGA). Support Care Cancer 2015:23:47–54. 23
Leunberger M, Kurmann S, Stanga Z. Nutritional screening tools in daily
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M AN U
SC
RI PT
clinical practice: the focus on cancer. Support Care Cancer 2010;18(Suppl 2):S17–S27.
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ACCEPTED MANUSCRIPT Highlights of the study
When comparing both screening tools, Malnutrition Universal Screening Tool had a higher specificity and sensitivity than Malnutrition Screening Tool.
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The values of sensitivity remained higher in Malnutrition Universal Screening Tool on the second assessment during hospitalization.
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Patients hospitalized worsened their nutritional status during hospitalization.
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