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The absence of volume overload (i.e., congestion) on the morning of day 4 was defined as the presence of no more than mild edema, no residual pleural effusion, and no residual ascites.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Javier Ena" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Javier" "apellidos" => "Ena" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256524000043" "doi" => "10.1016/j.rce.2023.12.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256524000043?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887424000067?idApp=WRCEE" "url" => "/22548874/0000022400000002/v1_202402111208/S2254887424000067/v1_202402111208/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2254887424000043" "issn" => "22548874" "doi" => "10.1016/j.rceng.2023.12.012" "estado" => "S300" "fechaPublicacion" => "2024-02-01" "aid" => "2163" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2024;224:96-104" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Polymorphisms of <span class="elsevierStyleItalic">CCR5</span>, <span class="elsevierStyleItalic">IL-6</span>, <span class="elsevierStyleItalic">IFN-γ</span> and <span class="elsevierStyleItalic">IL-10</span> genes in Cuban HIV/AIDS patients" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "96" "paginaFinal" => "104" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Polimorfismos de los genes <span class="elsevierStyleItalic">CCR5</span>, <span class="elsevierStyleItalic">IL-6</span>, <span class="elsevierStyleItalic">IFN-γ</span> e <span class="elsevierStyleItalic">IL-10</span> en pacientes cubanos con VIH/sida" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1900 "Ancho" => 2091 "Tamanyo" => 244569 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Distribution of HIV-1 plasma viral loads (log10) by the genotypes of the <span class="elsevierStyleItalic">ccr5</span> (a), <span class="elsevierStyleItalic">IL-6</span> (b), <span class="elsevierStyleItalic">IL-10</span> (c), and <span class="elsevierStyleItalic">IFN-γ</span> (d) genes in the HIV-1 seropositive group.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "D. Hernández Requejo, Y. de Armas, E. Iglesias, H.M. Díaz, R. Gravier, M.C. Godínez López, L. Fonte, M. Plascencia-Cruz, K. Pacheco-Quijano, J. Palomares, H.R. Pérez-Gómez, A. Plascencia-Hernández, E.J. Calderón" "autores" => array:13 [ 0 => array:2 [ "nombre" => "D." "apellidos" => "Hernández Requejo" ] 1 => array:2 [ "nombre" => "Y." "apellidos" => "de Armas" ] 2 => array:2 [ "nombre" => "E." "apellidos" => "Iglesias" ] 3 => array:2 [ "nombre" => "H.M." "apellidos" => "Díaz" ] 4 => array:2 [ "nombre" => "R." "apellidos" => "Gravier" ] 5 => array:2 [ "nombre" => "M.C." "apellidos" => "Godínez López" ] 6 => array:2 [ "nombre" => "L." "apellidos" => "Fonte" ] 7 => array:2 [ "nombre" => "M." "apellidos" => "Plascencia-Cruz" ] 8 => array:2 [ "nombre" => "K." "apellidos" => "Pacheco-Quijano" ] 9 => array:2 [ "nombre" => "J." "apellidos" => "Palomares" ] 10 => array:2 [ "nombre" => "H.R." "apellidos" => "Pérez-Gómez" ] 11 => array:2 [ "nombre" => "A." "apellidos" => "Plascencia-Hernández" ] 12 => array:2 [ "nombre" => "E.J." "apellidos" => "Calderón" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256524000092" "doi" => "10.1016/j.rce.2023.12.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256524000092?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887424000043?idApp=WRCEE" "url" => "/22548874/0000022400000002/v1_202402111208/S2254887424000043/v1_202402111208/en/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Impact of malnutrition on the quality of life in older patients with advanced heart failure: a cohort study" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "105" "paginaFinal" => "113" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.-M. Verdu-Rotellar, E. Calero, J. Duran, E. Navas, S. Alonso, N. Argemí, M. Casademunt, P. Furió, E. Casajuana, E. Vinyoles, M.A. Muñoz" "autores" => array:12 [ 0 => array:3 [ "nombre" => "J.-M." "apellidos" => "Verdu-Rotellar" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 1 => array:3 [ "nombre" => "E." "apellidos" => "Calero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Duran" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 3 => array:3 [ "nombre" => "E." "apellidos" => "Navas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "S." "apellidos" => "Alonso" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "N." "apellidos" => "Argemí" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "M." "apellidos" => "Casademunt" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 7 => array:3 [ "nombre" => "P." "apellidos" => "Furió" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 8 => array:3 [ "nombre" => "E." "apellidos" => "Casajuana" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 9 => array:3 [ "nombre" => "E." "apellidos" => "Vinyoles" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] 10 => array:4 [ "nombre" => "M.A." "apellidos" => "Muñoz" "email" => array:1 [ 0 => "mamunoz.bcn.ics@gencat.cat" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 11 => array:1 [ "colaborador" => "on behalf of HADES study" ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Gerencia Territorial de Barcelona (Primary Healthcare), Institut Català de la Salut, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departament de Ciències Experimentals i de la Salut, School of Medicine, Universitat Pompeu Fabra, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Bellvitge University Hospital, Institut Català de la Salut, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Clinica Sant Antoni (Institut Medic i de Rehabilitació), Barcelona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Departament de Medicina (School of Medicine, Universitat de Barcelona), Barcelona, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Impacto de la malnutrición en la calidad de vida de los pacientes ancianos con insuficiencia cardíaca avanzada" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1053 "Ancho" => 1675 "Tamanyo" => 74028 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Survival Curves assessing mortality depending on the nutritional status in patients with advanced heart failure.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0065" class="elsevierStylePara elsevierViewall">Heart failure (HF) represents the final stage of several heart diseases.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The incidence of HF dramatically increases with age, and due to the ageing population as well as advancements in survival, the prevalence of HF is increasing, associated with a significant burden on patients and healthcare costs and resources.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Advanced HF is frequently associated with muscle wasting, cardiac cachexia, and malnutrition due to poor nutrient intake and clinical circumstances related to the disease.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Malnutrition in the older population is the result of multifactorial health problems,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and it is particularly frequent in patients with HF.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> It has been reported that poor nutritional status in such populations is associated with worse health outcomes.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In addition to biological and clinical parameters, the use of patient reported outcome measures (PROMs) is increasingly recognised as an important way to assess the health status of a patient. PROMs are measurement tools whereby patients provide information on aspects of their health status, including symptoms, quality of life, functionality, physical, and mental health.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Amongst the several scales employed to determine malnutrition in HF patients,<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9–11</span></a> the Mini Nutritional Assessment Short Form (MNA-SF) has been shown to be a reliable and easy tool to detect abnormal nutritional status<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> and is a strong predictor of HF mortality.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Despite having several tools to assess nutritional status in HF, information regarding a holistic approach based on patient self-reported health status and behaviour towards their disease is scarce, particularly at advanced stages. Therefore, the aim of this study was to assess the impact of nutritional status on the quality of life, self-care abilities and activities of daily living in the older patients with advanced heart failure</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design and patients</span><p id="par0080" class="elsevierStylePara elsevierViewall">The HADES study (heart failure at advanced stages) is a prospective, multi-centre cohort study. It included HF patients ≥40 years with New York Heart Association IV (NYHA) functional status, or those who required hospitalisation at least twice in the previous six months. For the purpose of this study we focused on patients aged ≥65 years to make the sample more homogeneous and avoid biases related to age. All patients were clinically stable at the time of inclusion.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Patients were selected from primary care electronic medical records and hospital discharge reports. A total of 22 primary healthcare centres, three university hospitals, one acute-care hospital, and one geriatric rehabilitation unit in Barcelona (Spain) participated in the study between June 2017 and December 2019.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The study protocol was approved by the Ethics Committee of the IDIAP Jordi Gol Primary Healthcare Research Institute, (Reference P17/086).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Clinical and PROM assessments</span><p id="par0095" class="elsevierStylePara elsevierViewall">Since many patients could not come to the primary healthcare centre, 27 nurses from the research team went to the patient’s home to perform the questionnaires and clinical examinations. A sample of patients was assessed in an intermediate care unit where they were recovering after hospital discharge.</p><p id="par0100" class="elsevierStylePara elsevierViewall">To initially evaluate nutritional status and screen for malnutrition, the MNA-SF seven-item questionnaire was administered by the nurses. The MNA-SF has shown good sensitivity and specificity to detect malnutrition and those at risk of malnutrition among community-dwelling older adults.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> When the screening scores were lower than eleven points (which is considered the threshold for a risk of malnutrition), a set of additional items were used to classify patients into two categories: risk or established malnutrition.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Quality of life was assessed using the EQ-5D-3L instrument, with patient outcomes obtained from personal interviews conducted by the nurses. This instrument provides a simple descriptive profile and a single summary index value for health status. The instrument explores mobility, self-care, performing usual activities, pain or discomfort and the presence of anxiety or depression in patients. A visual analogue score (VAS) is also included, providing a numerical index between 0 (the worse) and 100 (the best health the patient can imagine).<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Self-care behaviour was assessed with the European Heart Failure Self-care Behaviour Scale.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and the Barthel Index was used to determine the impact on activities of daily living.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Both these PROMs were scored from 0 (the worse) to 100 (the best).</p><p id="par0110" class="elsevierStylePara elsevierViewall">Although BMI was evaluated as part of the MNA-SF, it was further included in the multivariate models to determine its independent association with increased malnutrition risk.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Clinical variables were gathered from medical records and clinical examination, echocardiography, and laboratory tests, including haemoglobin, renal function, ions and cardiac biomarkers.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analysis</span><p id="par0120" class="elsevierStylePara elsevierViewall">Descriptive statistics were used to summarise the demographic and clinical data, with continuous variables presented as mean and standard deviation (SD) or medians and interquartile range (IQR), and the categorical variables as frequencies and percentages.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Independent t- and nonparametric tests were used to compare medians across groups for normally and non-normally distributed variables, respectively. The chi-square test was used to compare proportions between groups.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Given that the descriptive analysis was carried out with respect to a variable with more than two categories (non-risk, risk and malnutrition), analysis of variance (ANOVA) was done for continuous variables that follow a normal distribution, while for continuous variables that do not follow a normal one, the Kruskal-Wallis test was used. In the case of categorical variables, the chi-square test is performed.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Time-to-event data are presented graphically using Kaplan-Meier curves to analyse the effect of malnutrition on mortality, and Log-rank tests were used to compare survival between groups. Variables associated with the probability of presenting malnutrition risk in the bivariate analysis (p < 0.01) were included in a logistic regression model following a stepwise procedure. Statistical analysis was conducted using R Software for Windows version 3.6.1, Vienna, Austria.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0140" class="elsevierStylePara elsevierViewall">Of the 271 participants initially included in the study, 265 were older than 64 years, and the MNA-SF was administered to 260 (98.05%) of these patients.</p><p id="par0145" class="elsevierStylePara elsevierViewall">Among participants >64 years, 158 (60.8%) were women and the mean age was 84.8 (SD 7.5) years. Patients ≥75 years represented 89.2%. Median follow-up was 14.9 months (IQR 25–75; 4.9–26.9). Using the MNA-SF, 126 (48.5%) patients were identified as being at risk of malnutrition and 33 (12.7%) patients as having confirmed malnutrition.</p><p id="par0150" class="elsevierStylePara elsevierViewall">During follow-up, 133 (51.2%) patients died. Mortality was 78.8% among 26 patients with confirmed malnutrition.</p><p id="par0155" class="elsevierStylePara elsevierViewall">Declining nutritional status (i.e. normal nutritional status vs. at risk malnutrition vs. confirmed malnutrition) was associated with increasing older age (mean [SD]: 83.5 [7.4] vs. 85.0 [7.4] vs. 88.0 [7.4]), lower BMI (29.1 [5.5] vs. 27.6 [5.4] vs. 25.3 [5.0]), lower haemoglobin levels (11.7 [1.6] vs. 11.4 [1.8] vs. 10.6 [1.4]), a higher dependency for daily activities (Barthel index scores: 69.8 [18.6] vs. 59.7 [25.0] vs. 31.4 [21.3]), worse perceived quality of life (EQ-5D-5L scores: 57.0 [16.4] vs. 52.0 [16.8] vs. 40.9 [19.9]) and worse self-care (European Heart Failure Self-care Behaviour scores: 24.6 [6.7] vs. 26.3 [7.1] vs. 31.2 [9.5]). Neither comorbidity nor medications used to manage HF were associated with malnutrition risk or mortality (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">Better Barthel index and quality of life scores were inversely related to the risk of malnutrition, [Odds Ratio (OR) 0.97 (95% Confidence interval 0.96; 0.98) and OR 0.98 (95% Confidence interval, 0.96; 0.99)], respectively. Higher scores in the European Heart Failure Self-care Behaviour Scale, which implies worse self care, were related to higher malnutrition risk, OR 1.05 (95% Confidence interval, 1.02; 1.09).</p><p id="par0165" class="elsevierStylePara elsevierViewall">Regarding quality of life, HF patients with malnutrition reported worse outcomes related to mobility, personal care, usual activities and anxiety or depression compared to HF patients with normal nutritional status (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Similarly, patients with malnutrition reported worse scores for most items of self-care behaviour (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">The Kaplan Meier curve analysis showed that the malnutrition group had a significantly higher risk of mortality (p ≤ 0.001) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">The adjusted multivariate model found that lower BMI and haemoglobin levels, and worse scores in quality of life and daily living activities, were predictive of malnutrition (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0180" class="elsevierStylePara elsevierViewall">In our cohort we found that malnutrition in patients with advanced HF was significantly associated with low haemoglobin levels, poor self-reported quality of life, adverse impacts on daily activities and self-care, and increased mortality. When combining both malnutrition risk and established malnutrition in our cohort, we observed that the prevalence was similar to previous studies from a recent systematic review describing the prevalence of malnutrition in patients with HF, which resulted in 46%.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">In an old, and chronically ill population with an important comorbidity, as the analysed in our study, the relationship among all the factors contributing to the fragility and prognosis is complex. Various factors may contribute to malnutrition, including loss of appetite, polypharmacy, and frailty and, in particular, the presence of chronic diseases.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Age, time elapsed since the diagnosis of heart failure, previous hospitalizations, social and family support, as well as other clinical and social characteristics may also influence the nutritional status, and contribute to the worsening in quality of life.</p><p id="par0190" class="elsevierStylePara elsevierViewall">A number of patients in our cohort had concomitant comorbidities such as cancer, depression, renal insufficiency, and chronic obstructive pulmonary disease, all of which could affect nutritional status and influence prognosis.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20–23</span></a> However, we did not find that any of these comorbidities were significantly associated with malnutrition. As reported in other studies, we found lower levels of haemoglobin in patients with malnutrition.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> However, a diagnosis of anaemia, which is defined by a cut-off of <12 or <13 gr/dL in women and men, respectively, was not associated with malnutrition in our patients, probably due to the low baseline levels in the whole cohort. It has been reported that more than half of older patients with HF have a haemoglobin level lower than 12 g/dL and, that among them, 79.1% were in NYHA class IV.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">In older population, anemia is caused by nutritional deficiencies chronic inflammation, chronic kidney diesases, or unexplained anemia in approximately one third each.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> In patients with HF the pathogenesis of anemia is multifactorial, playing a role the associated inflammation, renin-angiotensin sytem and hemodilution.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> A study by Opasich et al. found a specific cause of anemia in only 43% of patients with stable HF.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">It has also been described that some medications may negatively affect nutritional status by modifying the sensory perception of taste or the intestinal absorption, particularly in the older adults.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> In addition, side effects such as nausea and vomiting, diarrhoea, loss of appetite and fatigue can also influence nutritional intake. However, in our cohort we did not find a relationship with any of the medications listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and nutritional status, probably because these medications are well tolerated.</p><p id="par0205" class="elsevierStylePara elsevierViewall">The association between BMI and nutrition and cardiac cachexia remains unclear. In HF patients it is possible to find reduced muscle mass together with a normal BMI due to the presence of oedema or the accumulation of fat-free mass.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> It has been reported that up to 50% of HF patients classified as obese, were malnourished or at risk of malnutrition.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> Since it is well established that low BMI is related to worse prognosis in older and heart failure patients, it has been argued that a modification in cut off points of BMI should be applied in this population.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32,33</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Poor nutritional status has been associated with adverse impacts on quality of life in older patients with chronic diseases.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> In a recent study, patients with HF with insufficient calorie intake had worse quality of life and a greater risk of hospital readmission compared to HF patients with sufficient calorie intake.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Self-care is crucial in the management of HF, and includes treatment adherence, lifestyle changes, symptom monitoring and adequate attitude and response to deterioration indicators. Recent recommendations from the Heart Failure Association of the European Society of Cardiology highlighted the importance of self-care in the management of HF, including maintaining optimal nutritional status. It is necessary to consider weight reduction when BMI is higher than 35 kg/m<span class="elsevierStyleSup">2</span>, to seek for medical care when unintentional weight lost appears, and limit the intake of salt and alcohol.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">In our population, we found that malnutrition was associated with worse self-care. A study carried out in a geriatric rehabilitation ward in a hospital reported that older patients at risk for undernutrition had lower self-care ability, probably due to a lower capacity to use cognitive, affective, and behavioural strategies.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Functional dependency (i.e. requiring assistance for activities of daily living) is closely related to a deficient nutritional status.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> A reciprocal relationship between malnutrition and disability in the older population has been described whereby malnutrition can exacerbate disability and disability can exacerbate malnutrition. Aging, the presence of chronic diseases, and polypharmacy are associated with both functional dependency and poor nutritional status.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> A reduction in protein intake, as a consequence of poor nutritional status, has also been shown to result in reduced muscle mass and declining mobility, leading to reduced independence in activities of daily living.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Strengths and limitations</span><p id="par0230" class="elsevierStylePara elsevierViewall">This is the first study, to our knowledge, linking self-care with the risk of malnutrition in patients with advanced heart failure. However, the study also has some limitations. Since our study is focused on advanced HF status, the sample size may not be enough to provide a robust external validation. Nevertheless, it is one of a few studies to analyse the association between nutritional status and patient reported outcome measures.</p><p id="par0235" class="elsevierStylePara elsevierViewall">It would have been relevant to collect data regarding dysphagia, oropharyngeal disorders, and the administration of nutritional supplements, which may have contributed to the malnutrition, but unfortunately, we do not have access to this information.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusions</span><p id="par0240" class="elsevierStylePara elsevierViewall">In community-dwelling older patients with advanced HF, malnutrition was associated with worse patient reported outcome measures related to poor quality of life, and adverse impacts on self-care and daily activities. Poor nutritional status was also associated with higher rates of mortality. Nutritional status must be systematically addressed by primary care nurses and family doctors to improve survival rates in these patients. It would be helpful the incorporation of expert professionals in nutrition in the primary health care centres.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interest</span><p id="par0245" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres2088674" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1781143" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2088673" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1781142" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study design and patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Clinical and PROM assessments" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Strengths and limitations" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interest" ] 11 => array:2 [ "identificador" => "xack727641" "titulo" => "Acknowledgements and funding" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1781143" "palabras" => array:4 [ 0 => "Older patients" 1 => "Advanced heart failure" 2 => "Malnutrition" 3 => "Patient-reported outcomes." ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1781142" "palabras" => array:4 [ 0 => "Ancianos" 1 => "Insuficiencia cardíaca avanzada" 2 => "Malnutrición" 3 => "Resultados reportados por los pacientes" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The aim of this study was to assess the prevalence of malnutrition, the clinical characteristics associated with malnutrition and the impact of nutritional status on mortality, quality of life, self-care abilities, and activities of daily living in the older patients with advanced heart failure.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A prospective multicentre cohort study including 260 community-dwelling elderly patients with advanced HF was conducted between June 2017 and December 2019.</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">The study was carried out in 22 primary healthcare centres, three university hospitals, one acute-care hospital, and one geriatric rehabilitation unit in the city of Barcelona (Spain). Nutritional status was assessed at baseline using the Mini Nutritional Assessment questionnaire. Patient-reported outcome measures included quality of life (EQ-5D-3L), self-care behaviour (European Heart Failure Self-care Behaviour Scale) and impact on activities of daily living (Barthel Index).</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Using the MNA-SF, 126 (48.5%) patients were identified as being at risk of malnutrition and 33 (12.7%) patients as having confirmed malnutrition. Compared to HF patients with normal nutritional status, patients with confirmed malnutrition were significantly older, with a lower BMI, and with reduced haemoglobin levels. During follow-up (median 14.9 months, Interquartile Range; 4.9–26.9), 133 (51.2%) of the included participants died, and mortality was significantly higher among patients identified as having malnutrition (p < 0.001).</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Better Barthel index and quality of life scores were inversely related to the risk of malnutrition, [Odds Ratio (OR) 0.97 (95% Confidence interval 0.96; 0.98) and OR 0.98 (95% Confidence interval, 0.96; 0.99)], respectively. Higher scores in the European Heart Failure Self-care Behaviour Scale, which implies worse self care, were related to higher malnutri