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LETTERS TO THE EDITOR
the study, which was to determine whether low arginine values are associated with the onset of PUs. Earlier studies have demonstrated that comorbidity is a risk factor for the onset of PUs8 and that neurological pathologies and cancer are the comorbidities most associated with PUs in older adults.9 Neither comorbidities, reason for admission, nor time elapsed between admission and the onset of PUs was assessed in Yatabe and colleagues’ article.1 The reason for admission could explain the significant difference in average hospitalization time in individuals with and without PUs, with individuals with PUs spending almost three times as long in the hospital, on average. It is therefore important to know how many days after admission it was that subjects developed PUs, for two main reasons: first, because individuals who remain longer in the hospital tend to have more-serious clinical problems and therefore a higher risk of developing PUs, and second, because assessments on admission lose validity over a prolonged period in hospital. A recent meta-analysis has shown that a Braden score of 15 or less has a sensitivity of 0.33, a specificity of 0.91, and a positive likelihood ratio of 3.67, which indicates that individuals with a Braden score of 15 or less are 3.2 to 5.5 times as likely to develop PUs as those with a score greater than 15.10 The SGA and MNA-SF were administered to all participants. It would have been interesting to compare the two scales so as to determine the importance of nutrition assessment in predicting the development of PUs. The nutritional subscore of the Braden Scale loses significance as a nutritional marker because the Braden Scale was administered only to subjects with SGA indicative of malnutrition. We agree with the authors that nutritional status is one of the most important factors in the pathophysiology of PUs and that arginine supplementation can improve healing of the ulcers. In spite of this, the results presented in this article do not allow conclusions to be drawn as to whether the MNA-SF is a more-potent tool than the Braden Scale in predicitng the risk of developing PUs. There is a need for more research that correctly assesses nutritional status and that estimates the risk of developing PUs using validated scales, as well as for knowledge of the real effect of malnutrition on the risk of onset of PUs. Vincenzo Malafarina, MD, MSc Francisco Uriz-Otano, MD, MSc Department of Geriatric Rehabilitation, Hospital San Juan de Dios, Pamplona, Spain Claudia Fern andez-Catal an Dolores Tejedo-Flors Facultad de Medicina, Universidad de Navarra, Pamplona, Spain
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper.
JUNE 2014–VOL. 62, NO. 6
JAGS
Author Contributions: Malafarina: study concept and design, analysis and interpretation of data, preparation of manuscript. Uriz-Otano, Fern andez-Catal an, Tejedo-Flors: analysis and interpretation of data, preparation of manuscript. All authors approved the final version of the manuscript. Sponsor’s Role: None.
REFERENCES 1. Yatabe MS, Taguchi F, Ishida I et al. Mini Nutritional Assessment as a useful method of predicting the development of pressure ulcers in elderly inpatients. J Am Geriatr Soc 2013;61:1698–1704. 2. Detsky AS, McLaughlin JR, Baker JP et al. What is subjective global assessment of nutritional-status. JPEN J Parenter Enteral Nutr 1987;11:8– 13. 3. Vellas B, Guigoz Y, Garry PJ et al. The Mini Nutritional Assessment (MNA) and its use in grading the nutritional state of elderly patients. Nutrition 1999;15:116–122. 4. Vellas B, Villars H, Abellan G et al. Overview of the MNA—Its history and challenges. J Nutr Health Aging 2006;10:456–463; discussion 463–465. 5. Rubenstein LZ, Harker JO, Salva A et al. Screening for undernutrition in geriatric practice: Developing the Short Form Mini-Nutritional Assessment (MNA-SF). J Gerontol A Biol Sci Med Sci 2001;56A:M366–M372. 6. Bale S, Finlay I, Harding KG. Pressure sore prevention in a hospice. J Wound Care 1995;4:465–468. 7. Chou R, Dana T, Bougatsos C et al. Pressure ulcer risk assessment and prevention: Comparative effectiveness. Comparative effectiveness review no. 87. (Prepared by Oregon Evidence-Based Practice Center under contract no. 290–2007–10057-I.) AHRQ publication no. 12(13)-EHC148-EF [on-line]. Rockville, MD: Agency for Healthcare Research and Quality. Available at http://effectivehealthcare.ahrq.gov/ehc/products/309/1490/ pressureulcer-prevention-executive-130508.pdf Accessed May 8, 2013. 8. Hengstermann S, Fischer A, Steinhagen-Thiessen E et al. Nutrition status and pressure ulcer: What we need for nutrition screening. JPEN J Parenter Enteral Nutr 2007;31:288–294. 9. Brito PA, de Vasconcelos Generoso S, Correia MI. Prevalence of pressure ulcers in hospitals in Brazil and association with nutritional status—A multicenter, cross-sectional study. Nutrition 2013;29:646–649. 10. Garcia-Fernandez FP, Pancorbo-Hidalgo PL, Agreda JJ. Predictive capacity of risk assessment scales and clinical judgment for pressure ulcers: A meta-analysis. J Wound Ostomy Continence Nurs 2014;41:24–34.
RESPONSE TO MALAFARINA AND COLLEAGUES To the Editor: We appreciate the interest and comments by Malafarina and colleagues1 on our paper.2 First, it is widely accepted that the term “MNA” currently refers to the Mini Nutritional Assessment Short Form (MNA-SF) and that the “full MNA” refers to the original 18-item MNA. We did not differentiate the “full MNA” when we referred to its development because of space limitations. Second, an important limitation of the study was that not all subjects were assessed for Braden Scale and amino acid concentrations. This was clearly stated in the discussion. We are aware that it is not possible to compare the MNA and the Braden Scale directly because of this limitation, and that is why we describe the risk group as those with “a [Subjective Global Assessment] SGA rating of moderately or severely malnourished combined with a Braden Scale score of less than 15.” Third, the number in Table 4, 27 patients with pressure ulcers (PUs) of those assessed for the Braden Scale, is correct. Seventeen patients who scored less than 15 on the Braden Scale developed PUs, and 10
JAGS
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patients who scored 15 or above on the Braden Scale also developed PUs, making the total 27. This was described in the Results section. Fourth, we did not analyze comorbidity, the reason for admission, or the time between admission and the onset of PUs. These factors influence the likelihood of PU development, but our main interest was the relationship between different scores and PU development, so we used various scoring methods regardless of those factors. Fifth, Malafarina and colleagues suggested comparing the SGA with the MNA. The sensitivity and specificity of the SGA can be calculated using the results we have provided. The SGA rating of moderate or high risk has a sensitivity of 0.90 and specificity of 0.46. Therefore, a MNA score of less than 8 was more sensitive (0.97) but less specific (0.42) than the SGA in our subjects. Our study was limited mainly because of financial and manpower constraints, but we described our methods and results as accurately as possible so that the readers will be able to judge the relevance and usefulness of our data. We believe that, although it is not an ideal protocol, the results provide important addition to the present knowledge. We very much agree with Malafarina and colleagues on the importance of nutrition and look forward to results of future studies examining the role of nutrition in PU formation. Midori S. Yatabe, MD, PhD Fumie Taguchi, BS, RD Izumi Ishida, RD Atsuko Sato, LPN Toshio Kameda, MD, PhD Shuichi Ueno, MD, PhD
LETTERS TO THE EDITOR
1211
Kozue Takano, BN Tsuyoshi Watanabe, MD, PhD Hironobu Sanada, MD, PhD Junichi Yatabe, MD, PhD Department of Pharmacology, Fukushima Medical University, Fukushima, Japan
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Midori S. Yatabe: study design. Junichi Yatabe, Fumie Taguchi, Izumi Ishida, Atsuko Sato: data collection. Toshio Kameda: nutritional consultation. Shuichi Ueno: provided authorization for study, acquisition of subjects. Kozue Takano: built patient data registry. Tsuyoshi Watanabe, Hironobu Sanada: provided advice for study. Junichi Yatabe, Midori S. Yatabe: analysis and interpretation of data, preparation of manuscript. Sponsor’s Role: None.
REFERENCES 1. Malafarina V, Uriz-Otano F, Fernandez-Catalan C et al. Nutritional status and pressure ulcers. Risk assessment and estimation in older adults. J Am Geriatr Soc 2014;62:1209–1210. 2. Yatabe MS, Taguchi F, Ishida I et al. Mini Nutritional Assessment as a useful method of predicting the development of pressure ulcers in elderly inpatients. J Am Geriatr Soc 2013;61:1698–1704.
LETTERS TO THE EDITOR
the study, which was to determine whether low arginine values are associated with the onset of PUs. Earlier studies have demonstrated that comorbidity is a risk factor for the onset of PUs8 and that neurological pathologies and cancer are the comorbidities most associated with PUs in older adults.9 Neither comorbidities, reason for admission, nor time elapsed between admission and the onset of PUs was assessed in Yatabe and colleagues’ article.1 The reason for admission could explain the significant difference in average hospitalization time in individuals with and without PUs, with individuals with PUs spending almost three times as long in the hospital, on average. It is therefore important to know how many days after admission it was that subjects developed PUs, for two main reasons: first, because individuals who remain longer in the hospital tend to have more-serious clinical problems and therefore a higher risk of developing PUs, and second, because assessments on admission lose validity over a prolonged period in hospital. A recent meta-analysis has shown that a Braden score of 15 or less has a sensitivity of 0.33, a specificity of 0.91, and a positive likelihood ratio of 3.67, which indicates that individuals with a Braden score of 15 or less are 3.2 to 5.5 times as likely to develop PUs as those with a score greater than 15.10 The SGA and MNA-SF were administered to all participants. It would have been interesting to compare the two scales so as to determine the importance of nutrition assessment in predicting the development of PUs. The nutritional subscore of the Braden Scale loses significance as a nutritional marker because the Braden Scale was administered only to subjects with SGA indicative of malnutrition. We agree with the authors that nutritional status is one of the most important factors in the pathophysiology of PUs and that arginine supplementation can improve healing of the ulcers. In spite of this, the results presented in this article do not allow conclusions to be drawn as to whether the MNA-SF is a more-potent tool than the Braden Scale in predicitng the risk of developing PUs. There is a need for more research that correctly assesses nutritional status and that estimates the risk of developing PUs using validated scales, as well as for knowledge of the real effect of malnutrition on the risk of onset of PUs. Vincenzo Malafarina, MD, MSc Francisco Uriz-Otano, MD, MSc Department of Geriatric Rehabilitation, Hospital San Juan de Dios, Pamplona, Spain Claudia Fern andez-Catal an Dolores Tejedo-Flors Facultad de Medicina, Universidad de Navarra, Pamplona, Spain
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper.
JUNE 2014–VOL. 62, NO. 6
JAGS
Author Contributions: Malafarina: study concept and design, analysis and interpretation of data, preparation of manuscript. Uriz-Otano, Fern andez-Catal an, Tejedo-Flors: analysis and interpretation of data, preparation of manuscript. All authors approved the final version of the manuscript. Sponsor’s Role: None.
REFERENCES 1. Yatabe MS, Taguchi F, Ishida I et al. Mini Nutritional Assessment as a useful method of predicting the development of pressure ulcers in elderly inpatients. J Am Geriatr Soc 2013;61:1698–1704. 2. Detsky AS, McLaughlin JR, Baker JP et al. What is subjective global assessment of nutritional-status. JPEN J Parenter Enteral Nutr 1987;11:8– 13. 3. Vellas B, Guigoz Y, Garry PJ et al. The Mini Nutritional Assessment (MNA) and its use in grading the nutritional state of elderly patients. Nutrition 1999;15:116–122. 4. Vellas B, Villars H, Abellan G et al. Overview of the MNA—Its history and challenges. J Nutr Health Aging 2006;10:456–463; discussion 463–465. 5. Rubenstein LZ, Harker JO, Salva A et al. Screening for undernutrition in geriatric practice: Developing the Short Form Mini-Nutritional Assessment (MNA-SF). J Gerontol A Biol Sci Med Sci 2001;56A:M366–M372. 6. Bale S, Finlay I, Harding KG. Pressure sore prevention in a hospice. J Wound Care 1995;4:465–468. 7. Chou R, Dana T, Bougatsos C et al. Pressure ulcer risk assessment and prevention: Comparative effectiveness. Comparative effectiveness review no. 87. (Prepared by Oregon Evidence-Based Practice Center under contract no. 290–2007–10057-I.) AHRQ publication no. 12(13)-EHC148-EF [on-line]. Rockville, MD: Agency for Healthcare Research and Quality. Available at http://effectivehealthcare.ahrq.gov/ehc/products/309/1490/ pressureulcer-prevention-executive-130508.pdf Accessed May 8, 2013. 8. Hengstermann S, Fischer A, Steinhagen-Thiessen E et al. Nutrition status and pressure ulcer: What we need for nutrition screening. JPEN J Parenter Enteral Nutr 2007;31:288–294. 9. Brito PA, de Vasconcelos Generoso S, Correia MI. Prevalence of pressure ulcers in hospitals in Brazil and association with nutritional status—A multicenter, cross-sectional study. Nutrition 2013;29:646–649. 10. Garcia-Fernandez FP, Pancorbo-Hidalgo PL, Agreda JJ. Predictive capacity of risk assessment scales and clinical judgment for pressure ulcers: A meta-analysis. J Wound Ostomy Continence Nurs 2014;41:24–34.
RESPONSE TO MALAFARINA AND COLLEAGUES To the Editor: We appreciate the interest and comments by Malafarina and colleagues1 on our paper.2 First, it is widely accepted that the term “MNA” currently refers to the Mini Nutritional Assessment Short Form (MNA-SF) and that the “full MNA” refers to the original 18-item MNA. We did not differentiate the “full MNA” when we referred to its development because of space limitations. Second, an important limitation of the study was that not all subjects were assessed for Braden Scale and amino acid concentrations. This was clearly stated in the discussion. We are aware that it is not possible to compare the MNA and the Braden Scale directly because of this limitation, and that is why we describe the risk group as those with “a [Subjective Global Assessment] SGA rating of moderately or severely malnourished combined with a Braden Scale score of less than 15.” Third, the number in Table 4, 27 patients with pressure ulcers (PUs) of those assessed for the Braden Scale, is correct. Seventeen patients who scored less than 15 on the Braden Scale developed PUs, and 10
JAGS
JUNE 2014–VOL. 62, NO. 6
patients who scored 15 or above on the Braden Scale also developed PUs, making the total 27. This was described in the Results section. Fourth, we did not analyze comorbidity, the reason for admission, or the time between admission and the onset of PUs. These factors influence the likelihood of PU development, but our main interest was the relationship between different scores and PU development, so we used various scoring methods regardless of those factors. Fifth, Malafarina and colleagues suggested comparing the SGA with the MNA. The sensitivity and specificity of the SGA can be calculated using the results we have provided. The SGA rating of moderate or high risk has a sensitivity of 0.90 and specificity of 0.46. Therefore, a MNA score of less than 8 was more sensitive (0.97) but less specific (0.42) than the SGA in our subjects. Our study was limited mainly because of financial and manpower constraints, but we described our methods and results as accurately as possible so that the readers will be able to judge the relevance and usefulness of our data. We believe that, although it is not an ideal protocol, the results provide important addition to the present knowledge. We very much agree with Malafarina and colleagues on the importance of nutrition and look forward to results of future studies examining the role of nutrition in PU formation. Midori S. Yatabe, MD, PhD Fumie Taguchi, BS, RD Izumi Ishida, RD Atsuko Sato, LPN Toshio Kameda, MD, PhD Shuichi Ueno, MD, PhD
LETTERS TO THE EDITOR
1211
Kozue Takano, BN Tsuyoshi Watanabe, MD, PhD Hironobu Sanada, MD, PhD Junichi Yatabe, MD, PhD Department of Pharmacology, Fukushima Medical University, Fukushima, Japan
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Midori S. Yatabe: study design. Junichi Yatabe, Fumie Taguchi, Izumi Ishida, Atsuko Sato: data collection. Toshio Kameda: nutritional consultation. Shuichi Ueno: provided authorization for study, acquisition of subjects. Kozue Takano: built patient data registry. Tsuyoshi Watanabe, Hironobu Sanada: provided advice for study. Junichi Yatabe, Midori S. Yatabe: analysis and interpretation of data, preparation of manuscript. Sponsor’s Role: None.
REFERENCES 1. Malafarina V, Uriz-Otano F, Fernandez-Catalan C et al. Nutritional status and pressure ulcers. Risk assessment and estimation in older adults. J Am Geriatr Soc 2014;62:1209–1210. 2. Yatabe MS, Taguchi F, Ishida I et al. Mini Nutritional Assessment as a useful method of predicting the development of pressure ulcers in elderly inpatients. J Am Geriatr Soc 2013;61:1698–1704.
