BACKGROUND:Trimethylamine N-oxide (TMAO), a metabolite produced by the gut microbiota, is highly influenced by dietary factors and is linked to negative health outcomes including all-cause mortality and cardiovascular events. We evaluated the prognostic value of TMAO among hospitalized patients at nutritional risk participating in the Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) regarding clinical outcomes and response to nutritional support. CLINICAL TRIAL REGISTRATION:clinicaltrials.gov as NCT02517476 (registered 7 August 2015) METHODS: This secondary analysis is based on the randomized-controlled EFFORT trial, which compared individualized nutritional therapy with usual care in medical inpatients at nutritional risk. We studied the association of admission TMAO concentrations with all-cause mortality after 180 days (primary endpoint) and major adverse cardiovascular events (MACE) using quartile-based regression analysis. RESULTS:Among 218 patients with available TMAO measurements, those in higher quartiles showed an increased all-cause mortality compared to the lowest quartile after 180 days (adjusted HR 1.92 95% CI 1.03-3.56, p = 0.04) and 5 years (adjusted HR 2.01 95% CI 1.23-3.31, p = 0.006). A similar trend was observed for MACE. We found no significant associations between dietary factors or nutritional history and admission TMAO levels, nor was TMAO predictive regarding the response to nutritional therapy. CONCLUSION:The risk of mortality over six months nearly doubled in patients at risk of malnutrition with elevated baseline TMAO levels. Additional research is needed to determine if dietary interventions can successfully modulate TMAO levels and, in turn, improve clinical outcomes.

Introduction Malnutrition is a highly prevalent chronic condition that contributes to higher morbidity and mortality in patients with multiple comorbidities. While positive effects of nutritional therapy in the in-hospital setting have recently been demonstrated, the benefits of long-term nutritional therapy after hospital discharge remain uncertain. Herein, we outline the design and rationale of the EFFORTII trial, the largest nutritional trial to date to assess the effects of continued nutritional support after hospital discharge in medical patients, with particular attention to key design decisions regarding nutritional strategy, patient selection criteria and study endpoints.Methods and analysis The Effect of Continued Nutritional Support at Hospital Discharge on Mortality, Frailty, Functional Outcomes and Recovery (EFFORTII) is an investigator-initiated, non-commercial randomised controlled trial designed to evaluate whether ongoing, individualised nutritional therapy after hospital discharge—targeted to meet specific energy and protein requirements—offers a cost-effective approach to lowering mortality, minimising complications and maintaining functional status compared with standard care. Eligible participants are adult, chronically ill medical inpatients at risk of malnutrition. Patients in the intervention group receive individualised nutritional therapy delivered by an experienced dietitian through a combination of telemedicine and in-person consultations. The intervention aims to meet personalised nutritional targets, supported by a trained dietitian. Control group patients receive nutritional counselling at discharge, but no structured nutritional management during follow-up. We designed the trial as an event-driven trial with a target of 247 mortality events (primary endpoint), which will be assessed over approximately 5 years until event-driven endpoint is met. The minimum total sample size is at least 802 participants, based on the assumed treatment HR of 0.70. The main trial is enrolling patients across multiple sites in Switzerland. During the trial, additional sites in Spain joined the study, and their data will be analysed using a patient-level pooled approach.Ethics and dissemination This study involves human participants and was first granted ethical approval by the Ethics Committee Northwest- and Central Switzerland and then by all participating local ethics committees. Written informed consent will be obtained from all participants. Findings will be disseminated in peer-reviewed journals and academic conferences.Trial registration number NCT04926597.

Background & aims: Malnutrition is a growing global health concern associated with adverse clinical outcomes. Randomized controlled clinical trials have shown that personalized nutritional therapy can significantly patient outcomes. The selection of appropriate nutritional products (NPs) is challenging and time-consuming due to the large number of available options and the lack of standardized and comparable product information. The aim of this study was to develop a structured, company-independent digital platform (NutriPro™) for NP selection, based on a national needs assessment among healthcare professionals (HCP). Methods: NutriPro™ was developed in three steps. First, a hierarchical data structure was established to systematically map all relevant NP attributes, based on manufacturer information, regulatory documents, clinical nutrition handbooks, and international nutrition society guidelines. Second, an online questionnaire was sent to Swiss HCP via Google Forms between February and May 2023 to identify the clinically most relevant selection criteria. Third, the questionnaire findings informed the platform architecture, filter-based functionalities, and standardized fact sheets, which were technically implemented by a commissioned software company under scientific supervision of the study team. Results: A total of 92 HCP filled out the questionnaire that assessed the national needs for a digital platform for NP selection. The majority of respondents (54%, n = 49) were experts in nutrition with more than seven years of practical experience. The resulting key selection criteria for an NP in clinical practice were its macronutrient composition (79% agreement, n = 71), energy content (81% agreement, n = 73), protein content (98% agreement, n = 89), and the patient's health condition/indication (56% agreement, n = 50). These findings informed the structure and functionality of the NutriPro™ platform. The beta version was published in July 2023 and NutriPro™ was officially launched in September 2025. Conclusions: By translating HCP-defined selection criteria into a structured, company-independent digital tool, NutriPro™ closes a gap between available NP information and clinical decision-making in nutritional care. Preliminary usability evidence from the integrated clinicalnutrition.science workflow supports its feasibility, while dedicated prospective studies are planned to confirm NutriPro™'s standalone impact on workflow efficiency, quality of care, and patient outcomes.

Handgrip strength (HGS) is a simple yet effective bed-side tool for assessing muscle strength, which plays an important role in clinical evaluation and monitoring. We hypothesize that repeated measurements of HGS during the hospital stay may serve as a reliable and robust indicator of clinical course and outcomes. We re-analyzed data from 565 out of 2028 patients who had repeated handgrip measurement (on admission and on day 7) included in EFFORT, a Swiss-wide multicenter, randomized controlled trial comparing individualized nutritional support with usual care nutrition in medical inpatients. The primary endpoint was 180-day all-cause mortality. The mean change in HGS from baseline to day 7 was 0.6 kg (SD 4.2) in female and 0.7 kg (SD 3.7) in male patients. Patients with a positive HGS trend had a lower risk of dying within 180 days compared to patients without a positive trend (mortality 11.4

BACKGROUND:Assessing a patient's catabolism in clinical practice is challenging but could help guide nutritional interventions. The urea-to-creatinine ratio (UCR) reflects muscle breakdown and protein metabolism and has been associated with risk for overfeeding and adverse outcomes in the critical care setting. We validated this concept in a well-characterized population of medical ward patients from a previous nutritional trial. METHODS:This secondary analysis of the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT) examined baseline UCR and changes during follow-up in medical inpatients at risk for malnutrition. A catabolic state was defined as a high baseline UCR or an increase in UCR over 7 days. The primary endpoint was mortality at 30 days. RESULTS:We included 1595 of 2028 EFFORT patients with baseline UCR measurements and 870 who also had UCR measurements on day 7. A high baseline UCR, as well as an increase in UCR over 7 days, were associated with increased mortality (adjusted HR for 30-day mortality 2.05 (1.47-2.87) p < 0.001 and 2.02 (1.34-3.06) p = 0.001). There was no difference in treatment response when stratifying patients based on baseline or follow-up UCR. CONCLUSION:Assessment of catabolism through UCR measurement at baseline and changes during follow-up was associated with increased mortality and adverse outcomes in medical inpatients at nutritional risk. However, this stratification was not associated with response to nutritional therapy in our sample. Further studies into the dynamic changes in UCR are needed to better understand the clinical implications for medical ward patients. CLINICAL TRIAL REGISTRATION:Clinicaltrials.gov as NCT02517476 (registered 7 August 2015).

BACKGROUND:Inflammation is a key driver of disease-related malnutrition and patients with high inflammation may not show the same benefits from nutritional therapy as other patients. We compared in an exploratory manner the prognostic ability of interleukin- 6 (IL- 6), tumor necrosis factor-alpha (TNF-α) and C-reactive protein (CRP) to predict outcome and response to nutritional therapy, respectively, within a large cohort of patients from a previous nutritional trial. METHODS:This is a secondary analysis of the Swiss-wide, multicenter, randomized controlled Effect of early nutritional therapy on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) trial comparing individualized nutritional support with usual care nutrition in medical inpatients. The primary endpoint was 30-day all-cause mortality. RESULTS:We included 996 patients with an overall mortality rate of 6% within 30 days. Compared to patients with low IL- 6 level < 11.2pg/mL, patients with high levels had a more than 3-fold increase in mortality at 30-days (adjusted HR 3.5, 95% CI 1.95-6.28, p < 0.001), but tended to have a less pronounced mortality benefit from individualized nutritional therapy as compared to usual nutritional care (hazard ratio 0.82 vs. 0.32). CRP and TNF-α were not associated with mortality, but patients with increased CRP levels > 100 mg/dl also showed a trend towards a diminished response to nutritional intervention (hazard ratio 1.25 vs. 0.47). CONCLUSION:Our findings support the thesis that a high inflammatory state is linked to reduced benefits from nutritional therapy. Apparently, CRP and IL- 6 effectively predict treatment response, but IL- 6 may additionally serve as a prognostic marker for increased mortality. This finding might help to develop improved treatment strategies for patients with elevated inflammatory profiles. TRIAL REGISTRATION:Clinicaltrials.gov as NCT02517476 (registered 7 August 2015).

BACKGROUND:Ghrelin is an orexigenic hormone that stimulates food intake by hypothalamic actions. There is limited data on its circulating levels, pathophysiological role, and prognostic and therapeutic potential in disease-related malnutrition. METHODS:We investigated via this secondary analysis of the randomized controlled Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) the association of admission ghrelin levels in terms of malnutrition phenotype, nutritional target achievement, and treatment response. The primary outcome was 30-day all-cause mortality. RESULTS:A total of 997 patients with available ghrelin measurements were included. We found an association between high ghrelin levels upon admission and malnutrition severity according to the Nutritional Risk Screening 2002 (NRS) and an inverse association between high ghrelin levels and nutritional intake. Patients with high ghrelin levels had a 1.4-fold greater chance of reaching nutritional targets during hospitalization compared to those with lower levels (adjusted OR 1.40 [95% CI 1.01-1.93], P = 0.045). High ghrelin levels were not associated with mortality, complications, or adverse events, and both high and low ghrelin groups showed a similar response to nutritional therapy. CONCLUSION:We observed an association between high ghrelin levels upon admission in patients with more severe malnutrition according to the NRS and its components. A hypothesis may be generated that the hormone's orexigenic effect is impaired due to ghrelin resistance. However, under nutritional therapy, patients with high ghrelin levels were more likely to achieve nutritional targets. Ghrelin analogs during hospitalization may help facilitate beneficial nutritional intake in this vulnerable patient population. Nevertheless, future research should investigate where this resistance stems from and differentiate between active and total ghrelin, as this could influence efficacy.

AIM OF THE STUDY: Malnutrition is a common and complex challenge in inpatient and outpatient settings, associated with increased risk of morbidity and mortality. Its management is often neglected, despite strong evidence of the benefits of adequate nutritional therapy. We introduced clinicalnutrition.science (https://clinicalnutrition.science/en/), a digital platform that provides healthcare professionals with easy online access to evidence and streamlines the nutritional care process. The aim of this study was to assess the usability and to validate improvements in nutritional management when the digital platform is used by healthcare professionals. METHODS: The usability study, conducted from 28 September to 16 November 2023, involved 56 healthcare professionals from the University Hospital of Bern and the Cantonal Hospital of Aarau. In an adapted cross-over study design, participants completed key steps of nutritional management for a simulated hepatology and oncology case both with and without the clinicalnutrition.science platform. Usability was assessed using the validated Healthcare Systems Usability Scale questionnaire, supplemented by collection of demographic data. Subgroup analysis was performed for recommended protein and energy intakes by different professional representatives. RESULTS: Clinicalnutrition.science achieved a good overall usability score of 71.8%. Use of the platform significantly improved the protein intake recommendation (p = 0.03; median 96.5 and 80.0 g/d) and the basal metabolic rate estimate (p <0.01; median 1420.8 and 1755.5 kcal/d) of the simulated oncology case. The variance in protein and energy intake recommendations, basal metabolic rate estimation and energy deficit estimation was reduced by using the digital platform. These improvements were achieved without increasing the time required to complete key steps in nutritional management for the two patient cases (median between 10.5 and 15.0 minutes; p = 0.09 and p = 0.67) and without prior training on the platform. There was no effect on the malnutrition detection rate, the selection of an appropriate nutritional product or the identification of the most appropriate guideline. CONCLUSIONS: The use of clinicalnutrition.science improved evidence-based clinical practice in prescribing personalised nutritional therapy and increased the accuracy of both protein and energy intake recommendations, without increasing the time taken to complete key steps in the nutritional management process.

BackgroundTrimethylamine N-oxide (TMAO), a metabolite produced by the gut microbiota, is highly influenced by dietary factors and is linked to negative health outcomes including all-cause mortality and cardiovascular events. We evaluated the prognostic value of TMAO among hospitalized patients at nutritional risk participating in the Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) regarding clinical outcomes and response to nutritional support.MethodsThis secondary analysis is based on the randomized-controlled EFFORT trial, which compared individualized nutritional therapy with usual care in medical inpatients at nutritional risk. We studied the association of admission TMAO concentrations with all-cause mortality after 180 days (primary endpoint) and major adverse cardiovascular events (MACE) using quartile-based regression analysis.ResultsAmong 218 patients with available TMAO measurements, those in higher quartiles showed an increased all-cause mortality compared to the lowest quartile after 180 days (adjusted HR 1.92 95% CI 1.03 to 3.56, p = 0.04) and 5 years (adjusted HR 2.01 95% CI 1.23 to 3.31, p = 0.006). A similar trend was observed for MACE. We found no significant associations between dietary factors or nutritional history and admission TMAO levels, nor was TMAO predictive regarding the response to nutritional therapy.ConclusionThe risk of mortality over six months nearly doubled in patients at risk of malnutrition with elevated baseline TMAO levels. Additional research is needed to determine if dietary interventions can successfully modulate TMAO levels and, in turn, improve clinical outcomes.

Background & aims: Pancreatic lipase plays an essential role in digesting dietary fats in the intestine, facilitating nutrient absorption. Plasma lipase serves as a surrogate for pancreatic exocrine function, which decreases with age and potentially leads to inadequate nutrient digestion and gastrointestinal symptoms. We investigated clinical implications of plasma lipase among medical inpatients at nutritional risk. Methods: This secondary analysis investigated admission plasma lipase concentrations among patients at risk for malnutrition regarding clinical outcomes and treatment response in patients included in the Effect of Early Nutritional Support on Frailty Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), a randomized controlled trial comparing individualized nutritional support to usual care. Results: Of 810 patients with available admission plasma lipase concentrations, 158 (19.5 %) had concentrations below the reference range. Patients with low concentrations had a 1.6-fold higher risk of not reaching energy or protein targets during hospitalization (adjusted odds ratio 1.62 [95 % confidence interval 1.07 to 2.45], p = 0.022 and 1.61 [95 % confidence interval 1.07 to 2.44], p = 0.023, respectively). They also tended to have a more pronounced benefit from nutritional interventions in terms of reduced mortality (adjusted hazard ratio for patients with low lipase 0.48 [95 % confidence interval 0.18 to 1.26] compared to 0.99 [95 % confidence interval 0.60 to 1.63] in patients with normal lipase concentrations, p for interaction = 0.224). Conclusion: Findings from this multicenter trial indicate that around 20 % of polymorbid older patients had plasma lipase concentrations below the reference range, suggesting exocrine pancreatic insufficiency, which placed them at a greater risk for failing to meet nutritional targets; however, they also demonstrated a pronounced improvement from nutritional support. Further studies should assess the impact of pancreatic enzyme replacement therapy in this population. Trial registration: ClinicalTrials.gov Identifier: NCT02517476. (c) 2025 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Inflammation is a key driver of disease-related malnutrition and patients with high inflammation may not show the same benefits from nutritional therapy as other patients. We compared in an exploratory manner the prognostic ability of interleukin- 6 (IL- 6), tumor necrosis factor-alpha (TNF-α) and C-reactive protein (CRP) to predict outcome and response to nutritional therapy, respectively, within a large cohort of patients from a previous nutritional trial. This is a secondary analysis of the Swiss-wide, multicenter, randomized controlled Effect of early nutritional therapy on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) trial comparing individualized nutritional support with usual care nutrition in medical inpatients. The primary endpoint was 30-day all-cause mortality. We included 996 patients with an overall mortality rate of 6

Lysine, methionine, and threonine are essential amino acids with vital functions for muscle and connective tissue health, metabolic balance, and the immune system. During illness, the demand for these amino acids typically increases, which puts patients at risk for deficiencies with harmful clinical consequences. In a secondary analysis of the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), which compared individualized nutritional support to usual care nutrition in patients at nutritional risk, we investigated the prognostic impact of the lysine, methionine, and threonine metabolism. We had complete clinical and amino acid data in 237 patients, 58 of whom reached the primary endpoint of death at 30 days. In a model adjusted for comorbidities, sex, nutritional risk, and trial intervention, low plasma methionine levels were associated with 30-day mortality (adjusted HR 1.98 [95% CI 1.16 to 3.36], p = 0.01) and with a decline in functional status (adjusted OR 2.06 [95% CI 1.06 to 4.01], p = 0.03). The results for lysine and threonine did not show statistically significant differences regarding clinical outcomes. These findings suggest that low levels of methionine may be critical during hospitalization among patients at nutritional risk. Further studies should investigate the effect of supplementation of methionine in this patient group to improve outcomes.

The essential branched-chain amino acids leucine, isoleucine and valine are considered anabolic and stimulate protein synthesis in the muscles as well in the liver. They also promote muscle recovery and contribute to glucose homeostasis. Recent studies in critically ill patients have demonstrated that depletion of plasma leucine is associated with increased mortality, but data in the non-critical care setting is lacking. This secondary analysis of the randomized controlled Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT), investigated the impact of leucine, isoleucine, and valine metabolism on clinical outcomes. The primary endpoint was 180-day all-cause mortality. Among 238 polymorbid patients with available metabolite measurements, low serum leucin levels were associated with a doubled risk of 180-day all-cause mortality in a fully adjusted regression model (adjusted HR 2.20 [95

Background: Nutritional screening tools have proven valuable for predicting clinical outcomes but have failed to determine which patients would be most likely to benefit from nourishment interventions. The Nutritional Risk Screening 2002 (NRS) and the Mini Nutritional Assessment (MNA) are 2 of these tools, which are based on both nutritional parameters and parameters reflecting disease severity. Objectives: We hypothesized that the adaptation of nutritional risk scores, by removing parameters reflecting disease severity, would improve their predictive value regarding response to a nutritional intervention while providing similar prognostic information regarding mortality at short and long terms. Methods: We reanalyzed data of 2028 patients included in the Swiss-wide multicenter, randomized controlled trial EFFORT (Effect of early nutritional therapy on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial) comparing individualized nutritional support with usual care nutrition in medical inpatients. The primary endpoint was 30-d all-cause mortality. Results: Although stratifying patients by high compared with low NRS score showed no difference in response to nutritional support, patients with high adapted NRS showed substantial benefit, whereas patients with low adapted NRS showed no survival benefit [adjusted hazard ratio: 0.55 [95% confidence interval (CI): 0.37, 0.80]] compared with 1.17 (95% CI: 0.70, 1.93), a finding that was significant in an interaction analysis [coefficient: 0.48 (95% CI: 0.25, 0.94), P 1/4 0.031]. A similar effect regarding treatment response was found when stratifying patients on the basis of MNA compared with the adapted MNA. Regarding the prognostic performance, both original scores were slightly superior in predicting mortality than the adapted scores. Conclusions: Adapting the NRS and MNA by including nutritional parameters only improves their ability to predict response to a nutrition intervention, but slightly reduces their overall prognostic performance. Scores dependent on disease severity may best be considered prognostic scores, whereas nutritional risk scores not including parameters reflecting disease severity may indeed improve a more personalized treatment approach for nourishment interventions. The trial was registered at clinicaltrials.gov as NCT02517476.

BACKGROUND:Considering sex-specific factors has become an increasingly recognized area for research and practice, in the field of clinical nutrition, there is insufficient evidence regarding differences in clinical presentation, treatment response, and side effects of nutritional therapy among female and male patients. OBJECTIVES:We hypothesized that the clinical presentation, response to nutritional therapy, and side effects from the intervention would differ in the two sexes. METHODS:This secondary analysis investigated differences among female and male patients at risk for malnutrition regarding initial presentation, clinical outcomes, and treatment response in patients included in the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), a randomized controlled trial comparing individualized nutritional support to usual care. RESULTS:Of 2028 patients included in the trial, 964 were females and 1064 were males. The nutritional history and clinical presentation of female patients was different: they consumed less food and had a greater loss of appetite than the male population. Male patients had higher risk for mortality at 180 d [27% compared with 19%; adjusted hazards ratio (HR): 1.35; 95% CI: 1.12, 1.63] and further adverse clinical outcomes. However, there was no difference in the effect of nutritional support on mortality among female and male patients (HR: 0.76; 95% CI: 0.45, 1.27, compared with HR: 0.81; 95% CI: 0.54, 1.21, respectively; P-interaction = 0.939). CONCLUSIONS:Results of this multicenter randomized trial suggest that multimorbid female inpatients have a different clinical presentation and are more prone to loss of appetite and reduced daily dietary intake than male inpatients. Importantly, the favorable response to nutritional interventions was similar in both sexes. This trial was registered at clinicaltrials.gov as NCT02517476.

Background: Arginine, a conditionally essential amino acid, is key component in metabolic pathways including immune regulation and protein synthesis. Depletion of arginine contributes to worse outcomes in severely ill and surgical patient populations. We assessed prognostic implications of arginine levels and its metabolites and ratios in polymorbid medical inpatients at nutritional risk regarding clinical outcomes and treatment response. Methods: Within this secondary analysis of the randomized controlled Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT), we investigated the association of arginine, its metabolites and ratios (i.e., ADMA and SDMA, ratios of arginine/ADMA, arginine/ornithine, and global arginine bioavailability ratio) measured on hospital admission with short-term and long-term mortality by means of regression analysis. Results: Among the 231 patients with available measurements, low arginine levels <= 90.05 mmol/l (n = 86; 37 %) were associated with higher all-cause mortality at 30 days (primary endpoint, adjusted HR 3.27, 95 % CI 1.86 to 5.75, p < 0.001) and at 5 years (adjusted HR 1.50, 95 % CI 1.07 to 2.12, p = 0.020). Arginine metabolites and ratios were also associated with adverse outcome, but had lower prognostic value. There was, however, no evidence that treatment response was influenced by admission arginine levels. Conclusion: This secondary analysis focusing on medical inpatients at nutritional risk confirms a strong association of low plasma arginine levels and worse clinical courses. The potential effects of arginineenriched nutritional supplements should be investigated in this population of patients. Clinical trial registration: clinicaltrials.gov as NCT02517476 (registered 7 August 2015). (c) 2024 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Introduction The prevalence of the unspecified protein-calorie malnutrition (E46) has remained high stable in Switzerland for several years, despite E46 no longer affecting the flat rate per case. When E46 is documented, treatment for malnutrition is provided, but it is not eligible for additional reimbursement. Method In this retrospective economic evaluation, a hypothetical recoding of E46 cases (N=14'889) from the medical statistics of hospitals 2020 was conducted. The E46 diagnoses were transformed into specified malnutrition diagnoses using four scenarios, including recoding through Multiple Imputation. The changes in total revenue and average revenue were calculated for each scenario and several subgroups. Results The recoding resulted in an increase in total revenue of CHF 10.9 million (E43), CHF 6.0 million (E44.0), CHF 0 (E44.1), and CHF 6.1 million (mixed). The average revenue increased by CHF 732 (E43), CHF 404 (E44.0), CHF 0 (E44.1), and CHF 407 (mixed). Most subgroups experienced an increase in average revenue. Discussion By correctly implementing and mapping the criteria for coding energy and protein malnutrition according to the Swiss coding guidelines the specifying malnutrition instead of E46 could have led to a relevant increase in hospital revenues in 2020. The specifying malnutrition instead of E46 could have led to a significant increase in hospital revenues in 2020. To achieve a future reduction in E46 coding, a systematic implementation and execution of the Nutritional Risk Screening 2002 is necessary.

Background & aims: Red cell distribution width (RDW) has been proposed as a surrogate marker for acute and chronic diseases and may be influenced by nutritional deficits. We assessed the prognostic value of RDW regarding clinical outcomes and nutritional treatment response among medical inpatients at nutritional risk. Methods: This is a secondary analysis of EFFORT, a randomized, controlled, prospective, multicenter trial investigating the effects of nutritional support in patients at nutritional risk in eight Swiss hospitals. We examined the association between RDW and mortality in regression analysis. Results: Among 1,244 included patients (median age 75 years, 46.6 % female), high RDW (>= 15 %) levels were found in 38 % of patients (n = 473) with a significant association of higher malnutrition risk [OR 1.48 (95%CI 1.1 to 1.98); p = 0.009]. Patients with high RDW had a more than doubling in short-term (30 days) mortality risk [adjusted HR 2.12 (95%CI 1.44 to 3.12); p < 0.001] and a signficant increase in long-term (5 years) mortality risk [adjusted HR 1.73 (95%CI 1.49 to 2.01); p < 0.001]. Among patients with high RDW, nutritional support reduced morality within 30 days [adjusted OR 0.56 (95%CI 0.33 to 0.96); p = 0.035], while the effect of the nutritional intervention in patients with low RDW was markedly smaller. Conclusions: Among medical patients at nutritional risk, RDW correlated with several nutritional parameters and was a strong prognostic marker for adverse clinical outcomes at short- and long-term, respectively. Patients with high baseline RDW levels also showed a strong benefit from the nutritional intervention. Further research is needed to understand whether monitoring of RDW over time severs as a nutritional biomarker to assess effectiveness of nutritional treatment in the long run. Trial registration: ClinicalTrials.gov Identifier: NCT02517476. (c) 2024 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.