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Point-of-care ultrasound is essential in the initial assessment of polytrauma patients. The E-FAST protocol enables rapid detection of intra-abdominal free fluid, pericardial effusion, and pneumothorax, with particular usefulness in prehospital settings. However, ultrasound training among emergency nursing staff remains limited, especially within Advanced Life Support (ALS) mobile units. To evaluate the effect of a brief, structured training program on the acquisition of competencies for obtaining E-FAST windows in ALS mobile units nurses, assessing knowledge, technical skills, scanning sequence, and perceived confidence. A quasi-experimental pre-post intervention study was conducted with nurses with ≥6 months of experience in emergency or prehospital care. The intervention included baseline assessment, a 2-h theoretical module, high-fidelity simulation with Ultrasound Mentor®, and hands-on practice with human models. Final assessment combined a theoretical test, simulator-based practical evaluation, and scanning with a real ultrasound device. Knowledge, execution times, and confidence levels were recorded. Fourteen nurses participated, most without previous ultrasound training (85.7%). Initial confidence was low and improved significantly after the intervention. Theoretical performance increased in 5 of the 6 evaluated items, reaching up to 92.9% accuracy in key content areas. Practical assessment demonstrated an organized scanning sequence and appropriate times for prehospital care (medians of 118 s [IQR 24.5] in advanced simulation and 237 s [IQR 33.3] using a real ultrasound device). The program enabled the acquisition of essential skills even in professionals without prior ultrasound experience. The combination of theory, simulation, and hands-on practice facilitated rapid competency transfer and protocol standardization. A brief training program improves ALS mobile units nurses' competence and confidence in obtaining E-FAST windows, supporting the safe integration of point-of-care ultrasound into prehospital care.
The cyclical energy load imposed by the mechanical ventilator can influence mechanical efficiency and may be associated with an increased risk of lung injury. This study proposes the Viscoelastic Energy Index (VEI) and relative resilience, which incorporate biophysical, mathematical and geometric principles, to analyse the association between VEI and relative resilience with ARDS severity and ICU mortality. International, multicentre, retrospective study; quantitative analysis of pressure-volume curves to estimate energy delivered, dissipated, and recovered per ventilatory cycle. Bayesian modelling used to assess associations and perform subgroup analyses. 4 intensive care units across 4 Latin American countries PATIENTS: Adults who received invasive mechanical ventilation in volume-controlled mode, with (mild and moderate/severe ARDS) and without ARDS. VEI and relative resilience, ARDS severity, ICU mortality. High respiratory rate, elevated driving pressure and flow, lower compliance and reduced functional residual capacity were associated with lower VEI. In patients with moderate-severe ARDS, a higher VEI was associated with lower ICU mortality (posterior probability 89.6%). As VEI increased, dissipated energy rose marginally while relative resilience increased from 0.93 to 0.97, indicating improved initial mechanical efficiency. Hysteresis decreased progressively and the relative proportion of elastic and resistive components remained stable, suggesting energetic tolerance without structural overload. A higher VEI is associated with greater resilience and lower mortality in patients with ARDS. Prospective studies are needed to confirm these findings.
Microcirculatory integrity is essential for maintaining tissue homeostasis. In critically ill patients, microcirculatory dysfunction is strongly associated with tissue hypoperfusion, multiple organ failure, and increased mortality, yet remains frequently undetected by conventional macrocirculatory parameters. This discrepancy has driven growing interest in identifying reliable bedside tools for microcirculatory assessment in intensive care settings. To evaluate the prognostic and clinical utility of key microcirculatory monitoring parameters-including lactate, central venous oxygen saturation (SvcO₂), veno-arterial carbon dioxide difference (ΔPCO2), and capillary refill time (CRT)-in adult critically ill patients. A systematic review with narrative synthesis was conducted and reported in accordance with the PRISMA guidelines. The search encompassed publications from 2020-2024 in PubMed, Web of Science, ScienceDirect, and Cochrane Library. Studies involving adult ICU patients that assessed the relationship between microcirculatory parameters and clinical outcomes were selected. Out of 250 identified studies, 18 were included after screening, with their quality assessed using the Jadad and Newcastle-Ottawa scales. Methodological heterogeneity precluded meta-analysis. A ΔPCO₂ >6 mmHg and CRT > 3 s were associated with higher mortality and organ dysfunction, although CRT showed limitations due to subjectivity. Lactate ≥4.1 mmol/L at 6 h was the best predictor (AUC = .845), despite low specificity from non-hypoxic causes. SDF microscopy demonstrated microvascular dysfunction as an independent predictor, though requiring standardization. CRT-guided resuscitation reduced fluid overload; parameter combination improved prognostic accuracy compared to isolated use. The utility of ΔPCO₂, CRT, and lactate depends on clinical context, timing of measurement, and an integrative approach; however, their physiological and methodological limitations - lack of standardised protocols, need for training, and technical constraints - challenge isolated interpretation, reinforcing the need for multimodal strategies and dynamic monitoring. Integrating microcirculatory monitoring into standard hemodynamic assessment holds potential to improve individualized resuscitation strategies, minimize iatrogenic fluid burden, and enhance outcomes in critically ill patients.
Spontaneous intracerebral haemorrhage (ICH) is a neurological emergency. While code stroke has improved the management of ischaemic stroke in Spain, ICH lacks a specific protocol, leading to significant variability in its treatment. The ActúA project aims to standardise ICH care through recommendations tailored to the Spanish healthcare system. The project was conducted in four phases: 1) initial recommendation proposal by a multidisciplinary scientific committee (MSC); 2) 7 regional workshops to review and assess applicability; 3) final version prepared by the MSC; and 4) final validation using the Delphi methodology. Indicators were defined to evaluate the implementation and impact of the recommendations. The MSC identified key areas and proposed a total of 42 recommendations (17 pre-hospital, 12 in-hospital, and 13 post-discharge). These address, among other aspects, code stroke activation, the use of validated neurological scales, the implementation of essential care bundles, and early rehabilitation. Simultaneously, 27 clinical performance indicators were established. Subsequently, 217 healthcare professionals participated in the regional workshops. Finally, 43 experts took part in the validation phase, achieving consensus on all recommendations in a single round. The ActúA project provides a comprehensive framework for standardising ICH management in Spain, based on the available evidence and the consensus of a multidisciplinary panel. The coordinated implementation of these recommendations has the potential to contribute to more consistent and structured care, laying the groundwork for the development of a future national "code ICH."
This systematic review aims to assess the prevalence and incidence of pressure injury associated with non-invasive ventilation (NIV) in adult patients treated for acute respiratory failure (ARF). Facial pressure sores are a common complication of NIV, impairing skin integrity, patient comfort, and therapy efficacy. However, the ranges of incidence and prevalence reported in the literature are very wide. This review will include analytical observational and experimental studies reporting prevalence and/or incidence of pressure sores in adults treated with NIV for hypoxemic or hypercapnic ARF using oronasal, full-face, or hybrid masks. Any study or study arm testing interventions to reduce pressure sores will be excluded. Studies on pediatric patients and adult patients treated with other interfaces (ie, helmets) will also be excluded. This systematic review will be conducted in accordance with the JBI and PERSyst methodology for systematic reviews of prevalence and incidence. Searches will be conducted in PubMed, Cochrane Library, Web of Science, Embase, national health-agency surveillance systems, Centers for Disease Control and Prevention data, gray literature, and clinical trial registers to identify unpublished studies. No language limitations will be applied provided an English abstract is available. Two reviewers will independently select studies, and data will be extracted using a customized form. Narrative synthesis will be conducted and, where appropriate, pooled prevalence and incidence proportion will be calculated using the DerSimonian and Laird method. Methodological quality will be assessed using JBI's Critical Appraisal Tool for Prevalence and Incidence Studies. PROSPERO CRD42024604191.
ECMO survivors frequently develop post-intensive-care syndrome (PICS) with cognitive, psychological, and functional sequelae. Transitional care seeks to bridge ICU discharge and community recovery but remains variably structured, timed, and evaluated. To map transitional care models for ECMO survivors after ICU discharge, describing what is implemented, when (timing), and which outcomes are measured. Scoping review (JBI), reported per PRISMA-ScR. MEDLINE/PubMed, B-On, Web of Science (January 2015-June 2025). Grey literature: Google Scholar, OpenGrey, ELSO, OSF, ClinicalTrials.gov. Keywords and MeSH terms used: Extracorporeal Membrane Oxygenation [MeSH], Aftercare [MeSH], post-intensive care syndrome [MeSH], Critical Care [MeSH], Transitional Care [MeSH]. Eligibility: adults (≥18) on VV/VA ECMO with post-ICU data; excluded intra-operative ECMO < 24 h and studies without extractable ECMO-specific outcomes. Search retrieved 4101 studies, screening identified 740 records; 41 were included; 699 were excluded (duplicates; non-ECMO or intra-operative ECMO; no transitional intervention; no ECMO-specific outcomes). Seven domains were identified: structured follow-up pathways (n = 12); multidisciplinary interventions (n = 10); psychological/PICS support (n = 7); functional rehabilitation (n = 6); educational/organizational training (n = 5); telemonitoring/digital follow-up (n = 3); palliative/survivorship models (n = 2). Follow-up timings: pre-discharge; ∼1 month; 3-6 months; ≥12 months. Common outcomes: HRQoL, functional status (e.g., 6MWT/ADL), return to work, psychological symptoms (e.g., anxiety/depression/PTSD), readmissions/complications. Designs were predominantly observational/qualitative; trials with comparators were infrequent. Emerging concepts-ECMO survivorship, digital follow-up pathways-are not yet indexed in MeSH. Heterogeneity in structures, timing, and instruments limits comparability. Limitations include reliance on descriptive designs, variable reporting, and potential overlap across reviews. This scoping review identified seven domains of transitional care for ECMO survivors after ICU discharge. However, the implementation of these domains and the outcome measures used to evaluate them were heterogeneous and inconsistently reported across studies, highlighting the need for more robust, outcome-focused research.
Advances in oncology and critical care have reshaped the profile of intensive care unit (ICU) patients, increasing encounters with cancer patients who develop refractory cardiorespiratory failure. The use of Extracorporeal Circulatory Support (ECLS), including extracorporeal membrane oxygenation (ECMO), has expanded beyond traditional indications, raising complex clinical, physiological, and ethical questions in oncologic populations. This chapter describes the current role of ECLS in critically ill patients with solid and hematologic malignancies, integrating available evidence on indications, patient selection, physiological considerations, complications, and reported outcomes. The discussion emphasizes the heterogeneity of study findings and the consistently limited observed outcomes. The chapter frames ECLS as a highly selective intervention, best guided by emerging cohort-level data, multidisciplinary evaluation, and careful alignment with oncologic trajectory, reversibility of organ failure, and patient-centered goals of care.
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Higher nursing workload (NW) is associated with a negative impact on patient-focused clinical outcomes in critical care units. Adjusting the nursing staffing to the individualized care needs of critically ill patients' using a validated scale could constitute an efficient care management strategy in these settings. Assessing NW within 24 h of admission and discharge using the Nursing Activities Score (NAS) in 4 adult critical care units. Prospective, observational, single-center study. Patients admitted to the critical care units of a high-complexity hospital from October 2022 to February 2023. Descriptive analysis, Student's t-test, ANOVA, and multiple linear regression were performed using SPSS® v26. A total of 236 patients were included, of which 143 (60.9%) were male and the mean age was 61.30 (15.79). The reason for admission was medical in 151 (64.3%) cases, unplanned in 184 (78.3%) cases, APACHE II 17.09 (7.31), Charlson index of 5 [3-8], number of devices 4 [3-6], invasive ventilation 97 (41.1%), length of stay 5 [3-10] days, on admission ratio 1:2 in 203 (86.0%) and care level 3 in 236 (100.0%), on discharge with ratio 1:2 in 232 (98.3%) and care level 2 in 195 (82.6%). The mean NAS 24 h on admission was 59.46 (5.19) and on discharge was 51.13 (7.55). The variables that predicted the 24-h NAS on admission were the unit (P = .001), number of devices (P < .001), and APACHE IIs (P < .001); while those predicting 24-h NAS at discharge were unit (P < .001), mortality (P < .001), care level (P < .001), number of devices (P = .011), and length of ICU stay (P = .037). NW was high, both at admission and discharge, exceeding the 1:2 ratio. Higher rates were found in the afternoon shift. The variables that predict NW on admission are the unit, number of devices and severity of illness, and on discharge, also mortality, level of care, and length of ICU stay.
In biologic therapies targeting interleukin-23 (IL-23) for plaque psoriasis, parenteral administration can limit treatment adherence and quality of life. Icotrokinra is a first-in-class oral peptide that selectively antagonizes the IL-23 receptor and has shown promising efficacy in phase 2 and phase 3 trials. However, a comprehensive synthesis of efficacy and safety across these trials is currently lacking. To evaluate the efficacy and safety of Icotrokinra in adolescents (>12 years) and adults (>18) with moderate-to-severe plaque psoriasis. PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched on December 8th, 2025, with reference lists hand-searched for addition studies. Randomized controlled trials enrolling the target population which compared icotrokinra with placebo and reported efficacy or safety outcomes were included. Five randomized controlled trials (one phase 2 and four phase 3), comprising 4 reports, met inclusion criteria. Icotrokinra significantly increased the likelihood of achieving IGA 0/1 at week 16 compared with placebo (RR, 7.27; 95% CI, 5.80-9.11), with no heterogeneity (I2=0%). High-level skin clearance, represented by Psoriasis Area and Severity Index 90 was also significantly improved (RR, 13.82; 95% CI, 7.21-26.51). Rates of treatment-emergent and serious adverse events were comparable between icotrokinra and placebo, with no new safety signals identified over the 16-week trial period. Icotrokinra has shown short-term efficacy and a favorable safety profile in patients with moderate-to-severe plaque psoriasis. Combining biologic-level efficacy with ease of administration, icotrokinra may represent an important advance in psoriasis therapy.
Neuroworsening (NW) after traumatic brain injury (TBI) is a life-threatening complication affecting at least one in five patients. The current definition remains heterogeneous and does not integrate contemporary neuromonitoring tools that could help reduce this variability. Current diagnostic approaches are predominantly reactive, identifying deterioration only after brain herniation has occurred. To establish an expert consensus to update the definition of NW in TBI by proposing a stratified diagnostic framework aligned with precision and personalized medicine principles, aiming to shift a paradigm that has been in use for the past 50 years. A formal Delphi consensus process was conducted involving 25 experts from the Latin American Brain Injury Consortium (LABIC) and the Latin American Federation of Neurosurgical Societies (FLANC). A pre-consensus systematic literature review was performed, followed by structured electronic surveys with Likert-scale and multiple-choice items. Consensus was predefined as ≥80% agreement for establishing a statement. A 95.2% response rate was achieved in the first Delphi round, with 100% of statements reaching the consensus threshold. The panel agreed on a stratified three phenotype NW framework: Established NW, Subclinical NW and High-Risk Phenotype, including patients with pre-existing anatomical or systemic conditions that affect cerebral compliance or oxygenation reserve. This consensus proposes integrating clinical, imaging, and multimodal neuromonitoring parameters to update the definition of NW, thereby reducing heterogeneity in the current concept. Seven statements were established with >80% agreement. The new definition promotes a preventive approach to this critical condition, in contrast to the traditional reactive model.
External hydrocephalus is a frequent and poorly recognized condition in the adult population with acute brain injury. It refers to cerebrospinal fluid flow impairment, with enlargement of the subarachnoid space in the context of raised intracranial pressure. This manuscript reviews the current evidence on epidemiology, pathophysiology, neuroimaging, diagnostic criteria and treatment strategies of acute external hydrocephalus in adult patients with acute brain injury. A total of 15 studies were included, mainly retrospective and case series, with a limited methodological quality. Intracranial bleeding, tearing of the arachnoid membrane and excess of cerebrospinal fluid are the factors described in its pathogenesis. Neuroimaging is important in differentiating between external hydrocephalus and subdural hygroma. The key observation is the progressive enlargement of the subarachnoid space. The cornerstone of the management of acute external hydrocephalus is raised intracranial pressure control. An external lumbar drainage could be an effective measure in this scenario. Finally, an algorithm to manage acute external hydrocephalus with raised intracranial pressure is presented.
Although inappropriate therapy has been consistently associated with adverse outcomes, the magnitude and consistency of the benefit associated with appropriate empiric therapy in critically ill patients remain uncertain. We aimed to quantify the prevalence of appropriate empiric antimicrobial therapy and evaluate its association with outcomes and antimicrobial exposure in a large international ICU cohort. This predefined sub-analysis of the DIANA study included adult ICU patients receiving empirical antimicrobials for suspected or confirmed bacterial infection. Only patients with microbiologically confirmed infections were analyzed, and therapy was classified as appropriate if at least one agent demonstrated in vitro activity against the identified pathogen. Associations with 28-day mortality and antimicrobial-free days were assessed using multivariable logistic and Cox regression models. Pre-specified interaction analyses explored effect modification by disease severity and diagnostic certainty. Of 845 patients with microbiologically confirmed infections, 87.7% received appropriate empirical antimicrobial therapy. Compared with inappropriate therapy, appropriate therapy was associated with significantly lower ICU mortality and longer 28-day antimicrobial-free days and mechanical ventilation-free days. After multivariable adjustment, appropriate therapy remained independently associated with reduced 28-day mortality [adjusted odds ratio (OR) 1.83, 95% confidence interval 1.11-3.06, p = 0.02; hazard ratio (HR) 1.51, 95% CI 1.03-2.21, p = 0.035]. Effect-modification analyses demonstrated that the survival benefit of appropriate therapy was consistent across levels of diagnostic certainty and was most pronounced in patients with moderate illness severity (SOFA 3-9). In critically ill ICU patients, appropriate empirical antimicrobial therapy is independently associated with reduced 28-day mortality rates.
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Host genetic variability, particularly involving inborn errors of immunity (IEI), has emerged as a critical determinant of interindividual differences in COVID-19 severity, yet comprehensive genomic characterization of IEI-related variants in admixed Latin American populations remains scarce. To characterize rare pathogenic variants in IEI-related genes among previously healthy young Brazilian adults with severe COVID-19 and to evaluate their association with clinical outcomes and genetic ancestry. We performed whole-genome sequencing on 161 unrelated Brazilian adults aged 18-60 years, without comorbidities, who required intensive care unit admission for severe COVID-19 across six Brazilian states. A targeted analysis of 504 IEI-related genes, defined by the 2024 International Union of Immunological Societies (IUIS) classification, was conducted using a stringent variant filtering pipeline incorporating predicted functional impact, population rarity (minor allele frequency ≤ 0.01 in gnomAD v4.1 and the 1000 Genomes Project), Combined Annotation-Dependent Depletion (CADD) scores > 15, Gene Damage Index < 13.84, and pathogenicity classification according to American College of Medical Genetics and Genomics (ACMG) guidelines. Ancestry proportions were estimated using ADMIXTURE (K = 3). We identified 49 unique pathogenic or likely pathogenic (P/LP) variants across 37 IEI genes in 45 patients (27.9% of the cohort), comprising 21 pathogenic (42.9%) and 28 likely pathogenic (57.1%) variants. The most frequent molecular consequences were missense variants (n = 21, 42.9%), followed by frameshift (n = 10, 20.4%), stop-gained (n = 9, 18.4%), and splice-site variants (n = 8, 16.3%). Complement deficiencies constituted the largest IEI category (8 variants, 16.3%), followed by phagocyte defects and bone marrow failure (7 variants each, 14.3%). The most frequently affected gene was CFTR (n = 6 variants), and the PMS2 c.2186_2187del frameshift variant was shared among eight unrelated patients, representing the most recurrent variant in the cohort. Seven variants were entirely absent from gnomAD global and Americas databases, including novel variants in FANCA, MVK, TPP2, ELANE, TGFBR1, TCIRG1, and CARD9. Notably, the MVK c.658A > T nonsense variant was identified in two unrelated patients despite its complete absence from reference databases. Ancestry analysis revealed a tri-hybrid profile (European 60.5%, African 26.6%, Amerindian 13.0%), with no significant association between IEI variant carrier status and any ancestry component (all p > 0.6). Strikingly, IEI variant carriers exhibited significantly lower rates of circulatory shock (20.0% vs. 52.6%; OR = 0.23, 95% CI 0.10-0.51, p < 0.001) and acute respiratory distress syndrome (40.0% vs. 61.2%; OR = 0.42, 95% CI 0.21-0.85, p = 0.021) compared to non-carriers, alongside higher absolute lymphocyte counts (median 1,055 vs. 866 cells/mm3, p = 0.024). In-hospital mortality did not differ significantly between groups (11.1% vs. 24.1%; OR = 0.39, 95% CI 0.14-1.09, p = 0.082). These findings demonstrate that rare IEI-related germline variants are present in a substantial proportion of previously healthy young adults with life-threatening COVID-19 and suggest that IEI-associated immune attenuation may modulate disease phenotype by dampening hyperinflammatory responses-potentially protecting against cytokine storm-driven complications while still predisposing to severe illness through impaired viral clearance. This study underscores the relevance of host immunogenetic profiling in admixed populations for understanding the pathophysiology of severe infectious diseases.
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In the de-resuscitation phase of septic shock, resolving vasoplegia and fluid mobilisation can increase venous congestion in patients with sepsis-related myocardial dysfunction. This study will characterise the haemodynamic effects and safety of recombinant human brain natriuretic peptide (rh-BNP) in this population. This single-centre, prospective, single-arm study will enrol 30 adults recovering from septic shock with improving infection/vasopressor trends, sinus rhythm, ongoing pulse-index continuous cardiac output (PiCCO) monitoring and measurable arm-equilibrium pressure (Parm). Eligibility will require cardiac dysfunction (left-ventricular ejection fraction ≤50% and/or ≥10% absolute decline when available) and volume overload (global end-diastolic volume index >800 mL/m² and extravascular lung water index >10 mL/kg). Participants will receive rh-BNP (2 µg/kg intravenous bolus over 15 min, then a 0.01 µg/kg/min infusion for up to 72 hours). Measurements will be obtained at baseline, acute response (30-60 min), 24, 48 and 72 hours. The primary outcome will be within-patient change in venous return pressure gradient (ΔPVR, Parm-central venous pressure) from baseline to acute response. Secondary outcomes will include indices of preload, cardiac function, tissue perfusion and venous congestion. Haemodynamic instability will be the safety endpoint. Paired tests and repeated-measures analyses will estimate within-patient changes over time. Ethics approval has been obtained from the Ethics Committee of Sichuan Provincial People's Hospital, Sichuan Academy of Medical Sciences (No. 2024-653-1). Written informed consent will be obtained. Findings will be disseminated via peer-reviewed publications and conferences. NCT06745206.
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Malnutrition is a highly prevalent and underdiagnosed condition among hospitalized patients, especially in internal medicine wards. Hospital malnutrition is associated with increased morbidity, mortality, prolonged admissions, and a substantial economic burden. This study aimed to assess the clinical and economic impact of nutritional risk in patients admitted to internal medicine wards, focusing on mortality, hospital resource utilization, and the effectiveness of nutritional interventions. A retrospective cohort study was conducted at ULS Santo António, Porto, including 1,150 hospital admissions from January to December 2022. All adult patients with nutritional risk screening (NRS-2002) in the first 48 h of admission were included. Data were collected from hospital information systems on demographic, clinical, and economic variables, with outcomes including in-hospital mortality, readmissions at 30, 90, and 180 days, and one-year post-discharge mortality. Nutritional risk (NRS-2002 ≥ 3) was identified in 42.4% of patients (n = 488), while ICD-10 malnutrition coding at discharge was recorded in only 0.7% of admissions. Of patients at nutritional risk, 74.4% (n = 363) received no nutritional supplementation. Nutritional risk was associated with higher in-hospital mortality, longer length of stay, and increased costs across all resource categories. In the time-dependent Cox model, patients at nutritional risk without supplementation showed a markedly higher hazard of in-hospital death at admission (HR 23.32, 95% CI 13.09-41.56), with this excess hazard attenuating over time. Patients at nutritional risk who received supplementation also showed elevated early risk (HR 6.15, 95% CI 2.96-12.80), though lower than unsupplemented patients. A similar pattern was observed for one-year post-discharge mortality. Total hospitalization costs were approximately 79% higher in at-risk patients, driven mainly by longer length of stay. Nutritional risk affected 42.4% of internal medicine inpatients and was associated with higher mortality and resource use. The finding that 74.4% of at-risk patients received no nutritional intervention represents a substantial missed opportunity. Patients who received nutritional supplementation showed a pattern of lower mortality risk than unsupplemented at-risk patients, consistent with but not proving a beneficial association. These findings support systematic nutritional screening and timely intervention in hospital care.