Malnutrition and Laboratory Markers in Geriatric Patients. A Comparison of Neurologic-psychiatric, Internal and Trauma Surgical Diseases

WIfI Classification Based Analysis of Risk Factors for Outcomes in Patients with Chronic Limb Threatening Ischaemia after Endovascular Revascularisation Therapy

OBJECTIVE

The evaluation of limb status with the Wound, Ischaemia, and foot Infection (WIfI) classification and the assessment of patient risks combined with systemic factors, are recommended in patients with chronic limb threatening ischaemia (CLTI). However, there is little evidence of the application of the WIfI classification in the Chinese population. This study aimed to verify the use of the WIfI classification in a Chinese patient population, and to further identify local and systemic independent predictors of adverse CLTI outcomes.

METHODS

A total of 474 patients who underwent endovascular therapy (EVT) for CLTI in a tertiary hospital between July 2017 and September 2020 were included in this retrospective study. The outcomes included one year major adverse limb events (MALEs), one year all cause mortality, and one year amputation free survival (AFS). Cox regression was used to analyse the association between risk factors and adverse outcomes.

RESULTS

In total, 104 (21.9%) all cause deaths were recorded. The rate of MALEs was 17.5%, while the AFS was 71.9%. Multivariable analysis revealed that a body mass index (BMI) < 18.5 kg/m2 (p = .002), a left ventricular ejection fraction (LVEF) < 50% (p < .001), and WIfI wound grade (p < .001) were independent risk factors for MALEs, while age ≥ 77 years (p = .031), BMI < 18.5 kg/m2 (p < .001), coronary heart disease (p = .040), and WIfI clinical stages (p = .021) were independent risk factors for death in patients with CLTI. Age ≥ 77 years (p = .003), BMI < 18.5 kg/m2 (p < .001), coronary heart disease (p = .012), LVEF < 50% (p < .001), WIfI wound grade (p = .004), and WIfI clinical stages (p = .044) were independently associated with a decreased AFS rate.

CONCLUSIONS

This study has confirmed the predictive ability of the WIfI classification for Chinese patients with CLTI who underwent EVT. Wound grade was the most sensitive and important risk factor of the three components of WIfI. In addition, systemic factors should be considered to ensure a more accurate prognosis prediction and appropriate clinical decision making in patients with CLTI.

Comprehensive comparison between geriatric and nongeriatric patients with trauma

The incidence of geriatric trauma is increasing due to the growing elderly population. Healthcare providers require a global perspective to differentiate critical factors that might alter patients' prognosis.We retrospectively reviewed all adult patients admitted to a trauma center during a 4-year period. We identified 655 adult trauma patients aged from 18 to 64 (nongeriatric group) and 273 trauma patients ≥65 years (geriatric group). Clinical data were collected and compared between the 2 groups.The geriatric group had a higher incidence of trauma and higher Injury Severity Scores than did the nongeriatric group. Fewer geriatric patients underwent surgical treatment (all patients: geriatric vs nongeriatric: 65.9% vs 70.7%; patients with severe trauma: geriatric vs nongeriatric: 27.6% vs 44.5%). Regarding prognosis, the geriatric group exhibited higher mortality rate and less need for long-term care (geriatric vs nongeriatric: mortality: 5.5% vs 1.8%; long-term care: 2.2% vs 5.0%).We observed that geriatric patients had higher trauma incidence and higher trauma mortality rate. Aging is a definite predictor of poor outcomes for trauma patients. Limited physiological reserves and preference for less aggressive treatment might be the main reasons for poor outcomes in elderly individuals.

Low skeletal muscle mass predicts poor clinical outcomes in patients with abdominal trauma

OBJECTIVE

The aim of this study was to investigate whether low skeletal muscle mass is associated with clinical outcomes in patients with abdominal trauma.

METHODS

Patients presenting to our institution with abdominal trauma from January 2010 to April 2020 were retrospectively included. Low skeletal muscle mass was defined, using computed tomography, as skeletal muscle index (SMI) at the third lumbar vertebra below the lowest sex-specific quartile within 1 wk of admission. Clinical outcomes such as complications, hospital stay, and hospital cost were recorded, and univariate and multivariate analyses were performed.

RESULTS

Among 684 patients, 451 were eligible. Of these, 112 (24.8%) were classified as having low skeletal muscle mass, based on SMI diagnostic cutoff values (42.08 cm²/m² for men and 37.35 cm²/m² for women). Low skeletal muscle mass was significantly associated with longer hospital length of stay, longer intensive care length of stay, higher cost, higher frequency of mechanical ventilation, longer duration of vasopressor use, and higher incidence of massive transfusion and overall complications (P < 0.05). Subgroup analysis showed that pneumonia, acute gastrointestinal dysfunction, cholecystitis, digestive tract fistula, gastric fistula, and intestinal fistula were significantly associated with low skeletal muscle mass (P < 0.05). Multivariate analysis showed that low skeletal muscle mass was an independent risk factor for overall complications (odds ratio [OR], 2.44; 95% confidence interval [CI], 1.33-4.49; P = 0.004), hospital length of stay (OR, 3.49; 95% CI, 1.96-6.20; P < 0.001), and hospital cost (OR, 2.67; 95% CI, 1.48-4.80; P = 0.001).

CONCLUSIONS

Low skeletal muscle mass could be an independent predictor of poor clinical outcomes in patients with abdominal trauma.

Serum Biomarkers Associated with Malnutrition and Nutritional Risk in Elderly Primary Care Patients: A Cross-sectional Study from Bosnia and Herzegovina

BACKGROUND

The aim of the study was to determine the ability of ferritin, haemoglobin, albumin and total cholesterol to identify nutritional risk and malnutrition among elderly primary care patients.

METHODS

The cross-sectional study included 446 elderly adults over 65 years of age from four areas of Bosnia and Herzegovina. In addition to anthropometric, functional, cognitive and biochemical indicators, nutritional status was evaluated using 24-hour recall of meals, the Mini Nutritional Assessment (MNA), and Seniors in the Community: Risk Evaluation for Eating and Nutrition, Version II (SCREEN II).

RESULTS

Malnourished/at-risk study respondents had lower mean levels of haemoglobin (P=0.001) and total cholesterol (P<0.001), compared to those with normal nutritional status. Albumin levels significantly differed regarding nutritional status (P=0.004), but not nutritional risk level (P=0.521). Significant differences in serum ferritin levels were not found between malnourished and normally nourished study respondents (P=0.779) Determinants of albumin level were eating more than three meals a day (P<0.001), fewer than two portions of fruit and vegetables a day (P=0.024), drinking one glass of wine (P<0.001) and reporting functional independence (P=0.011). The AUC curves for serum ferritin, albumin and total cholesterol levels in men and women, as well as for haemoglobin levels in women, were poor to fair (AUC<0.800).

CONCLUSION

Although ferritin, haemoglobin, albumin and total cholesterol may be useful biomarkers of nutritional status, their accuracy in diagnosing malnutrition and nutritional risk among elderly primary health care patients is limited.

Low serum cholinesterase predicts complication risk after orthopedic surgery in elderly patients: an observational pilot study

BACKGROUND

Serum cholinesterase (ChE) in elderly adults is associated with geriatric conditions such as sarcopenia and malnutrition. The aim of this study is to examine the impact of preoperative serum ChE on the development of complications after noncardiac surgery in elderly patients without liver cirrhosis.

METHODS

We retrospectively identified all patients aged ≥ 65 years who underwent orthopedic surgery over a 1.5-year period in our hospital. The main outcome was postoperative complications, defined as a deviation from the normal postoperative course within 30 days postoperatively.

RESULTS

A total of 313 patients (median age 79 years) were included. The incidence of all-cause postoperative complications was 15.7% (49/313 patients). Receiver operating characteristic curve analysis showed that serum ChE was a univariable factor that predicted all-cause complications with moderate accuracy (area under the curve = 0.694, 95% confidence interval (CI) 0.604-0.783), with an optimal serum ChE cutoff level of 200 units/L. After multivariate analyses adjusted by baseline characteristics, low serum ChE remained a significant risk factor for postoperative complications (odds ratio = 2.99, 95% CI 1.41-6.33, P = 0.004).

CONCLUSIONS

Low serum ChE (< 200 unit/L) is a significant risk factor for postoperative complications after orthopedic surgery in patients aged ≥ 65 years.

Second-line chemotherapy in biliary tract cancer: Outcome and prognostic factors

BACKGROUND & AIMS

The prognosis of biliary tract cancer (BTC) is poor. Standard treatment for advanced BTC is a chemotherapy (CT) with gemcitabine and cisplatin. Phase III evidence for a second-line (2L) CT is lacking. We aimed to investigate the feasibility of a 2L CT, to estimate the outcome and to identify prognostic markers.

METHODS

Patients of our institution with advanced BTC between 2000 and 2015 receiving CT were included. Data were analysed in univariate and multivariate analysis.

RESULTS

Three-hundred and fifteen and 144 patients (45.7%) received first-line (1L) and 2L CT respectively. The OS of patients receiving 2L CT was 16.67 and 9.9 months from the beginning of 1L and 2L CT respectively. The overall response rate and the disease control rate after 3 months were 9.7% and 33.6% respectively. Adverse events of grade 3 or more were observed in 26.1%. One patient died of gemcitabine-related haemolytic uraemic syndrome. Age of more than 70 years was not associated with a poor outcome. In multivariate analysis, CEA levels of >3 µg/L (P = 0.004, hazard ratio [HR] 1.89, 95% CI 1.22, 2.91), cholinesterase (CHE) levels of <5 kU/L (P = 0.001, HR 2.11, 95% CI 1.34, 3.31) and leukocytosis (P = 0.001, HR 2.90, 95% CI 1.51, 5.56) were associated with poor survival.

CONCLUSIONS

Despite a relevant toxicity, our data suggest that 2L CT may be feasible in fit BTC patients. CEA elevation, leukocytosis and low CHE levels are unfavourable prognostic markers. Results from prospective randomized trials are urgently awaited.

Are Albumin Levels a Good Predictor of Mortality in Elderly Patients with Neck of Femur Fractures?

BACKGROUND

Neck of femur (NOF) fractures are associated with significant morbidity and mortality in elderly people with multiple co-morbidities; making management of this patient subgroup challenging. Predictors of an increase in morbidity and mortality would therefore provide a useful framework for the assessment and management of this demographic. Within the current literature, hypoalbuminaemia (<35g/dl) has been highlighted as being a good biochemical predictor of short-term mortality (<12 months). Our aims were to assess whether there was an association between low albumin levels and mortality and whether the severity adversely affects outcomes.

MATERIALS AND METHODS

Patients admitted to our large district hospital between January 2011 and December 2012 who had sustained a NOF fracture, were over 65 years old and had a pre-operative albumin level were included. This retrospective, longitudinal, observational study concluded in July 2014. Demographic and pre-operative function and albumin data was collated retrospectively. An association with mortality was made.

RESULTS

471 patients had usable data. Mean pre-operative albumin level was 29.5g/dl (SD 6.22g/dl) in patients who died and 32.8g/dl (SD 6.43g/dl) in patients who survived during the study period. Pre-operative albumin level was significantly associated with survival (hazard ratio 0.957: 95% CI (0.937, 0.978); p<0.001). Thus, a reduction of 1g/dl in pre-operative albumin is associated with an increased hazard of death of 4.3%.

CONCLUSIONS

Early identification of patients with hypoalbuminaemia on admission with a venous blood sample and timely input from orthogeriatrians could optimise these patients pre- and post-operatively. This may enable rates of morbidity and mortality to fall. Hypoalbuminaemia may be a reasonable predictor of shorter-term mortality in this patient subgroup. However, this may reflect existing co-morbidities rather than an isolated cause. This study supports an association between hypoalbuminaemia and poorer outcome for patients with NOF fractures.