Is this elderly patient dehydrated? Diagnostic accuracy of hydration assessment using physical signs, urine, and saliva markers. J Am Med Dir Assoc. 2015;16:221-228. [PMID: 25444573 DOI: 10.1016/j.jamda.2014.09.012]

Hand-carried ultrasound for volaemia assessment in older adults: A prospective observational study

BACKGROUND

Clinical assessment of volaemia is a daily challenge in geriatric care. Access to standard transthoracic echocardiography may be limited. Right atrial pressure is influenced by volaemia and can be estimated from inferior vena cava (IVC) diameter and collapsibility measured by hand-carried ultrasound (HCU). These pocket-size devices enable rapid bedside evaluation.

AIMS

To determine the added value of HCU performed by geriatricians in addition to clinical and biological data for assessing volaemia (hypovolaemia, euvolaemia or hypervolaemia).

METHODS

This single-centre prospective observational cross-sectional study included patients hospitalized in geriatric care units whose extracellular volume status was in doubt, based on clinical and biological data. IVC diameter and collapsibility index were assessed by geriatricians using HCU.

RESULTS

Overall, 102 patients were included (median [interquartile range] age 89 [84-94] years, 58% women). Volaemia based on clinical and biological data was different from that assessed by HCU in 54 patients (53%, 95% confidence interval [CI] 43-63%; Cohen's κ=0.15). This discordance was associated with the absence of clinically detectable jugular vein distension (P=0.014). The most frequent discordance (n=37) was clinical-biological suspicion of hypervolaemia in euvolaemic patients according to HCU. This led to a therapeutic impact (stopping or starting drugs) in 36 patients (35%, 95% CI 26-44%).

CONCLUSION

HCU performed during hospitalization for a suspicion of volaemia imbalance provides an assessment that differs from clinical-biological assessment in approximately 50% of cases. HCU could be a useful tool in geriatric care units to improve the diagnosis and management of volaemia.

Development and evaluation of a rapid skin taurine measurement device using skin blotting for the early detection of dehydration

AIM

Skin blotting is a noninvasive method to collect molecules like skin taurine, a dehydration indicator, by applying a membrane to the skin. However, quantifying skin taurine takes an hour due to the long process of staining and measurement. This study aimed to determine optimal staining conditions and assess the reliability and validity of spraying and light transmittance as new methods for skin blotting. Image analysis was used to evaluate the impact of these methods.

METHODS

This study consisted of two parts. Study 1 focused on determining taurine staining conditions on the anion exchange membrane. Ethanol concentration for dissolving ninhydrin and spray time were optimized using a standard sample. Light transmittance and image analysis were used to quantify taurine. The relationship between taurine concentration and light transmittance or brightness (from image analysis) was evaluated. Study 2 confirmed the reliability and validity of the new methods using human samples. Reliability was assessed using the intraclass correlation coefficient (ICC), and validity was determined by correlation coefficients between taurine levels quantified by the conventional method with those quantified by light transmittance or image analysis.

RESULTS

The optimal spray time and ethanol concentration were 0.5 s and 90%, respectively, reducing measurement time to 7 min (light transmittance) and 10 min (image analysis). The ICC was 0.48 for light transmittance and 0.81 for image analysis. The correlation coefficients were r = 0.530 for light transmittance and r = 0.609 for image analysis.

CONCLUSIONS

Image analysis, which measures a wider area, showed better reliability and validity in quantifying skin taurine.

Risk Factors and Preventive Measures of Venous Thromboembolism in Trauma Patients using Trauma Embolic Scoring System: A retrospective chart review

BACKGROUND

Venous thromboembolism (VTE) is a major preventable complication in trauma patients, with varying incidence and risk factors across populations.

AIM/OBJECTIVE

To categorize VTE risk in Korean trauma patients using the Trauma Embolic Scoring System (TESS) and assess the application of prophylaxis by risk level.

METHODS

This retrospective study at Korea University Guro Hospital involved 1913 trauma patients over two years. Data on demographics, injury specifics, and preventive treatments were analyzed using TESS. The study examined general, mechanical, and chemical interventions for VTE prevention.

RESULTS

Of the patients, 1.4% were diagnosed with VTE. The average TESS score was 3.20, indicating lower injury severity but higher percentages of surgeries over 2 h and serious injuries. The findings showed VTE occurrences even in patients with TESS scores below the high-risk threshold, particularly in limb injuries. Nurse-led interventions like early physical activity were most common in the low-risk group, while mechanical prophylaxis like anti-embolism stockings was also predominantly used in this group. Chemical prophylaxis showed consistent administration across groups, with 37.5% of the high-risk group receiving Low Molecular Weight Heparin (LMWH), although only a minority received it within the recommended 48-hour.

CONCLUSIONS

The study reveals a need for vigilant monitoring and intervention across all risk categories, underscoring the importance of tailored VTE prevention guidelines in South Korea. It highlights the role of comprehensive management, including patient education and adherence to updated guidelines.

TWEETABLE ABSTRACT

New study categorizes VTE risk in Korean trauma patients using TESS, showing the need for tailored prophylaxis across risk levels #VTEPrevention #TraumaCare.

Association of dietary water intake with body composition and the potential mechanism based on urinary metabolic signatures in Chinese elderly individuals aged 75 years and above

With the rising global aging rate, elderly nutrition and health issues are major concerns. Current research focuses on nutrients such as protein and vitamins, while there are limited studies on water intake in the elderly. The aim of this study was to assess whether Chinese people aged over 75 years are meeting the recommended adequate intake (AI) for total water intake and its relationship with body composition. This was done by exploring potential mechanisms through the analysis of urinary metabolites. Water intake and dietary status were collected from 456 community seniors aged over 75 years using a 24-hour water intake and dietary record form. Body composition was determined by bioelectrical impedance analysis (BIA). We found that 16.01% of community seniors reached the AI. The protein, fat-free mass (FFM) and skeletal muscle mass (SMM) levels were all increased in the AI group compared to the Collapse

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MESH Headings

• Humans
• Aged
• Body Composition
• Male
• Female
• Aged, 80 and over
• China
• Drinking
• Diet
• East Asian People

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Grants Collapse

Affiliation(s)

Sai Yao Institute of Nutrition and Health, School of Public Health, Qingdao University, Qingdao, Shandong, 266000, China.
Tianlin Gao Institute of Nutrition and Health, School of Public Health, Qingdao University, Qingdao, Shandong, 266000, China.
Yajun Liu Institute of Nutrition and Health, School of Public Health, Qingdao University, Qingdao, Shandong, 266000, China.
Ying Zhou Institute of Nutrition and Health, School of Public Health, Qingdao University, Qingdao, Shandong, 266000, China.
Zhixuan Zhao Institute of Nutrition and Health, School of Public Health, Qingdao University, Qingdao, Shandong, 266000, China.
Yinkun Wang Institute of Nutrition and Health, School of Public Health, Qingdao University, Qingdao, Shandong, 266000, China.
Xincen Wang Institute of Nutrition and Health, School of Public Health, Qingdao University, Qingdao, Shandong, 266000, China.
Aiguo Ma Institute of Nutrition and Health, School of Public Health, Qingdao University, Qingdao, Shandong, 266000, China.
Feng Zhong Institute of Nutrition and Health, School of Public Health, Qingdao University, Qingdao, Shandong, 266000, China.

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Collaborators Collapse

Assessment of Exercise-Induced Dehydration Status Based on Oral Mucosal Moisture in a Field Survey

Background/Objective: Conventional techniques for evaluating hydration status include the analysis of blood, urine, and body weight. Recently, advancements in dentistry have introduced capacitance sensor-based oral epithelial moisture meters as promising avenues for assessment. This study aimed to examine the correlation between oral mucosal moisture content, as determined using a capacitance sensor, and exercise-induced dehydration. Methods: A total of 21 participants engaged in a 120 min slow distance exercise session. A series of measurements were taken before and after the exercise session, including body weight, sweat rate, secretory immunoglobulin A (s-IgA) concentration in saliva samples, saliva flow rate, and oral mucosal moisture content, which were assessed using a capacitance sensor. The relationship between physical dehydration and oral mucosal moisture content was investigated using statistical analysis. Receiver operating characteristic curves were constructed to ascertain whether variations in oral mucosal moisture content could discern body mass losses (BMLs) of 1.5% and 2%. Results: A significant correlation was observed between the sweat rate during exercise and the change in oral mucosal moisture content before and after exercise (Spearman's rank correlation coefficient: ρ = -0.58, p < 0.001). The salivary flow and s-IgA secretion rates were lower after the exercise period than before, whereas the s-IgA concentration was higher. Oral mucosal moisture decreased during the exercise period. Receiver operating characteristic curve analysis revealed that differences in oral mucosal moisture content exhibited discriminative capabilities, with area under the curve values of 0.79 at 1.5% BML and 0.72 at 2% BML. Conclusions: The measurement of oral mucosal moisture using capacitance sensors represents a promising noninvasive approach for the assessment of exercise-induced dehydration.

Reliability and minimal detectable change of the MX3 hydration testing system

Assessing hydration status outside of laboratories can be challenging given that most hydration measures are invasive, stationary, costly, or have questionable validity. This study investigated the within-day, test-retest reliability, and minimal detectable change (MDC) of the MX3 Hydration Testing System (MX3 Diagnostics), a relatively low cost, noninvasive, and portable method to measure saliva osmolality. Seventy-five adults (44 men, 31 women; 29.6±10.8 yr, 171.1±9.2 cm, 79.1±15.4 kg) presented two saliva samples approximately 3 to 5 minutes apart. Fluid intake was avoided for at least 5 minutes prior to sample collections. For each sample collection, a researcher used the MX3 to tap the tip of a test strip to saliva on a participant's tongue. Intra-class correlation coefficients (ICCs) and MDC were calculated as measures of reliability. Means for the two measurements were 64.3±19.0 mOsm and 65.5±17.9 mOsm (mean difference of -1.2±13.0 mOsm; t = -0.806, p = 0.423). Further analysis with a two-one-sided test procedure revealed equivalence between the two SOSM measurements (p < 0.001 for upper and lower bounds). Within-day repeat measures yielded an ICC of 0.75 and an MDC at the 90% confidence level of 21.3 mOsm. With moderate-to-good reliability, the MX3 appears to be a practical choice for reliably measuring moderate-sized changes (>20 mOsm) in saliva osmolality outside of laboratory constraints.

The Effects of Diet, Dietary Supplements, Drugs and Exercise on Physical, Diagnostic Values of Urine Characteristics

Background/Objectives: This review summarizes the current knowledge about factors that affect the physical characteristics of urine. It highlights proper urine sample collection and displays factors like diet, hydration status, and medications that can alter urine color, odor, clarity, specific gravity and pH. Results: Urinalysis is a minimally invasive examination of a patient's health, especially concerning nephrological and endocrinological abnormalities, as well as dietary habits and stimulants used. Certain deviations in appearance, composition or frequency/pain during urination may indicate an ongoing disease process in the body. Based on laboratory results, further medical treatment is determined. The reason for a change in the color of the urine, for its clouding or intense odor may be a disease, as well as the consumption of food, medication, intensive physical exercise or inadequate hydration of the body. Well-standardized procedures for collecting, transporting, preparing and analyzing samples should become the basis for an effective diagnostic strategy in urinalysis. It is worth noting that pharmacists in pharmaceutical care are often the first people to whom a patient turns for health advice and for the interpretation of simple laboratory tests. Acquiring the ability to interpret the results of laboratory tests and the principles of proper sampling for laboratory tests is indispensable in the process of possible counseling and providing reliable answers to patients' questions. Conclusions: Although urinalysis is not recommended as a routine screening tool for the general population, it can prove to be a valuable source of patient health data in some cases as the data will be useful to physicians and pharmacists to more effectively diagnose and better care for patients.

A novel test for hyposalivation using a sugar cube

BACKGROUND

Hyposalivation is a highly prevalent condition in old persons.

OBJECTIVES

The aim of this study was to assess a novel tool for the diagnosis of hyposalivation using a sugar cube and to compare its reliability to other validated test methods.

METHODS

Five tests were performed: unstimulated salivary flow test by draining method (USFT), oral moisture device Mucus® (MCS), sugar cube test (SCT), stimulated salivary flow test by chewing gum (CG) and Saxon test (SX). The sugar cube test consisted in measuring the time needed to disintegrate a standard-sized sugar cube N°4 (5.6 g) placed beneath the tongue. Bivariate correlation analyses were performed. ROC curve analysis and the Youden Index were used to determine the cut-off value. Sensitivity and specificity were calculated according to the determined cut-off point.

RESULTS

A total of 121 participants were recruited, with an average age of 49.8 ± 18.2 years. The USFT was best correlated with the SCT. No correlation was found between SCT and the stimulated saliva tests (CG, SX) as well as the MCS test. According to the Youden index, 140 s is appropriate to diagnose hyposalivation. Sensitivity of .64 and specificity of .91 were found for SCT using USFT as gold standard. The mean subjective evaluation score of the SCT was 3.1 ± 1, significantly higher than USFT 2.6 ± 1.1 (p < .05).

CONCLUSIONS

The sugar cube test proved to be a useful method for assessing unstimulated salivation, reducing test execution time and causing less participant discomfort than the gold standard unstimulated salivary flow test.

Towards non-invasive tissue hydration measurements with optical coherence tomography

The attenuation coefficient ( μ OCT ) measured by optical coherence tomography (OCT) has been used to determine tissue hydration. Previous dual-wavelength OCT systems could not attain the needed precision, which we attribute to the absence of wavelength-dependent scattering of tissue in the underlying model. Assuming that scattering can be described using two parameters, we propose a triple/quadrupole-OCT system to achieve clinically relevant precision in water volume fraction. In this study, we conduct a quantitative analysis to determine the necessary precision of μ OCT measurements and compare it with numerical simulation. Our findings emphasize that achieving a clinically relevant assessment of a 2% water fraction requires determining the attenuation coefficient with a remarkable precision of 0.01 m m - 1 . This precision threshold is influenced by the chosen wavelength for attenuation measurement and can be enhanced through the inclusion of a fourth wavelength range.

Optimizing Recovery in Elderly Patients: Anabolic Benefits of Glucose Supplementation during the Rehydration Period

BACKGROUND

Since many acutely admitted older adults display signs of dehydration, treatment using balanced crystalloids is an important part of medical care. Additionally, many of these patients suffer from chronic malnutrition. We speculated that the early addition of glucose might ameliorate the hospital-related drop of caloric intake and modify their catabolic status.

METHODS

We included patients 78 years and older, admitted acutely for non-traumatic illnesses. The patients were randomized into either receiving balanced crystalloid (PlasmaLyte; group P) or balanced crystalloid enriched with 100 g of glucose per liter (group G). The information about fluid balance and levels of minerals were collected longitudinally.

RESULTS

In the G group, a significantly higher proportion of patients developed signs of refeeding syndrome, i.e., drops in phosphates, potassium and/or magnesium when compared to group P (83.3 vs. 16.7%, p < 0.01). The drop in phosphate levels was the most pronounced. The urinalysis showed no differences in the levels of these minerals in the urine, suggesting their uptake into the cells. There were no differences in the in-hospital mortality or in the 1-year mortality.

CONCLUSION

The short-term administration of balanced crystalloids with glucose induced an anabolic shift of electrolytes in acutely admitted older adults.

Integration of a new technology into a work system: a case study of a smart drinking glass in French nursing homes

PURPOSE

To reduce the risk of dehydration in older adults, the French company Auxivia has developed a smart drinking glass (SDG) that can measure the amount of water drunk. The present study looked at the various work systems (WSs) designed for use of the SDG in a nursing home. The study's objectives were to (i) determine the WSs' impact on the staff's ability to comply with the device's prerequisites and ensure the device's effective use and (ii) draw up guidelines on designing work systems.

MATERIALS AND METHODS

At three nursing homes in France, two independent observers performed 9 h of observations at each site and a total of 29 interviews.

RESULTS

Decisions concerning implementation and the resulting WSs have an impact on the tasks to be performed, the tasks' inherent constraints and the use of the SDG. It is essential to take account of the sociotechnical system as a whole before integrating a technology. Ideally, the introduction of an SDG will go unnoticed by staff and residents; however, our results emphasize the value of highlighting work constraints via a human factors analysis.

CONCLUSIONS

It is essential to take account of sociotechnical WSs as a whole when integrating a technology.

Detection of low urine output by measuring urinary biomarkers

BACKGROUND

Urine output < 1 L per 24 h is a clinical warning sign that requires attention from hospital staff, who should determine whether the low flow is due to low habitual intake of water or disease-induced dehydration. The incidence of this condition is unclear.

METHODS

A cohort of 20 healthy volunteers (mean age 42 years, range 23-62 years) recorded their food and water intakes daily for 8 days. They also collected and measured all urine and delivered first morning urine samples for analysis of osmolality and creatinine. Optimal cutoffs for these biomarkers to indicate urine output of < 1 L or 15 mL/kg during the preceding 24 h were applied with and without correction for age to cross-sectional data from 1,316 subjects in various clinical settings, including healthy volunteers, preoperative patients, patients seeking acute care at a hospital, and patients receiving institutional geriatric care.

RESULTS

The urine output amounted to < 1 L during 22 of the 159 evaluable study days and was indicated by urine osmolality > 760 mosmol/kg or urine creatinine > 13 mmol/L, which had sensitivity and specificity of approximately 80%. Days with urine output < 1 L were associated with significantly less intake of both water (-41%) and calories (-22%) compared to other days. Application of age-corrected biomarker cutoffs to the 1,316 subjects showed a stronger dependency of low urine output on age than the clinical setting, occurring in 44% of the 72 participants aged 15-30 years and 18% of the 62 patients aged 90-104 years.

CONCLUSION

Biomarkers measured in morning urine of young and middle-aged volunteers indicated urine output of < 1 L with good precision, but the cutoffs should be validated in older age groups to yield reliable results.

TRIAL REGISTRATIONS

ISRCTN12215472 at http://www.isrctn.com ; NCT01458678 at ClinicalTrials.gov, and ChiCTR-TNRC-14,004,479 at the chictr.org/en.

Associations between genetically predicted sex and growth hormones and facial aging in the UK Biobank: a two-sample Mendelian randomization study

Background

Aging is an inescapable process, but it can be slowed down, particularly facial aging. Sex and growth hormones have been shown to play an important role in the process of facial aging. We investigated this association further, using a two-sample Mendelian randomization study.

Methods

We analyzed genome-wide association study (GWAS) data from the UK Biobank database comprising facial aging data from 432,999 samples, using two-sample Mendelian randomization. In addition, single-nucleotide polymorphism (SNP) data on sex hormone-binding globulin (SHBG) and sex steroid hormones were obtained from a GWAS in the UK Biobank [SHBG, N = 189,473; total testosterone (TT), N = 230,454; bioavailable testosterone (BT), N = 188,507; and estradiol (E2), N = 2,607)]. The inverse-variance weighted (IVW) method was the major algorithm used in this study, and random-effects models were used in cases of heterogeneity. To avoid errors caused by a single algorithm, we selected MR-Egger, weighted median, and weighted mode as supplementary algorithms. Horizontal pleiotropy was detected based on the intercept in the MR-Egger regression. The leave-one-out method was used for sensitivity analysis.

Results

SHBG plays a promoting role, whereas sex steroid hormones (TT, BT, and E2) play an inhibitory role in facial aging. Growth hormone (GH) and insulin-like growth factor-1 (IGF-1) levels had no significant effect on facial aging, which is inconsistent with previous findings in vitro.

Conclusion

Regulating the levels of SHBG, BT, TT, and E2 may be an important means to delay facial aging.

Hydration Status Assessment in Older Patients

BACKGROUND

Hydration disturbances are common in old age: the reported prevalence of dehydration in elderly patients ranges from 19% to 89%, depending on the definition and the population in question. However, the clinical assessment of patients' hydration status is difficult. In this review, we discuss the diagnostic value of currently used methods that may or may not be suitable for assessing older patients' hydration status.

METHODS

We conducted a selective literature search for relevant studies concerning patients aged 65 and above. Of the 355 articles retrieved by the initial search, a multistep selection process yielded 30 that were suitable for inclusion in this review.

RESULTS

107 different methods for the diagnostic assessment of dehydration in older persons were evaluated on the basis of the reviewed publications. High diagnostic value, especially for the determination of hyperosmolar dehydration, was found for serum osmolality, serum sodium concentration, inferior vena cava ultrasonography, a history (from the patient or another informant) of not drinking between meals, and axillary dryness. On the other hand, a variety of clinical signs such as a positive skin turgor test, sunken eyes, dry mouth, tachycardia, orthostatic dysregulation, and dark urine were found to be of inadequate diagnostic value.

CONCLUSION

Only five of the 107 methods considered appear to be suitable for determining that a patient is dehydrated. Thus, the available scientific evidence indicates that all clinicians should critically reconsider their own techniques for assessing hydration status in elderly patients. To optimize the clinical assessment of patients' hydration status, there seems to be a need for the rejection of unsuitable methods in favor of either newly developed criteria or of a combination of the best criteria already in use.

New horizons in the diagnosis and management of dehydration

Hydration is a fundamental aspect of clinical practice and yet it is an under-researched topic, particularly in older people, leading to many areas of uncertainty. There are two types of dehydration; hypertonic, which is a water deficit, and isotonic, which is a deficit of both water and salt. Individual clinical signs and bedside tests are poor diagnostic tools, making dehydration difficult to identify. However, the diagnostic value of a holistic clinical approach is not known. The gold-standard clinical test for dehydration is serum osmolality, but this cannot diagnose isotonic dehydration and may delay diagnosis in acute situations. Salivary osmolality point-of-care testing is a promising and rapid new diagnostic test capable of detecting both hypertonic and isotonic dehydration in older people, but further evidence to support its clinical utility is needed. Daily fluid requirements may be less than previously thought in adults, but the evidence specific to older people remains limited. Hydration via the subcutaneous route is safer and easier to initiate than the intravenous route but is limited by infusion speed and volume. Prompting older adults more frequently to drink, offering a wider selection of drinks and using drinking vessels with particular features can result in small increases in oral intake in the short-term. The ongoing clinically-assisted hydration at end of life (CHELsea II) trial will hopefully provide more evidence for the emotive issue of hydration at the end of life.

Low-intake dehydration prevalence in non-hospitalised older adults: Systematic review and meta-analysis

BACKGROUND & AIMS

Low-intake dehydration amongst older people, caused by insufficient fluid intake, is associated with mortality, multiple long-term health conditions and hospitalisation. The prevalence of low-intake dehydration in older adults, and which groups are most at-risk, is unclear. We conducted a high-quality systematic review and meta-analysis, implementing an innovative methodology, to establish the prevalence of low-intake dehydration in older people (PROSPERO registration: CRD42021241252).

METHOD

We systematically searched Medline (Ovid), Cochrane CENTRAL, Embase (Ovid), CINAHL and Proquest from inception until April 2023 and Nutrition and Food Sciences until March 2021. We included studies that assessed hydration status for non-hospitalised participants aged ≥65 years, by directly-measured serum/plasma osmolality, calculated serum/plasma osmolarity and/or 24-h oral fluid intake. Inclusion, data extraction and risk of bias assessment was carried out independently in duplicate.

RESULTS

From 11,077 titles and abstracts, we included 61 (22,398 participants), including 44 in quality-effects meta-analysis. Meta-analysis suggested that 24% (95% CI: 0.07, 0.46) of older people were dehydrated (assessed using directly-measured osmolality >300 mOsm/kg, the most reliable measure). Subgroup analyses indicated that both long-term care residents (34%, 95% CI: 0.09, 0.61) and community-dwelling older adults (19%, 95% CI: 0.00, 0.48) were highly likely to be dehydrated. Those with more pre-existing illnesses (37%, 95% CI: 0.14, 0.62) had higher low-intake dehydration prevalence than others (15%, 95% CI: 0.00, 0.43), and there was a non-significant suggestion that those with renal impairment (42%, 95% CI: 0.23, 0.61) were more likely to be dehydrated than others (23%, 95% CI: 0.03, 0.47), but there were no clear differences in prevalence by age, sex, functional, cognitive or diabetic status. GRADE quality of evidence was low as to the exact prevalence due to high levels of heterogeneity between studies.

CONCLUSION

Quality-effects meta-analysis estimated that a quarter of non-hospitalised older people were dehydrated. Widely varying prevalence rates in individual studies, from both long-term care and community groups, highlight that dehydration is preventable amongst older people.

IMPLICATIONS

One in every 4 older adults has low-intake dehydration. As dehydration is serious and prevalent, research is needed to better understand drinking behaviour and assess effectiveness of drinking interventions for older people.

Noninvasive Monitoring to Detect Dehydration: Are We There Yet?

The need for hydration monitoring is significant, especially for the very young and elderly populations who are more vulnerable to becoming dehydrated and suffering from the effects that dehydration brings. This need has been among the drivers of considerable effort in the academic and commercial sectors to provide a means for monitoring hydration status, with a special interest in doing so outside the hospital or clinical setting. This review of emerging technologies provides an overview of many technology approaches that, on a theoretical basis, have sensitivity to water and are feasible as a routine measurement. We review the evidence of technical validation and of their use in humans. Finally, we highlight the essential need for these technologies to be rigorously evaluated for their diagnostic potential, as a necessary step to meet the need for hydration monitoring outside of the clinical environment.

Elevated Serum Urea-to-Creatinine Ratio and In-Hospital Death in Patients with Hyponatremia Hospitalized for COVID-19

Hyponatremia is associated with adverse outcomes in hospitalized patients. An elevated value of the serum urea-to-creatinine ratio (UCR) has been proposed as a proxy of hypovolemia. The aim of this study was to investigate the relationship between the UCR and in-hospital death in patients hospitalized with COVID-19 and hyponatremia. We studied 258 patients admitted for COVID-19 between January 2020 and May 2021 with serum sodium at < 135 mmol/L. The primary end-point was all-cause mortality. A 5-unit increase in the serum UCR during hospital stays was associated with an 8% increase in the hazard of all-cause death (HR = 1.08, 95% CI: 1.03-1.14, p = 0.001) after adjusting for potential confounders. In patients with a UCR > 40 at baseline, a > 10 mmol/L increase in serum sodium values within the first week of hospitalization was associated with higher odds of in-hospital death (OR = 2.93, 95% CI: 1.03-8.36, p = 0.044) compared to patients who experienced a < 10 mmol/L change. This was not observed in patients with a UCR < 40. Hypovolemia developing during hospital stays in COVID-19 patients with hyponatremia detected at hospital admission bears an adverse prognostic impact. Moreover, in hypovolemic patients, a > 10 mmol/L increase in serum sodium within the first week of hospital stays may further worsen the in-hospital prognosis.

Prevalence and Risk Score for Hypertonic Dehydration among Community-Dwelling Older Adults: An Analysis of the Bangkok Falls Study

INTRODUCTION

Dehydration is associated with morbidity, and many factors affect dehydration in older adults including age and medication use. This study determined the prevalence of hypertonic dehydration (HD) and factors affecting HD in older adults and developed a risk score (a set of consistent weights that assign a numerical value to each risk factor) which is potentially useful in predicting HD among community-dwelling Thai older adults.

METHODS

Data were obtained from a cohort study of community-dwelling older adults aged ≥60 years in Bangkok, Thailand, between October 1, 2019, and September 30, 2021. Current HD was defined as a serum osmolality >300 mOsm/kg. Univariate and multivariate logistic regression analyses were used to identify factors associated with current and impending HD. The risk score for current HD was developed based on the final multiple logistic regression model.

RESULTS

A total of 704 participants were included in the final analysis. In this study, 59 (8.4%) participants had current HD and 152 (21.6%) had impending HD. We identified three risk factors for HD in older adults: age ≥75 years (adjusted odds ratio [aORs] 2.0, 95% confidence interval [CI]: 1.16-3.46), underlying diabetes mellitus (aORs 3.07, 95% CI: 1.77-5.31), and use of β-blocker medication (aORs 1.98, 95% CI: 1.04-3.78). The increasing risks of current HD with increasing risk scores were 7.4% for a score of 1, 13.8% for a score of 2, 19.8% for a score of 3, and 32.8% for a score of 4.

CONCLUSION

One-third of the older adults in this study had current or impending HD. We identified risk factors for HD and created a risk score for HD in one group of community-dwelling older adults. Older adults with risk scores of 1-4 were at 7.4%-32.8% risk for current HD. The clinical utility of this risk score requires further study and external validation.

Preoperative dehydration identified by serum calculated osmolarity is associated with severe frailty in patients with hip fracture

BACKGROUND & AIMS

Preoperative dehydration is a well-known predictor of in-hospital complications and poor functional outcomes in older patients with hip fractures. In an orthopedic and geriatric cooperative setting, we aimed to investigate whether preoperative dehydration was associated with frailty, prolonged hospital stays and short-term mortality in older patients with hip fractures.

METHODS

This retrospective cohort study was conducted in a Danish university hospital. The study population consisted of patients 65+ years surgically treated for hip fracture. Dehydration was defined as serum calculated osmolarity above 295 mmol/L. Outcomes were frailty at discharge measured by the Multidimensional Prognostic Index, hospital stay of 7 days or more and 90-day mortality.

RESULTS

In total, 214 patients were consecutively included in the study from March 11, 2018, to August 31, 2020. The mean age was 81.2 (SD: 7.6) and 69% of the patients were women. The prevalence of preoperative dehydration was 40%. It was associated with severe frailty (Odds Ratio (OR): 2.08 [95% confidence interval (CI): 1.11-3.90]; p = 0.02) and prolonged hospital stay (OR: 2.28 [95% CI: 1.29-4.04]; p = 0.02). Seven percent died when dehydrated compared to 5% in the non-dehydrated (p = 0.91).

CONCLUSION

Prevalence of preoperative dehydration is high among older patients with hip fractures and is associated with severe frailty and length of hospital stay. Systematic screening for dehydration on admission is advisable and may contribute to more adequate fluid management in the perioperative phase.

Point-of-Care Saliva Osmolarity Testing for the Screening of Hydration in Older Adults With Hypertension

OBJECTIVES

Older adults have an elevated risk of dehydration, a state with proven detrimental cognitive and physical effects. Furthermore, the use of diuretics by hypertensive patients further compounds this risk. This prospective study investigated the diagnostic accuracy of point-of-care (POC) salivary osmolarity (SOSM) measurement for the detection of dehydration in hypertensive adults with and without diuretic pharmacotherapy.

DESIGN

Prospective diagnostic accuracy study.

SETTING

Home visits to patients recruited from 4 community health centers in West Sulawesi, Indonesia.

PARTICIPANTS

A total of 148 hypertensive older adults (57 men, 91 women). The mean ages of male and female patients were 69.4 ± 11.4 and 68.1 ± 7.8 years, respectively.

METHODS

Hypertensive adults were divided into 2 groups based on the presence of diuretics in their pharmacotherapeutic regimen. First-morning mid-stream urine samples were used to perform urine specific gravity (USG) testing. Same-day SOSM measurements were obtained using a POC saliva testing system.

RESULTS

Both USG (P = .0002) and SOSM (P < .0001) were significantly elevated in hypertensive patients with diuretic pharmacotherapy. At a USG threshold of ≥1.030, 86% of diuretic users were classified as dehydrated compared with 55% of non-using participants. A strong correlation was observed between USG and SOSM measurements (r = 0.78, P < .0001). Using a USG threshold of ≥1.030 as a hydration classifier, an SOSM threshold of ≥93 mOsm had a sensitivity of 78.6% and a specificity of 91.1% for detecting dehydration.

CONCLUSIONS AND IMPLICATIONS

Hypertensive patients on diuretics have significantly higher first-morning USG and SOSM values, indicating a higher likelihood of dehydration relative to those on other classes of antihypertensive medication. POC SOSM assessment correlates strongly with first-morning USG assessment, and represents a rapid and noninvasive alternative to urinary hydration assessment that may be applicable for routine use in populations with elevated risk of dehydration.

Head computed tomography for elderly patients with acute altered mental status in the emergency setting: value for decision-making and predictors of abnormal findings

OBJECTIVE

This study evaluated the impact of head computed tomography (CT) on clinical decision-making about older adults with acute altered mental status (AMS) in the emergency department in terms of CT's diagnostic yield, emergency department length of stay, and changes in medical strategy. It also attempted to find predictors of an acute imaging abnormality.

METHODS

This was a 1-year, retrospective, single-center observational study of patients aged ≥75 years who underwent noncontrast head CT because of an isolated episode of AMS. The acute positive CT findings were ischemic strokes, hemorrhages, tumors, demyelinating lesions, hydrocephalus, and intracranial infections.

RESULTS

A total of 594 CTs were performed, of which 38 (6.4%) were positive. The main etiology of AMS was sepsis (29.1%). Changes in medical strategy were more common in patients with a positive CT, and the major changes were ordering additional neuro exams (odds ratio [OR], 95.3; 95% confidence interval [CI], 38.4-233.8; P<0.001), adjusting treatments (OR, 12.2; 95% CI, 5.0-29.5; P<0.001), and referral to a neurologic unit (OR, 7.3; 95% CI, 3.0-17.5; P<0.01). Three factors were significantly associated with a positive outcome: Glasgow Coma Scale <13 (OR, 8.5; 95% CI, 2.3-28.9; P<0.001), head wound (OR, 3.1; 95% CI, 1.1-8.2; P=0.025), and dehydration (OR, 0.3; 95% CI, 0.1-0.4; P=0.021). For elderly patients with a Glasgow Coma Scale ≥13 and no head wound or clinical dehydration, the probability of a positive CT was 0.02 (95% CI, 0.01-0.04). Considering only those patients, the diagnostic yield fell to 1.7%.

CONCLUSION

In elderly patients, the causes of AMS are primarily extracerebral. Randomized clinical trials are needed to validate a clinical pathway for selecting patients who require emergent neuroimaging.

Personalized wearable electrodermal sensing-based human skin hydration level detection for sports, health and wellbeing

Personalized hydration level monitoring play vital role in sports, health, wellbeing and safety of a person while performing particular set of activities. Clinical staff must be mindful of numerous physiological symptoms that identify the optimum hydration specific to the person, event and environment. Hence, it becomes extremely critical to monitor the hydration levels in a human body to avoid potential complications and fatalities. Hydration tracking solutions available in the literature are either inefficient and invasive or require clinical trials. An efficient hydration monitoring system is very required, which can regularly track the hydration level, non-invasively. To this aim, this paper proposes a machine learning (ML) and deep learning (DL) enabled hydration tracking system, which can accurately estimate the hydration level in human skin using galvanic skin response (GSR) of human body. For this study, data is collected, in three different hydration states, namely hydrated, mild dehydration (8 hours of dehydration) and extreme mild dehydration (16 hours of dehydration), and three different body postures, such as sitting, standing and walking. Eight different ML algorithms and four different DL algorithms are trained on the collected GSR data. Their accuracies are compared and a hybrid (ML+DL) model is proposed to increase the estimation accuracy. It can be reported that hybrid Bi-LSTM algorithm can achieve an accuracy of 97.83%.

A study on accuracy and precision of fluid volume measurements by nurses, patients and healthy persons in a clinical setting

AIM

To evaluate the accuracy and precision for assessing fluid intake by examining the ability of nurses, patients and healthy people to visually estimate fluid volumes, thereby reflecting the fluid monitoring process in clinical practice.

DESIGN

A cross-sectional study.

METHODS

This study used the convenience sampling method and involved twenty-five participants from three groups; nurses, patients and healthy people. The participants carried out a set of different visual volume assessments of two types of fluids using two fluid containers. The exact volumes were measured, and the results were compared with the target volumes.

RESULTS

High variations were observed in the fluid volume assessments for patients, nurses and healthy persons and also were observed to be an effect of environmental factors (fluid container or fluid type) on volume perceptions. This highlights the importance of finding new and innovative ways of measuring fluids for oral intake in a hospital setting, to ensure accurate and reliable data on fluid balance and thereby increase patient safety.

Admission Dehydration Status Portends Adverse Short-Term Mortality in Patients with Spontaneous Intracerebral Hemorrhage

The impact of dehydration at admission of patients with spontaneous intracerebral hemorrhage (ICH) on short-term mortality remains ambiguous due to scarce data. All of the consecutive patients with spontaneous ICH, who were referred to our neurovascular center in 2018/19, were assessed for hydration status on admission. Dehydration was defined by a blood urea-to-creatinine ratio > 80. In a cohort of 249 patients, 76 patients (31%) were dehydrated at the time of admission. The following factors were significantly and independently associated with increased 30-day mortality in multivariate analysis: “signs of cerebral herniation” (p = 0.008), “initial midline shift > 5 mm” (p < 0.001), “ICH score > 3” (p = 0.007), and “admission dehydration status” (p = 0.007). The results of the present study suggest that an admission dehydration status might constitute a significant and independent predictor of short-term mortality in patients with spontaneous ICH.

Impaired hydration status in acutely admitted older patients: prevalence and impact on mortality

BACKGROUND

impaired hydration is common in the older people, however studies of its effects on outcome in the acute setting are limited.

OBJECTIVES

to assess (i) the prevalence of impaired hydration, (ii) its relationship with laboratory markers of altered hydration and with (iii) short- and long-term mortality.

DESIGN

retrospective cohort study.

SETTING

University Hospital-Internal Medicine Department.

SUBJECTS

a total of 5,113 older patients consecutively acutely admitted from October 2015 to July 2016.

METHODS

according to calculated serum osmolarity at admission hydration status was stratified in: low osmolarity (<275 mmol/L), euhydration (275-295 mmol/L), impending (296-300 mmol/L) and current dehydration (>300 mmol/L). Relationships with serum sodium, potassium, glucose, urea, estimated glomerular filtration rate (eGFR), haematocrit, urea/creatinine ratio (Urea/Cr) and urine specific gravity (USG) were determined. Charlson Comorbidity Index, Modified Early Warning Score, Glasgow Prognostic Score, Norton score and Nutritional Risk Screening-2002 were calculated.

RESULTS

current and impending dehydration, euhydration and low-osmolarity were detected in 51.7, 17.1, 28.5 and 2.7% of the patients, respectively. Osmolarity correlated with urea (r = 0.846). Associations with serum sodium, creatinine, eGFR and urea/Cr were low but significant, being negligible that with USG and haematocrit. Serum sodium and urea increased in the transition from low- to high-osmolarity (P < 0.001 in all pairwise comparisons). In multivariate modelling current dehydration, functional dependence, clinical instability and high nutritional risk were associated (P < 0.001) with reduced short- and long-term survival.

CONCLUSIONS

impaired hydration is common in older people acutely admitted to medical care and is associated with poor outcome. Early assessment of calculated serum osmolarity is mandatory to target dehydration and hypoosmolar disorders.

A Portable Biodevice to Monitor Salivary Conductivity for the Rapid Assessment of Fluid Status

The evaluation of fluid status can save adults from life-threatening conditions, but the current methods are invasive or time-consuming. Therefore, we developed a portable device for measuring salivary conductivity. This prospective observational study enrolled 20 volunteers with no history of systemic diseases. Participants were observed for 13 h, including water restriction for 12 h followed by rehydration with 1000 mL water within 1 h. Serum and urine biomarkers for fluid status, thirst scales, and salivary conductivity were collected during dehydration and rehydration. No significant differences in age, body mass index, glycohemoglobin, and estimated glomerular filtration rate were noted between sexes. Salivary conductivity increased after water restriction and decreased after rehydration. Similarly, urine osmolality, urine specific gravity, thirst intensity scales, and body weight followed the same trend and were statistically significant. The angiotensin-converting enzyme and aldosterone levels showed the same trend, without reaching statistical significance. The red blood cell count and hemoglobin concentration also followed the same trend. Analyzing the receiver operating characteristic curves, the area under the curve was 0.707 (95% confidence interval 0.542–0.873, p = 0.025). Using the Youden index, the optimal cutoff determined as 2678.09 μs/cm (sensitivity: 90%, specificity: 55%). This biodevice effectively screened dehydration among healthy adults.

Fluid Intake Monitoring Systems for the Elderly: A Review of the Literature

Fluid intake monitoring is an essential component in preventing dehydration and overhydration, especially for the senior population. Numerous critical health problems are associated with poor or excessive drinking such as swelling of the brain and heart failure. Real-time systems for monitoring fluid intake will not only measure the exact amount consumed by the users, but could also motivate people to maintain a healthy lifestyle by providing feedback to encourage them to hydrate regularly throughout the day. This paper reviews the most recent solutions to automatic fluid intake monitoring both commercially and in the literature. The available technologies are divided into four categories: wearables, surfaces with embedded sensors, vision- and environmental-based solutions, and smart containers. A detailed performance evaluation was carried out considering detection accuracy, usability and availability. It was observed that the most promising results came from studies that used data fusion from multiple technologies, compared to using an individual technology. The areas that need further research and the challenges for each category are discussed in detail.

Detection of voluntary dehydration in paediatric populations using non-invasive point-of-care saliva and urine testing

AIM

Voluntary dehydration, or lack of fluid intake despite water availability, is common in otherwise healthy children, and can lead to adverse effects. Most dehydration biomarkers are impractical for routine assessment in paediatric populations. This study aimed to assess two non-invasive hydration assessment tools, urine specific gravity (U_SG ) and a novel point-of-care (POC) salivary osmolarity (SOSM) sensor, in healthy children.

METHODS

Volunteers were tested by colorimetric U_SG and a handheld SOSM system. Observed values were compared against previous studies to determine hydration status, as was the concordance between parameters.

RESULTS

At the common U_SG threshold of 1.020, 42.4% of the 139 healthy children were dehydrated. The same prevalence was found using the 70-mOSM cut-off value. Comparative analysis of SOSM at varying U_SG thresholds demonstrated significantly higher SOSM in dehydrated children with a U_SG  ≥ 1.030 (P = 0.002).

CONCLUSION

At the U_SG threshold of 1.020 and SOSM threshold of 70 mOSM, 42.4% of healthy children were found to be voluntarily dehydrated. Significantly higher SOSM was observed in dehydrated children (U_SG  ≥ 1.030). As the first study on the utility of POC SOSM measurements for detecting dehydration, these results provide a foundation for future POC characterisation of SOSM in other populations and clinical contexts.

Molecular and physical technologies for monitoring fluid and electrolyte imbalance: A focus on cancer population

Several clinical examinations have shown the essential impact of monitoring (de)hydration (fluid and electrolyte imbalance) in cancer patients. There are multiple risk factors associated with (de)hydration, including aging, excessive or lack of fluid consumption in sports, alcohol consumption, hot weather, diabetes insipidus, vomiting, diarrhea, cancer, radiation, chemotherapy, and use of diuretics. Fluid and electrolyte imbalance mainly involves alterations in the levels of sodium, potassium, calcium, and magnesium in extracellular fluids. Hyponatremia is a common condition among individuals with cancer (62% of cases), along with hypokalemia (40%), hypophosphatemia (32%), hypomagnesemia (17%), hypocalcemia (12%), and hypernatremia (1-5%). Lack of hydration and monitoring of hydration status can lead to severe complications, such as nausea/vomiting, diarrhea, fatigue, seizures, cell swelling or shrinking, kidney failure, shock, coma, and even death. This article aims to review the current (de)hydration (fluid and electrolyte imbalance) monitoring technologies focusing on cancer. First, we discuss the physiological and pathophysiological implications of fluid and electrolyte imbalance in cancer patients. Second, we explore the different molecular and physical monitoring methods used to measure fluid and electrolyte imbalance and the measurement challenges in diverse populations. Hydration status is assessed in various indices; plasma, sweat, tear, saliva, urine, body mass, interstitial fluid, and skin-integration techniques have been extensively investigated. No unified (de)hydration (fluid and electrolyte imbalance) monitoring technology exists for different populations (including sports, elderly, children, and cancer). Establishing novel methods and technologies to facilitate and unify measurements of hydration status represents an excellent opportunity to develop impactful new approaches for patient care.

Prevalence and risk factors of hypertonic dehydration among older patients admitted to the emergency department: A prospective cross-sectional study

AIM

The prevalence of hypertonic dehydration (HD) among community-dwelling and hospitalized populations has been evaluated. However, to our knowledge, no study had previously focused on older patients admitted to the emergency department (ED). The present study aimed to evaluate the prevalence, risk factors and short-term outcomes of HD among Thai older patients admitted to the ED.

METHODS

This was a prospective cross-sectional study at one urban ED in Thailand. Patients aged ≥65 years who were admitted to the ED were enrolled into the study. Data including clinical hydration status, Charlson Comorbidity Index (CCI) score, activities of daily living score, current use of medications, laboratory examination results and serum osmolarity level were collected. HD was defined as a serum osmolarity level of >300 mOsm/kg. The short-term outcomes were a 30-day ED revisit, hospital readmission and mortality rates.

RESULTS

In total, 80 (21.6%) of 370 patients presented with HD. A CCI score of ≥5 was found associated with HD among older patients (adjusted odds ratio: 1.82; 95% confidence interval: 1.03-3.21). The ED revisit rates were 18.1% in the dehydrated group and 10.9% in the non-dehydrated group. The hospital readmission rates were 8.3% in the dehydrated group and 10.6% in the non-dehydrated group. Furthermore, the 30-day mortality rates were 6.9% and 5.3% in the dehydrated and non-dehydrated groups, respectively.

CONCLUSIONS

One-fifth of older patients admitted to the ED presented with HD. A CCI score of ≥5 was considered a risk factor of HD. Moreover, further studies should focus on the long-term outcomes of HD and risk reduction. Geriatr Gerontol Int 2021; 21: 485-491.

Making the choice between bioelectrical impedance measures for body hydration status assessment

Situational or persistent body fluid deficit (i.e., de- or hypo-hydration) is considered a significant health risk factor. Bioimpedance analysis (BIA) has been suggested as an alternative to less reliable subjective and biochemical indicators of hydration status. The present study aimed to compare various BIA models in the prediction of direct measures of body compartments associated with hydration/osmolality. Fish (n = 20) was selected as a biological model for physicochemically measuring proximate body compartments associated with hydration such as water, dissolved proteins, and non-osseous minerals as the references or criterion points. Whole-body and segmental/local impedance measures were used to investigate a pool of BIA models, which were compared by Akaike Information Criterion in their ability to accurately predict the body components. Statistical models showed that ‘volumetric-based’ BIA measures obtained in parallel, such as distance²/R_p, could be the best approach in predicting percent of body moisture, proteins, and minerals in the whole-body schema. However, serially-obtained BIA measures, such as the ratio of the reactance to resistance and the resistance adjusted for distance between electrodes, were the best fitting in predicting the compartments in the segmental schema. Validity of these results should be confirmed on humans before implementation in practice.

Accuracy of the calculated serum osmolarity to screen for hyperosmolar dehydration in older hospitalised medical patients

BACKGROUND AND AIMS

Simple hyperosmolar dehydration, also termed water-loss dehydration (HD), is common in older hospitalised patients, thus increasing the risk of morbidity and mortality. Directly measured serum osmolality is the reference standard to determine HD; however, it is not a routine test due to its complexity and cost. Thus, a simple valid objective diagnostic tool to detect HD is needed. Consequently, we aimed to validate the agreement between measured s-osmolality (mOsm/kg) and calculated s-osmolarity (mOsm/L).

METHODS

Patients aged >65 were included from the emergency medical department at Herlev Hospital, Copenhagen, Denmark. Exclusion criteria were: eGFR< 30 mmol/L, severe heart failure, decompensated cirrhosis, alcohol intake or initiated rehydration treatment. We obtained data for measured s-osmolality as well as calculated osmolarity, using the by ESPEN recommended equation [1.86x (Na⁺ + K⁺)+1.15 ∗glucose + urea+14]. To determine accuracy, we used cut-off values of >295 mOsm/L versus >300 mOsm/kg.

RESULTS

A total of 90 patients (female 53%), age median 78 yrs (72-86 yrs) were included. According to the measured mOsm/kg, impending HD was evident in 32% (n = 10), of these 11% (n = 10) had current HD. There was a significant association between calculated mOsm/L and measured Osm/kg (r² = 0.7513, p < 0.0001). A sensitivity of 90% (95% CL: 56%-100%), a specificity of 68% (95% CL: 56%-78%), Positive predictive value (PPV) of 26% (95% CL: 12%-43%), and Negative predictive value (NPV) of 98% (95% CL: 90%-100%) were observed. Notably, only 20% (n = 2) of the patients who were dehydrated according to the measured Osm/kg were correctly clinically diagnosed with dehydration.

CONCLUSIONS

The equation recommended by ESPEN to calculate osmolarity was found to be an accurate objective diagnostic tool to assess HD in older hospitalised medical patients. The method is markedly superior to the current clinical practice.

Evaluation of urinary chloride dipsticks for the rapid estimation of hydration status in patients receiving artificial nutrition: Feasibility study

BACKGROUND AND AIMS

The home parenteral nutrition (HPN) population face many challenges, especially with respect to fluid balance management. A low urinary sodium concentration of <20 mmol/L is commonly used as an indicator of dehydration that requires clinical assessment in these patients. The Quantab titrator dipstick measures chloride concentration of a solution and correlates with sodium concentration. We assessed whether it would be feasible to use the Quantab dipstick in the HPN population and explored relationships between Quantab dipstick estimated chloride concentration and quality of life (QOL).

METHODS

Patients on HPN were asked to collect urine samples at 5 specific times points (day 0,7,14, 21 and 28) to send to the laboratory for formal electrolyte analysis. The participant and a member of laboratory staff tested these samples with the Quantab dipstick to estimate urinary chloride concentration. Participants were instructed to complete a QOL questionnaire at each of the 5 time-points in addition to a baseline demographic questionnaire and an end-of-study questionnaire. Six participants completed an interview at the end of the study period. The relationship between participant-derived and laboratory-derived data was assessed using rank correlation coefficients. QOL assessment was correlated with urine dipstick measurements.

RESULTS

10 patients on HPN completed the study. Data on chloride concentration as estimated by the dipstick (assessed by participants and by the laboratory) and sodium concentration from the laboratory were available for 47 urine samples. There was a positive relationship between participant dipstick estimated chloride concentration and laboratory sodium (Kendall's τ = 0.45; P < 0.001; Spearman's r_s = 0.58 P < 0.001; 47 pairs). There was a strong correlation between chloride concentrations estimated by dipstick in the laboratory and by participants (Kendall 0.58 p < 0.001, Spearman's 0.69 p < 0.001; 47 pairs). In exploratory analyses, there was no relationship between QOL and dipstick estimated chloride concentration. Participants had no issues collecting urine samples but some difficulties were reported with determining the dipstick reading.

CONCLUSIONS

Patients on HPN are able to collect urine specimens, complete QOL questionnaires, and are capable of using the Quantab dipstick to estimate urinary chloride concentration. The Quantab dipstick correlates with laboratory measured sodium and chloride concentrations. Further work is required to fully establish whether this point-of-care test could be used to guide fluid balance management in the HPN population.

The Effect of Hydration on Urine Color Objectively Evaluated in CIE L*a*b* Color Space

Urine color has been shown to be a viable marker of hydration status in healthy adults. Traditionally, urine color has been measured using a subjective color scale. In recent years, tristimulus colorimetry developed by the International Commission on Illumination (CIE L^*a^*b^*) has been widely adopted as the reference method for color analysis. In the L^*a^*b^* color space, L^* indicates lightness ranging from 100 (white) to 0 (black), while a^* and b^* indicate chromaticity. a^* and b^* are color directions: –a^* is the green axis, +a^* is the red axis, –b^* is the blue axis, and +b^* is the yellow axis. The L^*a^*b^* color space model is only accurately represented in three-dimensional space. Considering the above, the purpose of the current study was to evaluate urine color during different hydration states, with the results expressed in CIE L^*a^*b^* color space. The study included 28 healthy participants (22 males and 6 females) ranging between the age of 20 and 67 years (28.6 ± 11.3 years). One hundred and fifty-one urine samples were collected from the subjects in various stages of hydration, including morning samples after 7–15 h of water deprivation. Osmolality and CIE L^*a^*b^* parameters were measured in each sample. As the urine osmolality increased, a significant linear increase in b^* values was observed as the samples became more pronouncedly yellow (τ_b = 0.708). An increase in dehydration resulted in darker and significantly more yellow urine, as L^* values decreased in lightness and b^* values increased along the blue–yellow axis. However, as dehydration increased, a notable polynomial trend in color along the green–red axis was observed as a^* values initially decreased, indicating a green hue in slightly dehydrated urine, and then increased as urine became more concentrated and thus more dehydrated. It was determined that 74% of the variance seen in urine osmolality was due to CIE L^*a^*b^* variables. This newfound knowledge about urine color change along with the presented regression model for predicting urine osmolality provides a more detailed and objective perspective on the effect of hydration on urine color, which to our knowledge has not been previously researched.

Hypotheses about sub-optimal hydration in the weeks before coronavirus disease (COVID-19) as a risk factor for dying from COVID-19

To address urgent need for strategies to limit mortality from coronavirus disease 2019 (COVID-19), this review describes experimental, clinical and epidemiological evidence that suggests that chronic sub-optimal hydration in the weeks before infection might increase risk of COVID-19 mortality in multiple ways. Sub-optimal hydration is associated with key risk factors for COVID-19 mortality, including older age, male sex, race-ethnicity and chronic disease. Chronic hypertonicity, total body water deficit and/or hypovolemia cause multiple intracellular and/or physiologic adaptations that preferentially retain body water and favor positive total body water balance when challenged by infection. Via effects on serum/glucocorticoid-regulated kinase 1 (SGK1) signaling, aldosterone, tumor necrosis factor-alpha (TNF-alpha), vascular endothelial growth factor (VEGF), aquaporin 5 (AQP5) and/or Na⁺/K⁺-ATPase, chronic sub-optimal hydration in the weeks before exposure to COVID-19 may conceivably result in: greater abundance of angiotensin converting enzyme 2 (ACE2) receptors in the lung, which increases likelihood of COVID-19 infection, lung epithelial cells which are pre-set for exaggerated immune response, increased capacity for capillary leakage of fluid into the airway space, and/or reduced capacity for both passive and active transport of fluid out of the airways. The hypothesized hydration effects suggest hypotheses regarding strategies for COVID-19 risk reduction, such as public health recommendations to increase intake of drinking water, hydration screening alongside COVID-19 testing, and treatment tailored to the pre-infection hydration condition. Hydration may link risk factors and pathways in a unified mechanism for COVID-19 mortality. Attention to hydration holds potential to reduce COVID-19 mortality and disparities via at least 5 pathways simultaneously.

Gastroesophageal Reflux Predicts Utilization of Dehydration Treatments After Bariatric Surgery

BACKGROUND

Dehydration treatments (DT) provide intravenous fluids to patients in the outpatient setting; however, the utilization of DT is not well-described. We characterize the cohort receiving DT, the first year it was recorded in a bariatric-specific database.

SETTING

A retrospective cohort analysis of patients undergoing bariatric surgery between January 1, 2016, and December 31, 2016, in 791 centers in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data file.

METHODS

Patients ≥ 18 years with a body mass index (BMI) ≥ 35 kg/m² who underwent laparoscopic adjustable gastric band (LAGB), sleeve gastrectomy (LSG), Roux-en-Y gastric bypass (LRYGB), and biliopancreatic diversion with duodenal switch (LBPD/DS) were identified. Unadjusted and adjusted rates of DT were analyzed. In addition, adjusted rates and indication for readmission were reviewed.

RESULTS

The overall rate of dehydration treatments was 3.5% for the 141,748 bariatric surgery cases identified. Patient comorbidities of gastroesophageal reflux (GERD) (odds ratio (OR) 1.49; 95% CI, 1.40-1.59), insulin-dependent diabetes (OR = 1.19; 95% CI, 1.07-1.33), and LRYGB (OR = 1.45; 95% CI, 1.36-1.54) were associated with higher odds of DT. DT only had the highest odds of readmission (OR = 6.22; 95% CI, 5.55-6.98) compared to other outpatient visits. Nausea and vomiting, or fluid, electrolyte, or nutritional depletion was the most common indication for readmission in all groups.

CONCLUSIONS

Patients with GERD utilized dehydration treatments after bariatric surgery. DT was highly associated with readmissions, and a better understanding of the clinical application of DT will allow bariatric centers to develop programs to further optimize outpatient treatments.

Association between genetically predicted telomere length and facial skin aging in the UK Biobank: a Mendelian randomization study

Are shorter telomeres causal risk factors for facial aging on a large population level? To examine if longer, genetically predicted telomeres were causally associated with less facial aging using Mendelian randomization analysis. Two-sample Mendelian randomization methods were applied to the summary statistics of a genome-wide association study (GWAS) for self-reported facial aging from 417, 772 participants of the UK Biobank data. Twenty single-nucleotide polymorphisms (SNPs) that were of genome-wide significance were selected as instrumental variables for leukocyte telomere length. The main analyses were performed primarily using the random-effects inverse-variance weighted method and were complemented with the MR-Egger regression, weighted median, and weighted mode approaches. The intercept of MR-Egger regression was used to assess horizontal pleiotropy. Longer genetically predicted telomeres were associated with a lower likelihood of facial aging (β = − 0.02, 95% confidence interval: − 0.04, − 0.002). Comparable results were obtained using MR-Egger regression, weighted median, and weighted mode approaches. The intercept of MR-Egger regression was close to zero (0.002) that was not suggestive of horizontal pleiotropy. Our findings provided evidence to support a potential causal relationship between longer genetically predicted telomeres and less facial aging.

Sublingual microcirculation detects impaired perfusion in dehydrated older patients

BACKGROUND: Dehydration occurs frequently in older patients and constitutes a significant clinical problem. OBJECTIVE: This proof-of-concept study examines whether 1) sublingual measurement in dehydrated old patients is feasible, 2) frailty and incompliance in old, awake patients affects video-quality, 3) dehydration impacts microcirculation METHODS: This prospective observational study included clinically dehydrated patients aged ≥65 years immediately after admission. Dehydration was assessed clinically. A sidestream dark field camera (SDF) was used for measurement. Video-quality was evaluated with MIQS (microcirculation image quality score). Both AVA 4.3C- and AVA POEM-software analyzed the videos. Seventeen patients ≥65 years not showing dehydration served as control. RESULTS: Thirteen patients (8 female) were included. The average age was 83±8 years. The mini-mental test was 17±15 points, the Clinical Frailty Scale 4±3, the Barthel-Index 59±39. None of these parameters correlated with MIQS (3.4±4.2 SD (“acceptable”)). Dehydrated patients had a slightly impaired microcirculation, with a significantly lower percentage of perfused small vessels compared to control (83.1±7.7% versus 88.0±6.0%, P < 0.05). After rehydration, there was acute improvement in the microcirculation. CONCLUSIONS: Sublingual microcirculatory SDF-measurement is both, safe and valid for dehydrated old patients - regardless of frailty, age or cognitive performance. Dehydration leads to an impaired microcirculation.

Signs of Dehydration after Hip Fracture Surgery: An Observational Descriptive Study

Background and Objectives: Dehydration might be an issue after hip fracture surgery, but the optimal tools to identify the dehydrated condition have not been determined. The aim of the present study was to compare the characteristics of elderly postoperative patients who were classified as dehydrated according to the methods used in the clinic. Materials and Methods: Thirty-eight patients aged between 65 and 97 (mean, 82) years were studied after being admitted to a geriatric department for rehabilitation after hip fracture surgery. Each patient underwent blood analyses, urine sampling, and clinical examinations. Results: Patients ingested a mean of 1,008 mL (standard deviation, 309 mL) of fluid during their first day at the clinic. Serum osmolality increased significantly with the plasma concentrations of sodium, creatinine, and urea. Seven patients had high serum osmolality (≥300 mosmol/kg) that correlated with the presence of tongue furrows (p < 0.04), poor skin turgor (p < 0.03), and pronounced albuminuria (p < 0.03). Eight patients had concentrated urine (urine-specific gravity ≥ 1.025) that correlated with a low intake of liquid and with a decrease in body weight during the past month of −3.0 kg (25–75 th percentiles, −5.1 to −0.9) versus +0.2 (−1.9 to +2.7) kg (p < 0.04). Conclusions: Renal fluid conservation of water, either in the form of hyperosmolality or concentrated urine, was found in 40% of the patients after hip fracture surgery. Hyperosmolality might not indicate a more severe fluid deficit than is indicated by concentrated urine but suggests an impaired ability to concentrate the urine.

Non Invasive Skin Hydration Level Detection Using Machine Learning

Dehydration and overhydration can help to improve medical implications on health. Therefore, it is vital to track the hydration level (HL) specifically in children, the elderly and patients with underlying medical conditions such as diabetes. Most of the current approaches to estimate the hydration level are not sufficient and require more in-depth research. Therefore, in this paper, we used the non-invasive wearable sensor for collecting the skin conductance data and employed different machine learning algorithms based on feature engineering to predict the hydration level of the human body in different body postures. The comparative experimental results demonstrated that the random forest with an accuracy of 91.3% achieved better performance as compared to other machine learning algorithms to predict the hydration state of human body. This study paves a way for further investigation in non-invasive proactive skin hydration detection which can help in the diagnosis of serious health conditions.

Design of Appropriate Technology-Assisted Urine Tester Enabling Remote and Long-Term Monitoring of Health Conditions

A novel design idea supported by affordable design processes can address unresolved social problems such as the imbalance of opportunity in healthcare services, owing to high costs and a lack of access. We designed an appropriate technology-assisted urine tester to provide healthcare services for the elderly and underprivileged in order to monitor their health conditions daily and remotely help them determine whether to visit hospitals/clinics for in-depth diagnoses. To minimize production costs, we used a charge-coupled device camera for colorimetric-type urine analysis in conjunction with commercially available urine test strips; all other electronic components were mass-produced. We calibrated this urine tester and compared it with a commercially available high-end tester; the results showed high accuracy for most urine compounds. We verified its major device functions by recruiting four participants who tested their urine over four weeks and provided self-surveys of their health conditions. The proposed tester demonstrates a low price-to-performance ratio with high reliability, while its production and maintenance costs are as low as 20 USD per set. We focused on a human-centered technological approach from a simple and innovative design point of view in order to serve people and healthcare providers in an affordable way. We believe that the tester can be widely distributed, exemplifying appropriate technological application for those who require, but cannot enjoy, proper medical services, thereby improving social healthcare sustainability.

Diagnosing dehydration in the nursing home: international consensus based on a modified Delphi study

Aim

To assess which method (or combination of methods) are relevant and feasible to diagnose dehydration in nursing home residents.

Findings

International experts agreed on the relevance and feasibility of 9 anamnestic items, 8 physical symptoms and 3 blood tests to diagnose dehydration. This resulted in a diagnostic strategy consisting of a suspicion phase (including anamnestic items and physical symptoms) and a confirmation phase (including blood tests).

Message

This is the first study reaching international consensus about a strategy to diagnose dehydration in the nursing home.

Electronic supplementary material

The online version of this article (10.1007/s41999-020-00304-3) contains supplementary material, which is available to authorized users.

Purpose

Even though dehydration is a big problem among nursing home residents, a universally agreed method to diagnose dehydration among nursing home residents is missing. Therefore, this study aimed to establish consensus on a method to diagnose dehydration in this population.

Methods

Using an international Delphi study, 53 experts (physicians and advanced nurse practitioners) were asked to judge various methods to diagnose dehydration on relevance and feasibility in the nursing home. Based on the methods that gained consensus in the first and second round (≥ 75% consensus), a step-by-step diagnostic strategy was developed which was presented to, and judged by, the experts in round three.

Results

After the first and second round, consensus was reached on nine anamnestic items, eight physical symptoms and three blood tests. In the third round, 24 experts agreed with the developed step-by-step diagnostic strategy as a standard to diagnose dehydration in nursing home residents.

Conclusion

This is the first study reaching international consensus on a strategy to diagnose dehydration in the nursing home. This strategy comprehends a presumption phase, where anamnestic items and physical symptoms are examined, followed by a confirmation phase with blood tests to confirm the diagnosis of dehydration. Using this strategy, it is important to take the individual characteristics (e.g. co-morbidity) of the resident and its care environment (e.g. ambient temperature) into account.

Electronic supplementary material

The online version of this article (10.1007/s41999-020-00304-3) contains supplementary material, which is available to authorized users.

Emergency department non-invasive cardiac output study (EDNICO): an accuracy study

BACKGROUND

There is little published data investigating non-invasive cardiac output monitoring in the emergency department (ED). We assess here the accuracy of five non-invasive methods in detecting fluid responsiveness in the ED: (1) common carotid artery blood flow, (2) suprasternal aortic Doppler, (3) bioreactance, (4) plethysmography with digital vascular unloading method, and (5) inferior vena cava collapsibility index. Left ventricular outflow tract echocardiography derived velocity time integral is the reference standard. This follows an assessment of feasibility and repeatability of these methods in the same cohort of ED patients.

METHODS

This is a prospective observational study of non-invasive methods for assessing fluid responsiveness in the ED. Participants were non-ventilated ED adult patients requiring intravenous fluid resuscitation. Sensitivity and specificity of each method in determining the fluid responsiveness status of participants is determined in comparison to the reference standard.

RESULTS

Thirty-three patient data sets were included for analysis. The specificity and sensitivity to detect fluid responders was 46.2 and 45% for common carotid artery blood flow (CCABF), 61.5 and 63.2% for suprasternal artery Doppler (SSAD), 46.2 and 50% for bioreactance, 50 and 41.2% for plethysmography vascular unloading technique (PVUT), and 63.6 and 47.4% for inferior vena cava collapsibility index (IVCCI), respectively. Analysis of agreement with Cohen's Kappa - 0.08 for CCABF, 0.24 for SSAD, - 0.04 for bioreactance, - 0.08 for PVUT, and 0.1 for IVCCI.

CONCLUSION

In this study, non-invasive methods were not found to reliably identify fluid responders. Non-invasive methods of identifying fluid responders are likely to play a key role in improving patient outcome in the ED in fluid depleted states such as sepsis. These results have implications for future studies assessing the accuracy of such methods.