Muscle Mass Loss Is a Potential Predictor of 90-Day Mortality in Older Adults with Aspiration Pneumonia

CT-derived pectoralis composition and incident pneumonia hospitalization using fully automated deep-learning algorithm: multi-ethnic study of atherosclerosis

BACKGROUND

Pneumonia-related hospitalization may be associated with advanced skeletal muscle loss due to aging (i.e., sarcopenia) or chronic illnesses (i.e., cachexia). Early detection of muscle loss may now be feasible using deep-learning algorithms applied on conventional chest CT.

OBJECTIVES

To implement a fully automated deep-learning algorithm for pectoralis muscle measures from conventional chest CT and investigate longitudinal associations between these measures and incident pneumonia hospitalization according to Chronic Obstructive Pulmonary Disease (COPD) status.

MATERIALS AND METHODS

This analysis from the Multi-Ethnic Study of Atherosclerosis included participants with available chest CT examinations between 2010 and 2012. We implemented pectoralis muscle composition measures from a fully automated deep-learning algorithm (Mask R-CNN, built on the Faster Region Proposal Network (R-) Convolutional Neural Network (CNN) with an extension for mask identification) for two-dimensional segmentation. Associations between CT-derived measures and incident pneumonia hospitalizations were evaluated using Cox proportional hazards models adjusted for multiple confounders which include but are not limited to age, sex, race, smoking, BMI, physical activity, and forced-expiratory-volume-at-1 s-to-functional-vital-capacity ratio. Stratification analyses were conducted based on baseline COPD status.

RESULTS

This study included 2595 participants (51% female; median age: 68 (IQR: 61, 76)) CT examinations for whom we implemented deep learning-derived measures for longitudinal analyses. Eighty-six incident pneumonia hospitalizations occurred during a median 6.67-year follow-up. Overall, pectoralis muscle composition measures did not predict incident pneumonia. However, in fully-adjusted models, only among participants with COPD (N = 507), CT measures like extramyocellular fat index (hazard ratio: 1.98, 95% CI: 1.22, 3.21, p value: 0.02), were independently associated with incident pneumonia.

CONCLUSION

Reliable deep learning-derived pectoralis muscle measures could predict incident pneumonia hospitalization only among participants with known COPD.

CLINICAL RELEVANCE STATEMENT

Pectoralis muscle measures obtainable at zero additional cost or radiation exposure from any chest CT may have independent predictive value for clinical outcomes in chronic obstructive pulmonary disease patients.

KEY POINTS

•Identification of independent and modifiable risk factors of pneumonia can have important clinical impact on patients with chronic obstructive pulmonary disease. •Opportunistic CT measures of adipose tissue within pectoralis muscles using deep-learning algorithms can be quickly obtainable at zero additional cost or radiation exposure. •Deep learning-derived pectoralis muscle measurements of intermuscular fat and its subcomponents are independently associated with subsequent incident pneumonia hospitalization.

Prognostic factors of poor outcomes in pneumonia in older adults: aspiration or frailty?

PURPOSE

Little is known about the long-term and functional prognoses of older adults with pneumonia, which complicates their management. There is a common belief that aspiration is a poor prognostic factor; however, the diagnosis of aspiration pneumonia (AP) lacks consensus criteria and is mainly based on clinical characteristics typical of the frailty syndrome. Therefore, the poor prognosis of AP may also be a result of frailty rather than aspiration. This study investigated the impact of AP and other prognostic factors in older patients with pneumonia.

METHODS

We performed a retrospective cohort study of patients aged 75 years and older, admitted with pneumonia in 2021. We divided patients according to their initial diagnosis (AP or non-AP), compared outcomes using Kaplan-Meier curves, and used logistic regression to identify independent prognostic factors.

RESULTS

803 patients were included, with a median age of 84 years and 52.7% were male. 17.3% were initially diagnosed with AP. Mortality was significantly higher in those diagnosed with AP than non-AP during admission (27.6% vs 19.0%, p = 0.024) and at 1 year (64.2% vs 53.1%, p = 0.018), with survival analysis showing a median survival time of 62 days and 274 days in AP and non-AP, respectively (χ2 = 9.2, p = 0.002). However, the initial diagnosis of AP was not an independent risk factor for poor prognosis in multivariable analysis. Old age, frailty and cardio-respiratory comorbidities were the main factors associated with death.

CONCLUSION

The greater mortality in AP may be a result of increased frailty rather than the diagnosis of aspiration itself. This supports our proposal for a paradigm shift from making predictions based on the potentially futile labelling of AP or non-AP, to considering frailty and overall condition of the patient.

Extremely Poor Post-discharge Prognosis in Aspiration Pneumonia and Its Prognostic Factors: A Retrospective Cohort Study

There is little evidence regarding the long-term prognosis of patients with aspiration pneumonia. This study aimed to investigate post-discharge survival time and prognostic factors in older patients hospitalized for aspiration pneumonia. This retrospective cohort study included patients aged ≥ 65 years hospitalized for aspiration pneumonia and discharged alive from a tertiary care hospital in Japan between April 2009 and September 2014. Candidate prognostic factors were patient's age, sex, body mass index (BMI), performance status, chronic conditions, CURB-65 score, serum albumin level, hematocrit concentration, nutritional pathway at discharge, and discharge location. Kaplan-Meier curves were determined and multivariable survival analysis using Cox regression model was performed to analyze the effect of each factor on mortality. In total, 209 patients were included in this study. The median age was 85 years, 58% of the patients were males, 33% had a performance status of 4 and 34% were discharged home. Among the patients, 65% received oral intake, 23% received tube feeding, and 21% received parenteral nutrition at discharge. During the follow-up period, 77% of the patients died, and the median post-discharge survival time was 369 days. Besides male sex and low BMI, tube feeding (adjusted hazard ratio (aHR) = 1.70, 95% confidence interval (CI) 1.11-2.59) and parenteral nutrition (aHR = 4.42, 95% CI 2.57-7.60) were strongly associated with mortality. Long-term prognosis of patients hospitalized for aspiration pneumonia was extremely poor. The nutritional pathway at discharge was a major prognostic factor. These results may be useful for future care and research.

Effect of insulin insufficiency on ultrastructure and function in skeletal muscle

BACKGROUND

Decreased insulin availability and high blood glucose levels, the hallmark features of poorly controlled diabetes, drive disease progression and are associated with decreased skeletal muscle mass. We have shown that mice with β-cell dysfunction and normal insulin sensitivity have decreased skeletal muscle mass. This project asks how insulin deficiency impacts on the structure and function of the remaining skeletal muscle in these animals.

METHODS

Skeletal muscle function was determined by measuring exercise capacity and specific muscle strength prior to and after insulin supplementation for 28 days in 12-week-old mice with conditional β-cell deletion of the ATP binding cassette transporters ABCA1 and ABCG1 (β-DKO mice). Abca1 and Abcg1 floxed (fl/fl) mice were used as controls. RNAseq was used to quantify changes in transcripts in soleus and extensor digitorum longus muscles. Skeletal muscle and mitochondrial morphology were assessed by transmission electron microscopy. Myofibrillar Ca2+ sensitivity and maximum isometric single muscle fibre force were assessed using MyoRobot biomechatronics technology.

RESULTS

RNA transcripts were significantly altered in β-DKO mice compared with fl/fl controls (32 in extensor digitorum longus and 412 in soleus). Exercise capacity and muscle strength were significantly decreased in β-DKO mice compared with fl/fl controls (P = 0.012), and a loss of structural integrity was also observed in skeletal muscle from the β-DKO mice. Supplementation of β-DKO mice with insulin restored muscle integrity, strength and expression of 13 and 16 of the dysregulated transcripts in and extensor digitorum longus and soleus muscles, respectively.

CONCLUSIONS

Insulin insufficiency due to β-cell dysfunction perturbs the structure and function of skeletal muscle. These adverse effects are rectified by insulin supplementation.

Association between timed up-and-go test and subsequent pneumonia: A cohort study

BACKGROUND

Sarcopenia is a risk factor for pneumonia in the elderly, and the timed up-and-go test (TUG) can be used as a screening tool for sarcopenia in this population. This study aimed to evaluate the association between TUG test results and future pneumonia or ventilator care.

MATERIALS AND METHODS

From the National Health Insurance Service-Senior Cohort database, we identified 19,804 people without neurological diseases who underwent the TUG test in the National Screening Program for Transitional Ages at the age of 66 years during 2007-2008. Gait abnormality was defined as taking 10 s or longer to perform the TUG test. Pneumonia occurrence was defined using the International Classification of Diseases 10th Revision (ICD-10) code for pneumonia (J12-J18, J69), and ventilator care was defined by procedure codes (M5830, M5850, M5867, M5858, M5860, M5859) according to the Healthcare Common Procedure Coding system codes from 2007 to 2015.

RESULTS

The mean follow-up period was 7.4 years (standard error, SE 0.02). The incidence rates of pneumonia in the normal and slow TUG groups were 38 and 39.5/1000 person-years, respectively. The slow TUG group did not show a higher risk of pneumonia (adjusted hazard ratio [aHR], 1.042; 95% confidence interval [95% CI], 0.988-1.107]). Regarding ventilator care, the incidence was 4.7 and 5.2 cases per 1,000 person-years in the normal and slow TUG groups, respectively. Slow TUG groups also did not show an increased risk of ventilator occurrence (aHR, 1.136, [95% CI = 0.947-1.363]).

CONCLUSION

The TUG test result was not associated with future pneumonia or ventilator care and may not be useful for predicting pneumonia in community-dwelling elderly individuals. Further studies are needed to identify additional functional tools for sarcopenia associated with future pneumonia occurrences.

Predictors of aspiration pneumonia: developing a new matrix for speech and language therapists

INTRODUCTION

The contributing factors of aspiration pneumonia have been well documented. However, there are gaps in the literature regarding identifying the weight associated with each factor and the relationship between factors.

METHOD

In this study, 20 potential predictors of aspiration pneumonia (with four additional variables) have been applied to historic Speech and Language Therapy records to greater understand the significance of each contributor of aspiration pneumonia. 152 cases with an oropharyngeal dysphagia, and a Speech and Language Therapy recommendation of eating and drinking with known aspiration and the associated potential risk of developing an aspiration pneumonia, were included in the data. These were inpatients and outpatients, and had various diagnoses but all had had a videofluoroscopy.

RESULTS

Logistic regression analysis found seven factors that were individually significant in predicting the development of aspiration pneumonia with 84.93% sensitivity and 91.03% specificity DISCUSSION: Logistic regression and random forest analyses led to the proposal of a new matrix of predictors of aspiration pneumonia with respective scoring weights for individual and cumulative contributors (a direction for future research).

Comparison of the thickness of the erector spinae muscles between aspiration pneumonia and bacterial pneumonia patients

BACKGROUND AND AIMS

Aspiration pneumonia is generally associated with deterioration of skeletal muscle mass, which is usually evaluated by the erector spinae muscle cross-sectional area (ESMCSA); however, no report has assessed ESMCSA in patients with aspiration pneumonia. Furthermore, erector spinae muscle thickness (ESMT) was developed to be easier to measure than ESMCSA. Therefore, this study investigated the relationship between ESMT and ESMCSA in aspiration pneumonia patients compared to bacterial pneumonia patients.

METHODS

We retrospectively collected data for 164 patients with aspiration pneumonia and 480 patients with bacterial pneumonia who were hospitalized at Fukujuji Hospital between September 2018 and May 2022. We assessed the correlations between ESMCSA and ESMT and compared the data between the two groups.

RESULTS

ESMT had a strong, proportional relationship with ESMCSA in all patients (r = 0.908, p < 0.001) and those with aspiration pneumonia (r = 0.896, p < 0.001). ESMCSA (median 671.8 mm2 [range 164.0-1636.7] vs. median 1057.0 mm2 [range 161.3-2412.5], p < 0.001) and ESMT (median 17.1 mm [range 6.95-34.4] vs. median 23.8 mm [range 6.95-43.7], p < 0.001) were significantly lower in patients with aspiration pneumonia. A multivariate analysis of aspiration pneumonia diagnosis showed significant independent differences from bacterial pneumonia in ESMCSA (odds ratio 0.998 [95% CI: 0.996-0.999], p = 0.001) and ESMT (odds ratio 0.90 [95% CI: 0.84-0.96], p = 0.002).

CONCLUSION

This study demonstrates a strong correlation between ESMCSA and ESMT. ESMT can be more easily used to evaluate skeletal muscle mass and can help in diagnosing aspiration pneumonia.

Clinical efficacy of assessment of swallowing ability for pneumonia and other assessment tools for occurrence and mortality from pneumonia among older inpatients in a long-term care hospital

BACKGROUND

Aspiration pneumonia is an important condition in elderly patients and detecting dysphagia early can help clinicians identify patients with a high risk of aspiration pneumonia. We previously reported the usefulness of the Assessment of Swallowing Ability for Pneumonia (ASAP) in predicting the occurrence of and mortality from pneumonia in patients in acute care hospitals; however, there are very few reports on the utility of this screening test for patients in stable condition.

METHODS

Elderly patients in stable condition (n = 133) without pneumonia were prospectively enrolled. Associations between ASAP, Functional Independence Measure (FIM), Controlling Nutrition Status (CONUT), and Charlson Co-morbidity Index (CCI) scores and occurrence of/mortality from pneumonia during hospitalization were evaluated.

RESULTS

The occurrence of pneumonia was observed in 27 (20.3%) patients, and 18 (13.5%) died during hospitalization. Multivariate analysis showed that low ASAP score and low FIM motor were independent predictors for the occurrence of pneumonia, and low ASAP score was an independent predictor for mortality from pneumonia. Areas under the curve for ASAP, FIM motor, FIM cognition, and CONUT scores were 0.895 (95% confidence interval [CI], 0.829-0.960), 0.913 (95% CI, 0.860-0.968), 0.841 (95% CI, 0.761-0.921), and 0.753 (95% CI, 0.649-0.858), respectively, for occurrence, and 0.881 (95% CI, 0.807-0.955), 0.904 (95% CI, 0.860-0.949), 0.829 (95% CI, 0.727-0.931), 0.746 (95% CI, 0.617-0.874), respectively, for mortality.

CONCLUSION

The ASAP and FIM motor are useful for predicting the occurrence of and mortality from pneumonia in elderly inpatients in long-term care hospitals.

Utility of the Global Leadership Initiative on Malnutrition criteria for the nutritional assessment of patients with end-stage renal disease receiving chronic hemodialysis

BACKGROUND

Malnutrition is associated with adverse outcomes in patients on chronic haemodialysis. Thus, identifying accurate methods for diagnosing malnutrition is essential. The present retrospective study investigated the utility of the new Global Leadership Initiative on Malnutrition (GLIM) criteria in patients undergoing chronic haemodialysis.

METHODS

Phase angle and fat-free mass index (FFMI) were derived using bioelectrical impedance analysis. Malnutrition was determined when the subjects had at least one phenotypic criterion (weight loss, low body mass index [BMI] or FFMI).

RESULTS

This study included 103 patients undergoing chronic haemodialysis and 46 (44.7%) patients were diagnosed as malnourished. Malnutrition determined using the GLIM criteria was associated with increased risks of all-cause death (hazard ratio = 3.0, p = 0.044) and infection requiring hospitalisation (hazard ratio = 2.4, p = 0.015), independent of age, sex and comorbidities. However, malnutrition was not related to major adverse cardiovascular events (p = 0.908). We further evaluated the longitudinal changes in phenotypic parameters. Subjects with median levels of high-sensitivity C-reactive protein exceeding 5 mg L^-1 exhibited decreased body weight and BMI (p = 0.015 and 0.016, respectively). In addition, body weight, BMI and FFMI were reduced in subjects with a median protein catabolic rate of < 1.0 mg kg^-1 day^-1 , even after adjustment for age, sex and comorbidities (p = 0.026, 0.053 and 0.039, respectively).

CONCLUSIONS

Malnutrition assessed using the GLIM criteria could be a useful predictor of mortality and infection in patients on chronic haemodialysis. To improve nutritional status, approaches for decreasing inflammation and increasing protein intake are needed.

Sarcopenia and COVID-19 Outcomes

Coronavirus disease 2019 (COVID-19) spread rapidly and became a severe global public health threat. Older adults have a high risk of COVID-19 and its associated mortality. Sarcopenia has emerged as a predictor of poor outcomes in COVID-19 patients, including lengthy hospital stays, mortality, intensive care unit admission, need for invasive mechanical ventilation, and poor rehabilitation outcomes. Chronic inflammation, immune dysfunction, respiratory muscle dysfunction, and swallowing dysfunction may underlie the association between sarcopenia and the poor outcomes of COVID-19 patients. Interleukin 6 receptor blockers (tocilizumab or sarilumab) are recommended for treating patients with severe COVID-19, and their therapeutic effects on sarcopenia are of great interest. This review aimed to analyze the current reports on the association between sarcopenia and COVID-19 and provide an update on the contribution of sarcopenia to the severity and adverse outcomes of COVID-19 and its underlying mechanisms. We also aimed to explore the different screening tools for sarcopenia concurrent with COVID-19, and advocate for early diagnosis and treatment of sarcopenia. Given that the fight against the COVID-19 pandemic may be long-term, further research into understanding the effects of sarcopenia in patients infected with the Omicron variant is necessary.

Myosteatosis predicting risk of transition to severe COVID-19 infection

BACKGROUND

About 10-20% of patients with Coronavirus disease 2019 (COVID-19) infection progressed to severe illness within a week or so after initially diagnosed as mild infection. Identification of this subgroup of patients was crucial for early aggressive intervention to improve survival. The purpose of this study was to evaluate whether computer tomography (CT) - derived measurements of body composition such as myosteatosis indicating fat deposition inside the muscles could be used to predict the risk of transition to severe illness in patients with initial diagnosis of mild COVID-19 infection.

METHODS

Patients with laboratory-confirmed COVID-19 infection presenting initially as having the mild common-subtype illness were retrospectively recruited between January 21, 2020 and February 19, 2020. CT-derived body composition measurements were obtained from the initial chest CT images at the level of the twelfth thoracic vertebra (T12) and were used to build models to predict the risk of transition. A myosteatosis nomogram was constructed using multivariate logistic regression incorporating both clinical variables and myosteatosis measurements. The performance of the prediction models was assessed by receiver operating characteristic (ROC) curve including the area under the curve (AUC). The performance of the nomogram was evaluated by discrimination, calibration curve, and decision curve.

RESULTS

A total of 234 patients were included in this study. Thirty-one of the enrolled patients transitioned to severe illness. Myosteatosis measurements including SM-RA (skeletal muscle radiation attenuation) and SMFI (skeletal muscle fat index) score fitted with SMFI, age and gender, were significantly associated with risk of transition for both the training and validation cohorts (P < 0.01). The nomogram combining the SM-RA, SMFI score and clinical model improved prediction for the transition risk with an AUC of 0.85 [95% CI, 0.75 to 0.95] for the training cohort and 0.84 [95% CI, 0.71 to 0.97] for the validation cohort, as compared to the nomogram of the clinical model with AUC of 0.75 and 0.74 for the training and validation cohorts respectively. Favorable clinical utility was observed using decision curve analysis.

CONCLUSION

We found CT-derived measurements of thoracic myosteatosis to be associated with higher risk of transition to severe illness in patients affected by COVID-19 who presented initially as having the mild common-subtype infection. Our study showed the relevance of skeletal muscle examination in the overall assessment of disease progression and prognosis of patients with COVID-19 infection.

Clinical muscle mass-related biomarkers that predict mortality in older patients with community-acquired pneumonia

Objective

Community-acquired pneumonia (CAP) is associated with elevated morbidity and mortality, and it usually occurs in older adults. Our goal here was to assess the efficacies of muscle mass-related biomarkers, such as, aspartate transaminase/alanine transaminase (AST/ALT) and creatinine/cystatin C*100 (Cr/CysC*100), in predicting 1-, 2-, and 3-year mortalities of older CAP patients.

Methods

Design: Retrospective cohort study. Setting and Participants: A teaching hospital in western China. Hospitalized CAP patients, aged≥60 years. We separated patients into a high or low muscle mass group, according to the median AST/ALT and Cr/CysC*100, respectively. We acquired data from medical records and local government mortality databases, as well as telephonic interviews. We analyzed the association between low muscle mass (AST/ALT and Cr/CysC*100) and all-cause mortality at 1, 2, and 3 years in older patients with CAP.

Results

We enrolled 606 patients (58.58% male; median age: 81 years) for analysis. The 1-, 2-, and 3-year mortality in older patients with CAP in the low muscle mass group (AST/ALT) was higher than in the high muscle mass group (AST/ALT) (1-year: 51.16% vs. 36.96%, p < 0.001; 2-year: 54.46% vs. 41.25%, p = 0.001; 3-year: 54.79% vs. 42.9%, p = 0.003). Upon adjustment of potential confounding factors, we revealed, using cox regression analysis, that the low muscle mass group (AST/ALT) experienced enhanced mortality risk at the 1-, 2-, and 3-year follow-ups, compared to the high muscle mass group (AST/ALT) (1-year: hazard ratios (HR) = 1.46, 95% confidence interval (CI): 1.13–1.88; 2-year: HR = 1.39, 95% CI: 1.09–1.77; 3-year: HR = 1.35, 95% CI: 1.06–1.72). The 1-, 2-, and 3-year mortality of older CAP patients in the low muscle mass group (Cr/CysC*100) was also higher than the high muscle mass group (Cr/CysC*100) (1-year: 56.29% vs. 31.91%, p < 0.001; 2-year: 60.26% vs. 35.53%, p < 0.001; 3-year: 61.26% vs. 36.51%, p < 0.001). Compared to the high muscle mass group (Cr/CysC*100), the low muscle mass group (Cr/CysC*100) experienced enhanced mortality risk at the 1-, 2-, and 3-year follow ups (1-year: HR = 1.9, 95% CI: 1.46–2.48; 2-year: HR = 1.85, 95% CI: 1.44–2.39; 3-year: HR = 1.85, 95% CI: 1.44–2.37).

Conclusions

Low muscle mass (AST/ALT and Cr/CysC*100) were associated with enhanced 1-, 2-, and 3-year mortality risk in older patients with CAP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03626-y.

Risk factors for mortality in aspiration pneumonia: a single-center retrospective observational study

Aspiration pneumonia (AP) is the leading cause of death among the elderly in Japan. The factors associated with the survival of elderly patients with AP are investigated in this retrospective observational study. Patients with AP over the age of 60 who were assessed for swallowing function in our hospital between April 2015 and March 2016 were eligible. Data on patients' body mass index (BMI), food consistency, and Karnofsky performance status were collected from medical records in hospital and again after recovery. Following hospital discharge, eligible patients were sent questionnaires containing information about their physical conditions, such as body weight and the Japanese version of the functional independence measure. Respondents were divided into two groups: those who died and those who survived, and the factors associated with patient mortality were investigated. There were 19 responses from 50 eligible patients, and seven patients died. The participants' average age was 81 years (SD 9.32). There were ten male participants (52.6%, p=1.00), and there were no significant differences in the mortality and survival groups. The most significant finding was that BMI was significantly lower in the patients who died (p=0.037, Cohen’s d=1.10). Fisher's exact tests clearly demonstrated that patients with a BMI <19.9 had a higher mortality rate (p=0.017). Lower BMI may be associated with increased mortality in elderly patients with a history of AP. In general practice, BMI is simple to measure and may allow for an easy assessment of the risk of AP-related mortality 

Dose-Dependent Effects of Amino Acids on Clinical Outcomes in Adult Medical Inpatients Receiving Only Parenteral Nutrition: A Retrospective Cohort Study Using a Japanese Medical Claims Database

The majority of inpatients requiring parenteral nutrition (PN) do not receive adequate amino acid, which may negatively impact clinical outcomes. We investigated the influence of amino acid doses on clinical outcomes in medical adult inpatients fasting >10 days and receiving only PN, using Japanese medical claims database. The primary endpoint was in-hospital mortality, and the secondary endpoints included deterioration of activities of daily living (ADL), intravenous catheter infection, hospital readmission, hospital length of stay (LOS), and total medical costs. Patients were divided into four groups according to their mean prescribed daily amino acid doses from Days 4 to 10 of fasting: Adequate (≥0.8 g/kg/day), Moderate (≥0.6−<0.8 g/kg/day), Low (≥0.4−<0.6 g/kg/day), and Very low (<0.4 g/kg/day). Multivariate logistic or multiple regression analyses were performed with adjustments for patient characteristics (total n = 86,702). The Adequate group was used as the reference in all analyses. For the Moderate, Low, and Very low groups, adjusted ORs (95% CI) of in-hospital mortality were 1.20 (1.14−1.26), 1.43 (1.36−1.51), and 1.72 (1.62−1.82), respectively, and for deterioration of ADL were 1.21 (1.11−1.32), 1.34 (1.22−1.47), and 1.22 (1.09−1.37), respectively. Adjusted regression coefficients (95% CI) of hospital LOS were 1.2 (0.4−2.1), 1.5 (0.6−2.4), and 2.9 (1.8−4.1), respectively. Lower prescribed doses of amino acids were associated with worse clinical outcomes including higher in-hospital mortality.

The effectiveness of the sarcopenia index in predicting septic shock and death in elderly patients with community-acquired pneumonia

Background

Community-acquired pneumonia (CAP) causes high morbidity and mortality in all age groups worldwide. Lower muscle radiodensity was associated with worse clinical outcomes (including shock) and higher in-hospital mortality. Prompt detection of sarcopenia in older adults with CAP is important. The measurement of muscle mass often involves specialized and expensive techniques. A relatively simple and inexpensive method such as the sarcopenia index (SI) to measure muscle mass would be helpful. Therefore, we performed a retrospective cohort study to assess the association between SI and septic shock risk and mortality in older patients with CAP.

Study design

In this retrospective cohort study, information on hospitalized CAP patients, including general information and septic shock, were obtained from the medical record database of the Southwest Medical University Zigong Affiliated Hospital, China. Data on patient survival and mortality (all-cause) were acquired from government authorities and telephonic follow-up. Serum creatinine (Cr) and cystatin-C (CysC) levels on admission were included in the database. The SI was determined as the serum Cr/CysC ratio × 100 and the participants were assigned to low and high SI groups. The association between SI and septic shock was evaluated by logistic regression, and that between SI and mortality by Cox regression analysis.

Results

In total, 769 older adults (≥ 60 years) with CAP were included, of which 480(62.4%) were male and 289(37.6%)were female. We found that the total prevalence of septic shock in older adults with CAP was 16.0%. In the female group, septic shock was more prevalent in the low SI group than in the high SI group (low SI vs. high SI, 22.22% vs. 11.52%, p = 0.024). Following adjustment for confounders, there was a significant association between high SI and a lower risk of septic shock in female patients (OR = 0.38, 95%CI: 0.16–0.94; p < 0.05). The total death toll of older adults with CAP was 332(43.2%). Irrespective of sex, there was a higher risk of mortality in the low SI group (total group: low SI vs. high SI, 63.02% vs. 36.57%, p < 0.001; male group: low SI vs. high SI, 63.03% vs. 39.34%, p < 0.001; female group: low SI vs. high SI, 73.61% vs. 28.57%, p < 0.001) and, after adjustment for confounding factors and irrespective of sex, high SI was a protective factor for mortality in older adults with CAP (total group: HR = 0.64, 95%CI: 0.48–0.84; p < 0.05; male: HR = 0.69, 95%CI: 0.49–0.97; p < 0.05; female: HR = 0.39, 95%CI: 0.24–0.62; p < 0.05).

Conclusion

While the SI effectively predicts mortality in older adults with CAP, it was only found to be associated with septic shock in older females.

Association of body mass index with Clostridioides difficile infection among older patients with pneumonia in Japan

AIM

Obesity is reported to be a risk factor for Clostridioides difficile infection. However, obesity rarely occurs in older Asian patients, and the effects of obesity on health and disease are different in Asian and Western countries. This study aimed to assess the association between body mass index and C. difficile infection risk among older patients with pneumonia in Japan.

METHODS

This retrospective observational cohort study used data from the nationwide database of acute hospital inpatients' data in Japan between July 2014 and March 2016. All patients aged ≥65 years admitted with a primary diagnosis of pneumonia were enrolled. Risk factors for C. difficile infection were determined by logistic regression analysis, including known risks as covariates.

RESULTS

Among 221 242 pneumonia patients, 611 developed C. difficile infection. Underweight patients (body mass index <18.5 kg/m² ) showed higher odds for C. difficile infection (odds ratio 1.38, 95% confidence interval 1.17-1.62, P < 0.001) than normal weight patients (body mass index 18.5-24.9 kg/m² ), whereas overweight patients (body mass index ≥25 kg/m² ) showed lower odds (odds ratio 0.63, 95% confidence interval 0.45-0.89, P < 0.01).

CONCLUSIONS

Body mass index was associated with C. difficile infection in older pneumonia patients in Japan. Underweight was a risk factor, whereas overweight was a protective factor for C. difficile infection. Geriatr Gerontol Int 2021; ••: ••-••.

Is sarcopenia a risk factor for reduced diaphragm function following hepatic resection? A study protocol for a prospective observational study

INTRODUCTION

Sarcopenia is associated with reduced pulmonary function in healthy adults, as well as with increased risk of pneumonia following abdominal surgery. Consequentially, postoperative pneumonia prolongs hospital admission, and increases in-hospital mortality following a range of surgical interventions. Little is known about the function of the diaphragm in the context of sarcopenia and wasting disorders or how its function is influenced by abdominal surgery. Liver surgery induces reactive pleural effusion in most patients, compromising postoperative pulmonary function. We hypothesise that both major hepatic resection and sarcopenia have a measurable impact on diaphragm function. Furthermore, we hypothesise that sarcopenia is associated with reduced preoperative diaphragm function, and that patients with reduced preoperative diaphragm function show a greater decline and reduced recovery of diaphragm function following major hepatic resection. The primary goal of this study is to evaluate whether sarcopenic patients have a reduced diaphragm function prior to major liver resection compared with non-sarcopenic patients, and to evaluate whether sarcopenic patients show a greater reduction in respiratory muscle function following major liver resection when compared with non-sarcopenic patients.

METHODS AND ANALYSIS

Transcostal B-mode, M-mode ultrasound and speckle tracking imaging will be used to assess diaphragm function perioperatively in 33 sarcopenic and 33 non-sarcopenic patients undergoing right-sided hemihepatectomy starting 1 day prior to surgery and up to 30 days after surgery. In addition, rectus abdominis and quadriceps femoris muscles thickness will be measured using ultrasound to measure sarcopenia, and pulmonary function will be measured using a hand-held bedside spirometer. Muscle mass will be determined preoperatively using CT-muscle volumetry of abdominal muscle and adipose tissue at the third lumbar vertebra level (L3). Muscle function will be assessed using handgrip strength and physical condition will be measured with a short physical performance battery . A rectus abdominis muscle biopsy will be taken intraoperatively to measure proteolytic and mitochondrial activity as well as inflammation and redox status. Systemic inflammation and sarcopenia biomarkers will be assessed in serum acquired perioperatively.

ETHICS AND DISSEMINATION

This trial is open for recruitment. The protocol was approved by the official Independent Medical Ethical Committee at Uniklinik (Rheinish Westphälische Technische Hochschule (RWTH) Aachen (reference EK309-18) in July 2019. Results will be published via international peer-reviewed journals and the findings of the study will be communicated using a comprehensive dissemination strategy aimed at healthcare professionals and patients.

TRIAL REGISTRATION NUMBER

ClinicalTrials. gov (EK309-18); Pre-results.

Effect of parenteral energy or amino acid doses on in-hospital mortality, among patients with aspiration pneumonia: a cohort medical claims database study

Background

This study examined the association between parenteral energy/amino acid doses and in-hospital mortality among inpatients on long-term nil per os (NPO) status, using a medical claims database in Japan.

Methods

Hospitalized patients with aspiration pneumonia, aged 65 and older, and on more than 7-day NPO status were identified in a medical claims database between January 2013 and December 2018. Using multivariate logistic regression and regression analyses, we examined the association between mean parenteral energy/amino acid doses and in-hospital mortality, and secondarily, the association between prognosis (in-hospital mortality, inability to receive full oral intake, readmission, and hospital stay length) and 4 groups of mean amino acid doses (no dose: 0 g/kg/day; very low dose: >0, ≤0.3 g/kg/day; low dose: >0.3, ≤0.6 g/kg/day; moderate dose: >0.6 g/kg/day).

Results

The analysis population included 20 457 inpatients (≥80 years: 78.3%). In total, 5 920 mortalities were recorded. Increased amino acid doses were significantly associated with reduced in-hospital mortality (p < .001). With a no dose reference level, the odds ratios (95% confidence interval) of in-hospital mortality adjusted for potential confounders were 0.78 (0.72–0.85), 0.74 (0.67–0.82), and 0.69 (0.59–0.81) for very low, low, and moderate amino acid doses, respectively. Additionally, patients prescribed amino acid dose levels more than 0.6 g/kg/day had shorter hospitalization periods than those prescribed none.

Conclusions

Increased amino acid doses were associated with reduced in-hospital mortality. Sufficient amino acid administration is recommended for patients with aspiration pneumonia requiring NPO status.

Serum albumin levels as a predictive biomarker for low-load resistance training programs' effects on muscle thickness in the community-dwelling elderly Japanese population: interventional study result

Background

Resistance training has been recommended as an effective measure against age-related loss of muscle mass and muscle strength, called sarcopenia, even in older adults. However, despite subjecting each participant to the same training program, the training effect solely depended on the individual. This study aimed to evaluate whether certain blood parameters influenced the effect of a low-load resistance training program on muscle thickness in the community-dwelling elderly population.

Methods

Sixty-nine community-dwelling Japanese (49 women and 20 men) subjects aged 69.4 ± 6.5 years were included. Low-load resistance training was performed twice a week for 12 weeks. Muscle thickness at the anterior aspects of the thigh (AT) was measured using a B-mode ultrasound device, and 22 blood parameter levels were assessed before and after the program. We checked the first quartile value of each parameter to establish cutoff values, and participants were divided into low or normal groups for each parameter.

Results

A low-load resistance training program significantly increased muscle thickness at the AT. The interaction between time and groups was examined at low (< 4.1 g/dL) versus normal (≥ 4.1 g/dL) serum albumin (Alb) levels. Although there was no difference in muscle thickness at the AT before the training intervention, the hypertrophic effects were higher in the normal serum Alb level group than in the low serum Alb level group. The binomial logistic regression analysis showed that participants in the low serum Alb group had an odds ratio of 7.08 for decreased muscle thickness at the AT. The effect of a low-load resistance training program on lower limb muscle thickness appears to be limited in participants with low serum Alb levels before training interventions.

Conclusions

Serum Alb level may act as a biomarker to predict the effects of low-load resistance training programs on muscle hypertrophy in elderly individuals.

Trial registration

This study was retrospectively registered in UMIN-Clinical Trial Registry (CTR), ID: UMIN000042759 (date of registration, 14 Dec 2020).

Impact of physical frailty on the clinical outcomes of older patients hospitalized for pneumonia

AIM

This study aimed to assess the association between physical frailty and clinical outcomes among older patients hospitalized for pneumonia.

METHODS

This study examined 852 consecutive patients hospitalized for pneumonia between October 2018 and September 2020. Patients who were <65 years old, scheduled for admission, did not receive inpatient rehabilitation, or died during admission were excluded. A short physical performance battery (SPPB) test was performed by physical therapists upon discharge. The primary outcome measure was a composite endpoint of readmission or mortality due to any cause within 6 months of discharge.

RESULTS

In total, 521 patients (median age, 80 years; interquartile range, 74-86 years) were included in the analyses, and were divided into the following two groups: robust group with SPPB scores >9 (n = 150), and physical frailty group with SPPB scores ≤9 (n = 371). Of these, 346 (66.4%) patients were men; and the median SPPB score was 6 (interquartile range, 1-10). During the median follow-up period of 53 days (interquartile range, 4-180 days), 92 (17.6%) patients were readmitted and 25 (4.8%) patients died. Patients with physical frailty were at an increased risk for the primary endpoint (hazard ratio, 2.21; 95% confidence interval, 1.44-3.41; P < 0.001); the risk remained significant after adjusting for multiple variables (adjusted hazard ratio, 1.70; 95% confidence interval, 1.05-2.74; P = 0.028).

CONCLUSIONS

Among older patients with pneumonia, physical frailty status at discharge was an independent risk factor for readmission and mortality within 6 months after initial discharge. Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2021; ••: ••-••.

Percutaneous Endoscopic Gastrostomy Reduces Aspiration Pneumonia Rate in Stroke Patients with Enteral Feeding in Convalescent Rehabilitation Wards

OBJECTIVES

The effect of percutaneous endoscopic gastrostomy (PEG) on the prevention of aspiration pneumonia and improvements in activities of daily living (ADL) for enteral feeding-dependent stroke patients is unclear. We sought to clarify differences in the rates of aspiration pneumonia and ADL improvement between stroke patients receiving PEG and those receiving nasogastric tube feeding (NGT) in convalescent rehabilitation wards.

METHODS

We assessed 10 years of data from the Kaga Regional Cooperation Clinical Pathway for Stroke, which covers patients in the southern district of Ishikawa Prefecture of Japan. Logistic regression analysis with propensity score adjustment was used to examine how the enteral feeding method affected aspiration pneumonia rates. Linear regression analysis, adjusted by propensity scores, was also performed to ascertain the effect of the enteral feeding method on ADL improvement.

RESULTS

Overall, 47 patients with PEG and 49 patients with NGT were analyzed. The incidence of aspiration pneumonia was 4.67 times higher in the NGT group than in the PEG group in the propensity score-adjusted logistic regression analysis (odds ratio 4.67, 95% confidence interval 1.30-16.67, P=0.02). The enteral feeding method had no significant effect on ADL improvement in the propensity score-adjusted linear regression analysis.

CONCLUSIONS

In convalescent rehabilitation wards, aspiration pneumonia was more likely to occur in stroke patients with NGT than in those with PEG; however, the enteral feeding method did not affect ADL improvement. These results provide a basis for determining the appropriate enteral feeding method for stroke patients who cannot take adequate nutrition orally during convalescence/rehabilitation.

Anthropometric analysis of body habitus and outcomes in critically ill COVID-19 patients

Aims

This study aimed to determine whether anthropometric markers of thoracic skeletal muscle and abdominal visceral fat tissue correlate with outcome parameters in critically ill COVID-19 patients.

Methods

We retrospectively analysed thoracic CT-scans of 67 patients in four ICUs at a university hospital. Thoracic skeletal muscle (total cross-sectional area (CSA); pectoralis muscle area (PMA)) and abdominal visceral fat tissue (VAT) were quantified using a semi-automated method. Point-biserial-correlation-coefficient, Spearman-correlation-coefficient, Wilcoxon rank-sum test and logistic regression were used to assess the correlation and test for differences between anthropometric parameters and death, ventilator- and ICU-free days and initial inflammatory laboratory values.

Results

Deceased patients had lower CSA and PMA values, but higher VAT values (p < 0.001). Male patients with higher CSA values had more ventilator-free days (p = 0.047) and ICU-free days (p = 0.017). Higher VAT/CSA and VAT/PMA values were associated with higher mortality (p < 0.001), but were negatively correlated with ICU length of stay in female patients only (p < 0.016). There was no association between anthropometric parameters and initial inflammatory biomarker levels. Logistic regression revealed no significant independent predictor for death.

Conclusion

Our study suggests that pathologic body composition assessed by planimetric measurements using thoracic CT-scans is associated with worse outcome in critically ill COVID-19 patients.

The role of SARC-F scale in predicting progression risk of COVID-19 in elderly patients: a prospective cohort study in Wuhan

BACKGROUND

Since the outbreak of COVID-19, it has been documented that old age and underlying illnesses are associated with poor prognosis among COVID-19 patients. However, it is unknown whether sarcopenia, a common geriatric syndrome, is associated with poor prognosis among older COVID-19 patients. The aim of our prospective cohort study is to investigate the association between sarcopenia risk and severe disease among COVID-19 patients aged ≥60 years.

METHOD

A prospective cohort study of 114 hospitalized older patients (≥60 years) with confirmed COVID-19 pneumonia between 7 February, 2020 and 6 April, 2020. Epidemiological, socio-demographic, clinical and laboratory data on admission and outcome data were extracted from electronic medical records. All patients were assessed for sarcopenia on admission using the SARC-F scale and the outcome was the development of the severe disease within 60 days. We used the Cox proportional hazards model to identify the association between sarcopenia and progression of disease defined as severe cases in a total of 2908 person-days.

RESULT

Of 114 patients (mean age 69.52 ± 7.25 years, 50% woman), 38 (33%) had a high risk of sarcopenia while 76 (67%) did not. We found that 43 (38%) patients progressed to severe cases. COVID-19 patients with higher risk sarcopenia were more likely to develop severe disease than those without (68% versus 22%, p < 0.001). After adjustment for demographic and clinical factors, higher risk sarcopenia was associated with a higher hazard of severe condition [hazard ratio = 2.87 (95% CI, 1.33-6.16)].

CONCLUSION

We found that COVID-19 patients with higher sarcopenia risk were more likely to develop severe condition. A clinician-friendly assessment of sarcopenia could help in early warning of older patients at high-risk with severe COVID-19 pneumonia.

Oral Care in Hospital Settings: Breaking the Vicious Circle of Older Adult Deconditioning

Hospitalized older adults frequently develop aspiration pneumonia, swallowing dys-function (dysphagia), and sarcopenia. In the current study, we propose a framework that incorporates these three factors into a vicious circle that leads to deconditioning, a condition frequently experienced by this vulnerable population. Viewing aspiration pneumonia, dysphagia, and sarcopenia, along with their interrelationships through the lens of this vicious circle, illuminates the critical role that oral health plays in deconditioning. Moreover, this framework highlights oral care as a key nursing intervention for reducing deconditioning in hospitalized older adults. Supporting this view, several studies have shown that oral care can improve health outcomes for hospitalized older adults. However, despite oral care being an essential nursing intervention that restores oral function and promotes patient wellness, it is one of the most neglected nursing interventions. Missed oral care occurs due to staff's limited awareness of its significance for care-dependent older adults in hospital settings. We hope that this vicious circle paradigm helps raise awareness of the significance of oral care to prevent deconditioning in hospitalized older adults. [Journal of Gerontological Nursing, 47(6), 7-12.].

Coronavirus Disease 2019 (COVID-19) and Nutritional Status: The Missing Link?

Coronavirus disease 2019 (COVID-19) is an emerging disease that has reached pandemic status by rapidly spreading worldwide. Elderly individuals and patients with comorbidities such as obesity, diabetes, and hypertension show a higher risk of hospitalization, severe disease, and mortality by acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. These patients frequently show exacerbated secretion of proinflammatory cytokines associated with an overreaction of the immune system, the so-called cytokine storm. Host nutritional status plays a pivotal role in the outcome of a variety of different infectious diseases. It is known that the immune system is highly affected by malnutrition, leading to decreased immune responses with consequent augmented risk of infection and disease severity. Body composition, especially low lean mass and high adiposity, has consistently been linked to worsened prognosis in many different diseases. In this review, evidence concerning the impact of nutritional status on viral infection outcomes is discussed.

Relationships Between Survival and Oral Status, Swallowing Function, and Oral Intake Level in Older Patients with Aspiration Pneumonia

The factors affecting the survival of patients with aspiration pneumonia (AP) remain unclear. This study aimed to determine whether factors, including oral status, swallowing function, and oral intake level, were related to survival outcomes in older patients hospitalized for AP. The study enrolled patients with AP who were admitted to our hospital between February 2017 and November 2019. Patients were divided into two groups based on the 90-day mortality after the first swallowing function evaluation: survivors and deceased. The data were compared between the two groups. A total of 29 patients were diagnosed with AP. Of these patients, 13 died within 90 days. The numbers of patients who could not use removable dentures and required sputum suctioning and had cough reflex at rest were significantly higher in the deceased than in the survivors. The salivary pooling and pharyngeal clearance scores evaluated by videoendoscopy, International Dysphagia Diet Standardisation Initiative Functional Diet Scale score determined after swallowing function evaluation, and consciousness level were significantly worse in the deceased than in the survivors. There were significant differences in patients' oral status, swallowing function, oral intake level, and consciousness level between the survivors and deceased.

Pneumonia prevention in the elderly patients: the other sides

Pneumonia is one of the leading causes of morbidity and mortality from infection in elderly patients. The increased frequency of pneumonia among elderly subjects can be explained by the physiological changes linked to the progressive aging of the respiratory tree and the diminished immunological response. A spiral of event leads to frailty, infection and possible death; preventing pneumonia consists of controlling the risk factors. Dysphagia, which is associated with malnutrition and dehydration, is recognized as one of the major pathophysiological mechanism leading to pneumonia and its screening is crucial for the pneumonia risk assessment. The impairment in the oropharyngeal reflexes results in stagnation of foreign material in the lateral cavities of the pharynx which may then get aspirated repeatedly in the lungs and cause pneumonia. Pneumonia prevention starts with lifestyle modifications such as alcohol and tobacco cessation. A careful review of the risk-benefit of the prescribed medication is critical and adaptation may be required in elders with multiple morbidities. Respiratory physiotherapy and mobilization improve the functional status and hence may help reduce the risk of pneumonia. Maintaining teeth and masticatory efficiency is important if malnutrition and its consequences are to be avoided. Daily oral hygiene and regular professional removal of oral biofilm can prevent the onset of periodontitis and can avoid an oral environment favoring the colonization of respiratory pathogens than can then be aspirated into the lungs.

Nutritional management in inpatients with aspiration pneumonia: a cohort medical claims database study

BACKGROUND/OBJECTIVES

This study aimed to describe real-world nutrition management patterns among inpatients hospitalized for aspiration pneumonia, using a medical claims database in Japan.

METHODS

Patients aged ≥65 years hospitalized for aspiration pneumonia treatment were identified in a medical claims database between January 2013 and December 2018, to evaluate nutrition management initiation and adjustment timing, factors associated with >7-days nil per os (NPO) status, prescribed nutrition doses, and types of parenteral nutrition solutions. Patients who received oral intake or enteral nutrition on the day of admission (Day 1) were excluded.

RESULTS

The analysis population included 72,315 inpatients. The median (first quartile, third quartile) initiation date of oral nutrition intake was Day 4 (3, 7) and 65.1% of patients received oral nutrition intake by Day 7. Factors associated with >7-day NPO included sex, BMI, treatment years, Barthel Index score, Japan Coma Scale score, and oxygen inhalation on the day of hospital admission. Amongst NPO patients on Day 7, only 5.3% were prescribed the recommended doses of ≥20 kcal/kg; 6.4% were prescribed ≥1.0 g/kg amino acids, and 5.7% were prescribed fat energy ratio at ≥15% of non-protein calories. Commonly prescribed parenteral nutrition solutions on Day 7 were carbohydrate/electrolyte solutions (52.8%) and peripheral parenteral nutrition solutions (49.0%).

CONCLUSION

Prescribed parenteral energy, amino acids, and fat during the NPO period were lower than the recommended doses in the majority of patients. Prescribing recommended doses of each of these component nutrients may be beneficial when managing parenteral nutrition of patients during NPO.

CT-derived Chest Muscle Metrics for Outcome Prediction in Patients with COVID-19

Background Lower muscle mass is a known predictor of unfavorable outcomes, but its prognostic impact on patients with COVID-19 is unknown. Purpose To investigate the contribution of CT-derived muscle status in predicting clinical outcomes in patients with COVID-19. Materials and Methods Clinical or laboratory data and outcomes (intensive care unit [ICU] admission and death) were retrospectively retrieved for patients with reverse transcriptase polymerase chain reaction-confirmed SARS-CoV-2 infection, who underwent chest CT on admission in four hospitals in Northern Italy from February 21 to April 30, 2020. The extent and type of pulmonary involvement, mediastinal lymphadenopathy, and pleural effusion were assessed. Cross-sectional areas and attenuation by paravertebral muscles were measured on axial CT images at the T5 and T12 vertebral level. Multivariable linear and binary logistic regression, including calculation of odds ratios (ORs) with 95% CIs, were used to build four models to predict ICU admission and death, which were tested and compared by using receiver operating characteristic curve analysis. Results A total of 552 patients (364 men and 188 women; median age, 65 years [interquartile range, 54-75 years]) were included. In a CT-based model, lower-than-median T5 paravertebral muscle areas showed the highest ORs for ICU admission (OR, 4.8; 95% CI: 2.7, 8.5; P < .001) and death (OR, 2.3; 95% CI: 1.0, 2.9; P = .03). When clinical variables were included in the model, lower-than-median T5 paravertebral muscle areas still showed the highest ORs for both ICU admission (OR, 4.3; 95%: CI: 2.5, 7.7; P < .001) and death (OR, 2.3; 95% CI: 1.3, 3.7; P = .001). At receiver operating characteristic analysis, the CT-based model and the model including clinical variables showed the same area under the receiver operating characteristic curve (AUC) for ICU admission prediction (AUC, 0.83; P = .38) and were not different in terms of predicting death (AUC, 0.86 vs AUC, 0.87, respectively; P = .28). Conclusion In hospitalized patients with COVID-19, lower muscle mass on CT images was independently associated with intensive care unit admission and in-hospital mortality. © RSNA, 2021 Online supplemental material is available for this article.

Respiratory Muscle Weakness as a Risk Factor for Pneumonia in Older People

INTRODUCTION

The respiratory muscle strength regulates the effectiveness of coughing, which clears the airways and protects people from pneumonia. Sarcopenia is an aging-related loss of muscle mass and function, the worsening of which is associated with malnutrition. The loss of respiratory and swallowing muscle strength occurs with aging, but its effect on pneumonia is unclear. This study aimed to determine the risks of respiratory muscle weakness on the onset and relapse of pneumonia in older people in conjunction with other muscle-related factors such as malnutrition.

METHODS

We conducted a longitudinal study with 47 pneumonia inpatients and 35 non-pneumonia controls aged 70 years and older. We evaluated the strength of respiratory and swallowing muscles, muscle mass, and malnutrition (assessed by serum albumin levels and somatic fat) during admission and confirmed pneumonia relapse within 6 months. The maximal inspiratory and expiratory pressures determined the respiratory muscle strength. Swallowing muscle strength was evaluated by tongue pressure. Bioelectrical impedance analysis was used to evaluate the muscle and fat mass.

RESULTS

The respiratory muscle strength, body trunk muscle mass, serum albumin level, somatic fat mass, and tongue pressure were significantly lower in pneumonia patients than in controls. Risk factors for the onset of pneumonia were low inspiratory respiratory muscle strength (odds ratio [OR], 6.85; 95% confidence interval [CI], 1.56-30.11), low body trunk muscle mass divided by height2 (OR, 6.86; 95% CI, 1.49-31.65), and low serum albumin level (OR, 5.46; 95% CI, 1.51-19.79). For the relapse of pneumonia, low somatic fat mass divided by height2 was a risk factor (OR, 20.10; 95% CI, 2.10-192.42).

DISCUSSION/CONCLUSIONS

Respiratory muscle weakness, lower body trunk muscle mass, and malnutrition were risk factors for the onset of pneumonia in older people. For the relapse of pneumonia, malnutrition was a risk factor.

Systematic review and meta-analysis of lean mass and mortality: Rationale and study description

Objectives

Muscle mass is one of the key components in defining sarcopenia and is known to be important for locomotion and body homeostasis. Lean mass is commonly used as a surrogate of muscle mass and has been shown to be associated with increased mortality. However, the relationship of lean mass with mortality may be affected by different clinical conditions, modalities used, cut-off point to define low or normal lean mass, and even types of cancer among cancer patients. Thus, we aim to perform a comprehensive meta-analysis of lean mass with mortality by considering all these factors.

Methods

Systematic search was done in PubMed, Cochrane Library and Embase for articles related to lean mass and mortality. Lean mass measured by dual X-ray absorptiometry, bioelectrical impedance analysis, and computerized tomography were included.

Results

The number of relevant studies has increased continuously since 2002. A total of 188 studies with 98 468 people were included in the meta-analysis. The association of lean mass with mortality was most studied in cancer patients, followed by people with renal diseases, liver diseases, elderly, people with cardiovascular disease, lung diseases, and other diseases. The meta-analysis can be further conducted in subgroups based on measurement modalities, site of measurements, definition of low lean mass adopted, and types of cancer for studies conducted in cancer patients.

Conclusions

This series of meta-analysis provided insight and evidence on the relationship between lean mass and mortality in all directions, which may be useful for further study and guideline development.

Lean regional muscle volume estimates using explanatory bioelectrical models in healthy subjects and patients with muscle wasting

BACKGROUND

The availability of non-invasive, accessible, and reliable methods for estimating regional skeletal muscle volume is paramount in conditions involving primary and/or secondary muscle wasting. This work aimed at (i) optimizing serial bioelectrical impedance analysis (S_BIA ) by computing a conductivity constant based on quantitative magnetic resonance imaging (MRI) data and (ii) investigating the potential of S_BIA for estimating lean regional thigh muscle volume in patients with severe muscle disorders.

METHODS

Twenty healthy participants with variable body mass index and 20 patients with idiopathic inflammatory myopathies underwent quantitative MRI. Anatomical images and fat fraction maps were acquired in thighs. After manual muscle segmentation, lean thigh muscle volume (lV_MRI ) was computed. Subsequently, multifrequency (50 to 350 kHz) serial resistance profiles were acquired between current skin electrodes (i.e. ankle and hand) and voltage electrodes placed on the anterior thigh. In vivo values of the muscle electrical conductivity constant were computed using data from S_BIA and MRI gathered in the right thigh of 10 healthy participants. Lean muscle volume (lV_BIA ) was derived from S_BIA measurements using this newly computed constant. Between-day reproducibility of lV_BIA was studied in six healthy participants.

RESULTS

Electrical conductivity constant values ranged from 0.82 S/m at 50 kHz to 1.16 S/m at 350 kHz. The absolute percentage difference between lV_BIA and lV_MRI was greater at frequencies >270 kHz (P < 0.0001). The standard error of measurement and the intra-class correlation coefficient for lV_BIA computed from measurements performed at 155 kHz (i.e. frequency with minimal difference) against lV_MRI were 6.1% and 0.95 in healthy participants and 9.4% and 0.93 in patients, respectively. Between-day reproducibility of lV_BIA was as follows: standard error of measurement = 4.6% (95% confidence interval [3.2, 7.8] %), intra-class correlation coefficient = 0.98 (95% confidence interval [0.95, 0.99]).

CONCLUSIONS

These findings demonstrate a strong agreement of lean muscle volume estimated using S_BIA against quantitative MRI in humans, including in patients with severe muscle wasting and fatty degeneration. S_BIA shows promises for non-invasive, fast, and accessible estimation and follow-up of lean regional skeletal muscle volume for transversal and longitudinal studies.

The Association Between Body Mass Index and the Risk of Hospitalization and Mortality due to Infection: A Prospective Cohort Study

Background

We aim to determine whether obesity increases the risk of various infections using a large prospective population-based cohort.

Methods

A total of 120 864 adults were recruited from the New Taipei City health screening program from 2005 to 2008. Statistics for hospitalization and mortality due to infection were obtained from the National Health Insurance Database and the National Death Registry in Taiwan.

Results

During a mean follow-up period of 7.61 years, there were 438, 7582, 5298, and 1480 first hospitalizations due to infection in the underweight, normal, overweight, and obese groups, respectively. Obesity significantly increases the risk of hospitalization for intra-abdominal infections (adjusted hazard ratio [aHR], 1.19; 95% CI, 1.00–1.40), including diverticulitis, liver abscess, acute cholecystitis and anal and rectal abscess, reproductive and urinary tract infection (aHR, 1.38; 95% CI, 1.26–1.50), skin and soft tissue infection (aHR, 2.46; 95% CI, 2.15–2.81), osteomyelitis (aHR, 1.70; 95% CI, 1.14–2.54), and necrotizing fasciitis (aHR, 3.54; 95% CI,1.87–6.67), and this relationship is dose-dependent. This study shows that there is a U-shaped association between body mass index (BMI) and hospitalization for lower respiratory tract infection, septicemia, and the summation of all infections and that underweight people are at the greatest risk, followed by obese people. There is a clear negative relationship between BMI and infection-related mortality.

Conclusions

The pattern that BMI affects the risk of hospitalization and mortality due to infection varies widely across infection sites. It is necessary to tailor preventive and therapeutic measures against different infections in hosts with different BMIs.

Formula for the Cross-Sectional Area of the Muscles of the Third Lumbar Vertebra Level from the Twelfth Thoracic Vertebra Level Slice on Computed Tomography

The purpose of this study was to investigate a means by which to reflect muscle mass using chest computed tomography (CT). A cross-sectional study was conducted with patients aged ≥ 65 years having abdominal and chest CT scans. The formula to predict third lumbar vertebra (L3) cross-sectional area (CSA) of the muscles from the erector muscles of the spine at the twelfth thoracic vertebra (Th12) level slice on CT was created using the five-fold cross-validation method. Correlation between predicted L3 CSA and measured L3 CSA of the muscles was assessed by intraclass correlation coefficients (ICC) and correlation coefficients (r) in the data of the development, and predictability was examined with accuracy and F-values in the validation study. The development study included 161 patients. The developed formula was as follows: −1006.38 + 16.29 × age + 1161.80 × sex (if female, 0; if male, 1) + 55.91 × body weight + 2.22 × CSA of the erector muscles at Th12. The formula demonstrated strong concordance and correlation (ICC = 0.849 [0.800–0.887] and r = 0.858 [0.811–0.894]). The validation study included 34 patients. The accuracy and F-value between predicted CSA and measured CSA were high (accuracy = 0.889–0.944, F-value = 0.931–0.968). We developed a formula predicting CSA at L3 using Th12 CT slice. This formula could be used to assess decreased muscle mass even with chest CT alone.

Respiratory Muscle Strengths and Their Association with Lean Mass and Handgrip Strengths in Older Institutionalized Individuals

The study of reduced respiratory muscle strengths in relation to the loss of muscular function associated with ageing is of great interest in the study of sarcopenia in older institutionalized individuals. The present study assesses the association between respiratory muscle parameters and skeletal mass content and strength, and analyzes associations with blood cell counts and biochemical parameters related to protein, lipid, glucose and ion profiles. A multicenter cross-sectional study was performed among patients institutionalized in nursing homes. The respiratory muscle function was evaluated by peak expiratory flow, maximal respiratory pressures and spirometry parameters, and skeletal mass function and lean mass content with handgrip strength, walking speed and bioimpedance, respectively. The prevalence of reduced respiratory muscle strength in the sample ranged from 37.9% to 80.7%. Peak expiratory flow significantly (p < 0.05) correlated to handgrip strength and gait speed, as well as maximal inspiratory pressure (p < 0.01). Maximal expiratory pressure significantly (p < 0.01) correlated to handgrip strength. No correlation was obtained with muscle mass in any of parameters related to reduced respiratory muscle strength. The most significant associations within the blood biochemical parameters were observed for some protein and lipid biomarkers e.g., glutamate-oxaloacetate transaminase (GOT), urea, triglycerides and cholesterol. Respiratory function muscle parameters, peak expiratory flow and maximal respiratory pressures were correlated with reduced strength and functional impairment but not with lean mass content. We identified for the first time a relationship between peak expiratory flow (PEF) values and GOT and urea concentrations in blood which deserves future investigations in order to manage these parameters as a possible biomarkers of reduced respiratory muscle strength.

Low relative skeletal muscle mass predicts incident hypertension in Korean men: a prospective cohort study

OBJECTIVE

Previous cross-sectional studies suggest an association between low muscle mass and hypertension. However, whether low muscle mass predicts the development of hypertension is unknown. The aim of this study is to investigate the relationship between relative muscle mass and incident hypertension in a large prospective cohort of Korean adults.

METHODS

In this prospective cohort study, we analyzed 132 324 participants without hypertension at baseline who underwent two health check-ups in 2012 and 2016 or in 2013 and 2017 with a 4-year interval. The participants were divided according to skeletal muscle mass index quartiles (Q1--Q4) according to their baseline skeletal muscle mass index [skeletal muscle mass index (%) = total skeletal muscle mass (kg)/body weight (kg) × 100). Multivariate logistic regression was used to estimate the odds ratio and 95% confidence interval for the development of hypertension after 4 years.

RESULTS

After 4 years, 7180 (5.43%) participants developed hypertension. The incidence rates of hypertension were 12.11, 8.58, 6.93, and 4.37% in men and 4.02, 2.29, 1.73, and 1.18% in women in Q1, Q2, Q3, and Q4, respectively. The multivariate adjusted odds ratios (95% confidence intervals) for incident hypertension in Q1, Q2, and Q3, in comparison with Q4, were 1.46 (1.3-1.63), 1.31 (1.19-1.46), and 1.26 (1.14-1.40) in men and 0.97 (0.76-1.23), 1.12 (0.90-1.38), and 1.14 (0.92-1.42) in women, respectively.

CONCLUSION

Low relative skeletal muscle mass was independently and significantly associated with the incidence of hypertension only in Korean men. Further research is required to understand the underlying mechanisms of this relationship.

Low thoracic muscle radiation attenuation is associated with postoperative pneumonia following partial hepatectomy for colorectal metastasis

BACKGROUND

Low skeletal muscle radiation attenuation (SM-RA) is indicative of myosteatosis and diminished muscle function. It is predictive of poor outcome following oncological surgery in several cancer types. Postoperative pneumonia is a known risk factor for increased postoperative mortality. We hypothesized that low SM-RA of the respiratory muscles at the 4th thoracic-vertebra (T4) is associated with postoperative pneumonia following liver surgery.

METHODS

Postoperative pneumonia was identified using prospective infection control data. Computed tomography body composition analysis was performed at the L3-and T4 level to determine SM-RA. Body composition variables were corrected for confounders and related to postoperative pneumonia and admission time by multivariable logistic regression.

RESULTS

Body composition analysis of 180 patients was performed. Twenty-one patients developed postoperative pneumonia (11.6%). Multivariable analysis showed that low T4 SM-RA as well as low L3 SM-RA were significantly associated with postoperative pneumonia (OR 3.65, 95% CI 1.41-9.49, p < 0.01) and (OR 3.22, 95% CI 1.20-8.61, p = 0.02, respectively).

CONCLUSION

Low SM-RA at either the L3-or T4-level is associated with a higher risk of postoperative pneumonia following CLRM resection.

Asian Working Group for Sarcopenia: 2019 Consensus Update on Sarcopenia Diagnosis and Treatment

Clinical and research interest in sarcopenia has burgeoned internationally, Asia included. The Asian Working Group for Sarcopenia (AWGS) 2014 consensus defined sarcopenia as "age-related loss of muscle mass, plus low muscle strength, and/or low physical performance" and specified cutoffs for each diagnostic component; research in Asia consequently flourished, prompting this update. AWGS 2019 retains the previous definition of sarcopenia but revises the diagnostic algorithm, protocols, and some criteria: low muscle strength is defined as handgrip strength <28 kg for men and <18 kg for women; criteria for low physical performance are 6-m walk <1.0 m/s, Short Physical Performance Battery score ≤9, or 5-time chair stand test ≥12 seconds. AWGS 2019 retains the original cutoffs for height-adjusted muscle mass: dual-energy X-ray absorptiometry, <7.0 kg/m2 in men and <5.4 kg/m2 in women; and bioimpedance, <7.0 kg/m2 in men and <5.7 kg/m2 in women. In addition, the AWGS 2019 update proposes separate algorithms for community vs hospital settings, which both begin by screening either calf circumference (<34 cm in men, <33 cm in women), SARC-F (≥4), or SARC-CalF (≥11), to facilitate earlier identification of people at risk for sarcopenia. Although skeletal muscle strength and mass are both still considered fundamental to a definitive clinical diagnosis, AWGS 2019 also introduces "possible sarcopenia," defined by either low muscle strength or low physical performance only, specifically for use in primary health care or community-based health promotion, to enable earlier lifestyle interventions. Although defining sarcopenia by body mass index-adjusted muscle mass instead of height-adjusted muscle mass may predict adverse outcomes better, more evidence is needed before changing current recommendations. Lifestyle interventions, especially exercise and nutritional supplementation, prevail as mainstays of treatment. Further research is needed to investigate potential long-term benefits of lifestyle interventions, nutritional supplements, or pharmacotherapy for sarcopenia in Asians.

Impact of Energy intake at One Week after Hospitalization on Prognosis for Older Adults with Pneumonia

OBJECTIVES

This study objectives to investigate the influence of average energy intake at 1 week of hospitalization on prognosis for older adults with pneumonia.

DESIGN

Retrospective observational cohort study.

SETTING

The Japan Rehabilitation Nutrition Database comprise those with pneumonia in acute care hospitals.

PARTICIPANTS

The study included 329 pneumonia patients (aged over 65 years) who entered into the Japan Rehabilitation Nutrition Database (JRND) from November 2015 to March 2018.

MEASUREMENTS

Logistic regression analysis was performed to confirm the relationship of energy intake with the rate of mortality, discharge home, and pneumonia recurrence during hospitalization. Variables included in the multiple regression analysis model were age, sex, Mini Nutritional Assessment-Short Form score (MNA-SF) at hospitalization, A-DROP, Charlson comorbidity index (CCI), and presence or absence of rehabilitation.

RESULTS

Of 315 patients with pneumonia (median age 85 years), 63.8% were men. 57.7% were assigned to the lack of energy intake (LEI) at 1 week after admission. Patients in the LEI group were older (p = 0.033), had higher A-DROP score (p < 0.001), and showed higher malnutrition rate in MNA-SF at hospitalization (p < 0.001) than those in the control group. Mortality, pneumonia recurrence (p = 0.001), median body mass index (p = 0.012), and low malnutrition in MNA-SF (p < 0.001) at discharge were significantly higher in the LEI group than in the control group. Logistic regression analysis showed that LEI was an independent risk factor for mortality (Odds ratio: 5.07, p = 0.002), discharge home (Odds ratio: 0.33, p = 0.007), and pneumonia recurrence (Odds ratio: 3.26, p = 0.007).

CONCLUSIONS

LEI at 1 week after hospitalization in older adults with pneumonia was an independent risk factor for mortality, difficult at-home recovery, and pneumonia recurrence. These findings suggest the importance of adequate energy intake from the early days of hospitalization.

The Predictive Value of Sarcopenia and Its Individual Criteria for Cardiovascular and All-Cause Mortality in Suburb-dwelling Older Chinese

OBJECTIVES

The aim of the present study is to investigate the associations between the Asian Working Group for Sarcopenia (AWGS) sarcopenic definition, and its individual criteria, and risk of cardiovascular disease (CVD) and all-cause mortality in the Chinese elderly.

METHODS

Longitudinal analysis of 1,264 participants aged 60 years or older at baseline (2013-2014) living in suburban areas, China. Sarcopenia was defined according to the recommended algorithm of AWGS. Muscle mass was measured by a direct segmental multifrequency bioelectrical impedance analysis. Muscle strength was assessed by handgrip strength, and physical performance measured via usual walking speed.

RESULTS

Cox proportional hazard models were used to assess the risk of CVD and all-cause mortality. After 40 months of follow-up, forty-eight deaths (4.2%) died in this cohort. The mortality rate with sarcopenia was 4.7% in men and 3.8% in women. After adjusting for potential confounders, the risk of all-cause death was 4.15 times higher in subjects with sarcopenia. Furthermore, low muscle mass (HR: 2.62, 95% CI 1.34-5.13) and low grip strength (HR: 5.79; 95% CI 2.28-14.71), but not walking speed, were found to be significantly associated with all-cause mortality. Risk of CVD mortality was significantly greater in sarcopenia. Low grip strength and low walking speed were associated with 11 times (HR: 11.03, 95% CI 1.58-77.02) and 13 times (HR: 13.02; 95% CI 1.18-143.78) higher risk of CVD mortality.

CONCLUSIONS

Sarcopenia and components of sarcopenia were associated with greater CVD and all-cause mortality. Pertinent prevention or rehabilitation programs projects should look to promote healthy aging in different types of sarcopenia group.

Skeletal muscle as potential central link between sarcopenia and immune senescence

As our population grows older, age-related pathologies are becoming more prevalent. Deterioration of skeletal muscle and the immune system manifests as sarcopenia and immune senescence respectively. The disease burden of these pathologies emphasizes the need for a better understanding of the underlying mechanisms. Skeletal muscle has emerged as a potent regulator of immune system function. As such, skeletal muscle might be the central integrator between sarcopenia and immune senescence in an aging biological system. Therapeutic approaches targeting skeletal muscle might be able to restore both muscle and immune system function. In this review, we therefore outline the current - however still fragmentary - knowledge about the potential communication pathways of muscle and immune system, how they are affected by aging of skeletal muscle and discuss possible treatment strategies. The review intends to be hypothesis-generating and should thereby stimulate further research in this important scientific field.

Safety of transcutaneous electrical sensory stimulation of the neck in terms of vital parameters in dysphagia rehabilitation

Transcutaneous electrical sensory stimulation (TESS) devices are approved for use in Japan, but their safety when used through the neck skin for dysphagia rehabilitation has not been reported. This study aimed to verify the safety of TESS use through the neck skin. Twenty patients (mean age 86.5 ± 5.1 years) with aspiration pneumonia undergoing dysphagia rehabilitation were included in this retrospective observational and matched control study. We compared vital signs in 10 subjects who underwent swallowing rehabilitation with the TESS device, and matched control patients over 7 days. The results were the following: tachycardia, 0.60 ± 1.07 vs. 0.70 ± 0.67 days; high blood pressure, 0.40 ± 0.70 vs. 0.50 ± 1.08 days; low blood pressure, 0.40 ± 0.70 vs. 0.10 ± 0.32 days; low oxygen saturation, 0.60 ± 1.58 vs. 0.50 ± 1.08 days, p = 0.870; oxygen administration, 0.80 ± 2.20 vs. 1.20 ± 2.15 days; tachypnea, 0.50 ± 0.71 vs. 0.50 ± 0.53 days; elevated body temperature, 2.00 ± 1.41 vs. 1.60 ± 1.96 days. There were no significant differences in clinical stability between the TESS and control groups of patients with aspiration pneumonia. TESS through the neck appears safe as an intervention in dysphagia rehabilitation.

Predictors of Discontinuance of Oral Feeding in Patients With Advanced Alzheimer Dementia and Aspiration Pneumonia in Japan: A Single-center, Retrospective Observational Study

BACKGROUND

Difficulty with oral feeding, the most commonly observed complication of Alzheimer disease (AD) in its final stages, occurs in 86% of AD patients and may prevent achievement of oral feeding after aspiration pneumonia. However, no reliable indicators of discontinuance of oral feeding have yet been identified. We therefore aimed to identify predictors of discontinuance of oral feeding in postaspiration pneumonia patients with AD.

MATERIALS AND METHODS

Relevant clinical and laboratory data of 60 patients with AD admitted to our hospital in Japan for aspiration pneumonia were retrospectively compared between oral feeding and discontinuance groups.

RESULTS

The study groups differed in interval since diagnosis of AD, CURB-65 score, pneumonia severity index score, and proportion of patients who died (higher in the discontinuance group) and body mass index (BMI), Mini Mental State Examination (MMSE) score, and functional independence measure score (lower in the discontinuance group). According to multivariate logistic regression analysis of all identified independent variables, only CURB-65 and MMSE scores and BMI are significant predictors of discontinuance of oral feeding after aspiration pneumonia in patients with advanced AD.

CONCLUSIONS

In patients with advanced AD, discontinuance of oral feeding after aspiration pneumonia may be predicted by CURB-65 and MMSE scores and BMI.