Nutritional Status and Nutritional Treatment Are Related to Outcomes and Mortality in Older Adults with Hip Fracture

Relation between number of teeth, malnutrition, and 3-year mortality in elderly individuals ≥85 years

OBJECTIVE

The number of teeth has been shown to affect mortality. However, it is unclear why the number of teeth is associated with mortality. We focused on the number of teeth and malnutrition and examined whether these differences affect 3-year all-cause mortality among very elderly individuals.

METHODS

This analysis was conducted using data from the Tokyo Oldest Old Survey on Total Health study. Altogether 513 participants ≥85 years were categorized based on remaining teeth (0, 1-7, 8-18, ≥19). All-cause mortality was determined by calculating the cumulative 3-year survival rate according to the remaining number of teeth and the presence/absence of malnutrition. Further, hazard ratios (HRs) were analyzed using Cox regression analyses.

RESULTS

No difference was observed according to the number of teeth (p = 0.638), but the presence/absence of malnutrition was significantly associated with mortality (p < 0.001). Malnutrition was independently associated with higher HRs, even after adjusting for confounding factors associated with mortality. (HR: 2.315, 95% CI: 1.431-3.746). Additionally, adjusting for the number of teeth, HR remained significant (HR: 2.365, 95% CI: 1.449-3.853).

CONCLUSION

In the very elderly, malnutrition-but not the number of teeth-was independently associated with 3-year all-cause mortality after adjusting for various health issues.

Geriatric rehabilitation care after hip fracture

PURPOSE

After acute hospital admission, patients with a hip fracture are frequently discharged to skilled nursing homes providing geriatric rehabilitation (GR). There are few evidence-based studies regarding specific treatment times and assessments during GR. This study aims to provide a description of care for hip fracture patients during GR in the Netherlands.

METHODS

Descriptive study analyzing the care pathways from GR facilities, regarding healthcare professionals involved, allocated treatment time per profession, total length of rehabilitation stay, and assessment instruments. Based on the reimbursement algorithm (diagnostic treatment combination = DBCs), of 25 patients, the registered actual treatment time per profession was calculated.

RESULTS

The care pathways pivoted on three groups of health care professionals: medical team (MT), physiotherapy (PT), and occupational therapy (OT). There was some discrepancy between the allocated time in the care pathways and the calculated mean actual treatment time from the DBCs. First week: MT 120-180 min, DBC 120 (SD: 59) minutes; PT 120-230 min, DBC 129 (SD: 58) minutes; and OT 65-165 min, DBC 93 (SD: 61) minutes. From week two onwards, MT 15-36 min, DBC 49 (SD: 29) minutes; PT 74-179 min, DBC 125 (SD: 50) minutes; and OT 25-60 min, DBC 47 (SD: 44) minutes. Dieticians, psychologists, and social workers were sporadically mentioned. There was heterogeneity in the assessment and screening tools.

CONCLUSIONS

It is difficult to define current standard care in GR after hip fracture in the Netherlands due to the diversity in care pathways and large practice variation. This is a problem in conducting randomized effectiveness research with care provided as control.

TRIAL REGISTER AND DATE OF REGISTRATION

NL7491 04-02-2019.

Prognostic impact of tumor size on isolated hepatocellular carcinoma without vascular invasion may have age variance

Background

Previous studies suggested that tumor size was an independent risk factor of prognosis for hepatocellular carcinoma (HCC). However, the general prognostic analysis did not consider the interaction between variables. The purpose of this study was to investigate whether the effect of tumor size on the prognosis of isolated HCC without vascular invasion varies according to covariates.

Methods

Patients were selected from the Surveillance, Epidemiology, and End Results (SEER) database to investigate whether there was an interaction between age and tumor size on the prognosis. Then the trend test and the value of per 1 SD of tumor size were calculated. In addition, the data of Zhejiang Provincial People's Hospital meeting the requirements were selected to verify the obtained conclusions.

Results

Multivariable Cox regression analysis of the database cohort showed that age, gender, tumor size, pathological grade and marital status were independent risk factors for prognosis. Interaction test showed that there was an interaction between age and tumor size (P for interaction < 0.05). Stratified analysis by age showed that tumor size was an independent risk factor for prognosis when age ≤65 years old (HR:1.010,95%CI1.007-1.013 P < 0.001), while tumor size was not an independent risk factor for prognosis when age >65 years old. This result was confirmed by trend analysis (P for trend < 0.001), and the prognostic risk increased by 42.1% for each standard deviation increase of tumor size among patients age ≤65 years. Consistent conclusion was obtained by multivariable cox regression analysis and interaction test on the verification cohort. In the validation cohort, for each standard deviation increase of tumor size in patients ≤65 years old, the risk of prognosis increased by 52.4%.

Conclusion

Tumor size is not an independent risk factor for the prognosis of isolated HCC without vascular invasion when patient's age >65 years. Therefore, when analyzing the relationship between tumor size and prognosis, stratified analysis should be performed according to age.

Influence of Malnutrition on Outcome after Hip Fractures in Older Patients

Background: Malnutrition might lead to a worse outcome in hip fractures of older patients. The purpose of this study is to analyze different indicators of malnutrition that lead to worse outcomes. Methods: 252 patients of a geriatric trauma unit were analyzed prospectively. Different demographic, as well as data on the trauma and whether osteoporosis prophylaxis or anticoagulation was present, were recorded. The nutritional status with respect to laboratory parameters as well as nutritional risk score was also analyzed. Results: The main finding of this study is that a poor nutritional status is statistically significantly associated with higher mortality as well as worse independence (p < 0.05). A postoperatively prescribed osteoporosis prophylaxis is protective of mortality and independence (p < 0.05). Conclusions: Malnutrition of geriatric patients increases the risk for death, worse mobility, and independence after hip fractures. Osteoporosis prophylaxis prescribed during an inpatient stay enables patients to retain their independence. The nutritional status of geriatric patients with hip fractures should be obtained and provisions made.

Clinical and Demographic Characteristics of Centenarians versus Other Age Groups Over 75 Years with Hip Fractures

Objective

The primary objective was to describe the clinical characteristics, management, and outcomes of centenarians with fragility hip fracture and compare them to other age groups. The secondary objective was to determine the variables associated with length of stay, in-hospital mortality and 30-day mortality.

Materials and Methods

This is a secondary analysis of the Spanish National Hip Fracture Registry. We included patients ≥75 years admitted for fragility hip fractures in 86 Spanish hospitals between 2017 and 2019, dividing the sample into four age groups. The variables studied were baseline characteristics, type of fracture, management, length of stay, in-hospital mortality and 30-day mortality.

Results

We included 25,938 patients (2888 were 75-79 years old; 14,762 octogenarians; 8,035 nonagenarians and 253 centenarians). Of the centenarians, 83% were women, 33% had severe dementia, 9% had severe dependency and 36% lived in residential care homes. Six out of ten had intertrochanteric fracture. Length of hospital stay was 8.6 days; in-hospital mortality was 10.3% and 30-day mortality 20.9%. Older age groups had more women, severe functional dependency, severe dementia, intertrochanteric fracture, living in care facilities and being discharged to nursing care. They had less frequent early mobilization, osteoporosis treatment and discharge to rehabilitation units. In-hospital and 30-day mortality were higher with increasing age. In centenarians, time to surgery >48 hours was independently associated with length of stay (correlation coefficient 3.99 [95% CI: 2.35-5.64; p<0.001]) and anaesthetic risk, based on an ASA score of V, was related to 30-day mortality (ASA score II [OR 0.25, 95% CI: 0.09-0.70; p=0.009] and ASA score III [OR 0.43, 95% CI: 0.19-0.96; p=0.039]).

Conclusion

Centenarians had different clinical characteristics, management and outcomes. Although centenarians had worse outcomes, nearly 4 out of 5 centenarians were alive one month after surgery.

[Malnutrition management of hospitalized patients with diabetes/hyperglycemia and hip fracture]

Introduction

The yearly incidence of hip fracture is very high, which generates significant healthcare and socioeconomic burden. These fractures can occur at any age, but the vast majority occur in people over 65 years of age and predominantly in women, due to the increased risk of menopause-associated osteoporosis. Type 2 diabetes mellitus (DM2), apart from altering glucose, lipid and protein metabolisms, also causes a deregulation of calcium, phosphorus and magnesium and dysfunction in bone metabolism. The prevalence of malnutrition in patients with hip fracture is also high, due to their advanced age, and the acute injury itself provokes catabolic and inflammatory responses that result in disease-related malnutrition and sarcopenia, which aggravates the patient's clinical condition. This article describes the results of the expert consensus and the responses of the panelists on the nutritional management in routine clinical practice of patients with diabetes/hyperglycemia hospitalized (non-critically ill) with hip fracture.

The Neutrophil-to-Lymphocyte Ratio and Preoperative Pulmonary Function Test Results as Predictors of In-Hospital Postoperative Complications after Hip Fracture Surgery in Older Adults

Purpose: This study retrospectively evaluated the usefulness of the neutrophil-to-lymphocyte ratio (NLR), prognostic nutritional index (PNI), and pulmonary function test (PFT) results as objective predictors of in-hospital postoperative complications after hip fracture surgery in older adults. Methods: The patients aged >65 years who underwent hip fracture surgery under general anaesthesia were enrolled. In-hospital postoperative complications with preoperative NLR, PNI and PFT results were evaluated. The NLR was calculated as the preoperative neutrophil count/lymphocyte count in peripheral blood. The PNI was calculated as the serum albumin (g/dL) × 10 + total lymphocyte count × 0.005 (/mm3). Results: One hundred ninety nine patients were analysed. The most common postoperative complications were respiratory complications. Compared with patients who did not have postoperative complications, patients with postoperative complications had a significantly higher NLR (8.01 ± 4.70 vs. 5.12 ± 4.34, p < 0.001), whereas they had a significantly lower PNI (38.33 ± 6.80 vs. 42.67 ± 6.47, p < 0.001), preoperative functional vital capacity (FVC; 2.04 ± 0.76 vs. 2.45 ± 0.71 L, p < 0.001), and forced expiratory volume at 1 s (FEV1; 1.43 ± 0.53 vs. 1.78 ± 0.58 L, p < 0.001). Multiple logistic regression analysis identified NLR (odds ratio [OR], 1.142; 95% confidence interval [CI], 1.060−1.230; p < 0.001) and FEV1 (OR, 0.340; 95% CI, 0.191−0.603; p < 0.001) as risk factors for postoperative complications after hip fracture surgery. Conclusion: Preoperative NLR and FEV1 are objective predictors of in-hospital postoperative complications after hip fracture surgery in older patients.

Dietary recommendations in the prevention and treatment of osteoporosis

INTRODUCTION

This article presents the initial recommendations of the French Rheumatology Society (Société Française de Rhumatologie - SFR) and the Osteoporosis Research and Information Group (Groupe de Recherche et d'Informations sur les Ostéoporoses - GRIO) on the role of diet in the prevention and treatment of osteoporosis.

METHODS

The recommendations were produced by a working group composed of rheumatologists, physician nutrition specialists and a geriatrician. Fifteen (15) questions pertaining to "daily practices" were preselected by the working group. For the literature review, the working group focussed mainly on the effects of diet on bone mineral density (BMD) and fractures, and primarily on meta-analyses of longitudinal studies and dietary intervention studies.

RESULTS

A Mediterranean-type diet and the daily consumption of 2 to 3 dairy products are recommended. Together, these provide the calcium and "high quality" protein required to maintain a normal calcium-phosphorus balance and bone metabolism, and are associated with lower fracture risk. Conversely, unbalanced Western diets, vegan diets, weight-loss diets in non-overweight individuals, alcohol consumption and daily consumption of sodas are advised against. In terms of the beneficial effects on bone mineral density and fracture risk, current scientific data are either insufficient or too divergent to recommend increasing or restricting the consumption of tea or coffee, vitamins other than vitamin D, vitamin D-enriched or phytoestrogen-rich foods, calcium-enriched plant-based beverages, oral nutritional supplements, or dietary sources of prebiotics and probiotics.

CONCLUSIONS

These are the first set of recommendations addressing the role of diet in the prevention and treatment of osteoporosis. More research is necessary to direct and support guidelines.

Pretreatment Nutritional Status in Combination with Inflammation Affects Chemotherapy Interruption in Women with Ovarian, Fallopian Tube, and Peritoneal Cancer

BACKGROUND

Discontinuing chemotherapy worsens cancer prognosis. This study aimed to investigate the relationship between nutritional status at the start of chemotherapy and chemotherapy discontinuation in patients with ovarian, fallopian tube, and primary peritoneal cancer.

METHODS

This was a retrospective cohort study. One hundred and forty-six patients to whom weekly paclitaxel and carboplatin were administered as postoperative chemotherapy were included. Six courses in 21-day cycles were defined as complete treatment. As nutritional indicators, body mass index, weight change rate, serum albumin, total lymphocyte count, prognostic nutritional index, and C-reactive protein-to-albumin ratio (CAR) were compared between complete and incomplete treatment groups. Patients were divided into two groups according to CAR. The number of chemotherapy cycles was compared between these two groups. A Cox proportional hazard model was used for covariate adjustment.

RESULTS

Several indicators differed between complete and incomplete treatment groups, and among the indicators, CAR had the highest discriminatory ability. The number of chemotherapy cycles was shorter in the high CAR group than in the low CAR group. A high CAR was associated with chemotherapy interruption even after adjusting for covariates.

CONCLUSION

Based on CAR, nutritional status before chemotherapy is suggested to be associated with the risk of chemotherapy discontinuation.

Combined Effects of Cognitive Impairment and Nutritional Trajectories on Functional Recovery for Older Patients after Hip-Fracture Surgery

OBJECTIVES

Malnutrition and cognitive impairment are associated with poor functional recovery in older adults following hip-fracture surgery. This study examined the combined effects of cognitive impairment and nutritional trajectories on postoperative functional recovery for older adults following hip-fracture surgery.

DESIGN

Prospective longitudinal correlational study.

SETTING AND PARTICIPANTS

This study recruited 350 older adults (≥60 years of age) who received hip-fracture surgery at a 3000-bed medical center in northern Taiwan from September 2012 to March 2020.

METHODS

Participant data were collected over a 2-year period after surgery for nutritional and cognitive status and activities of daily living (ADLs). Participants were grouped by type of nutritional trajectory using group-based trajectory modeling. Generalized estimating equations analyzed associations between trajectory groups/cognitive status at discharge and performance of ADLs.

RESULTS

Nutritional trajectories best fit a 3-group trajectory model: malnourished (19%), at-risk of malnutrition (40%), and well-nourished (41%). Nutritional status for the malnourished group declined from 12 months to 24 months following surgery; nutritional status remained stable for at-risk of malnutrition and well-nourished groups. Interactions for cognitive impairment-by-nutritional status were significant: the malnourished + intact cognition subgroup had significantly better ADLs than the malnourished + cognitive impairment subgroup (b = 27.1, 95% confidence interval = 14.0-40.2; P < .001). For at-risk of malnutrition and well-nourished groups, there were no significant differences between cognitive impairment and intact cognition in ADLs. These findings suggest that nutritional status may buffer the negative effect of cognitive impairment on ADLs.

CONCLUSIONS AND IMPLICATIONS

Better nutritional status over time for older adults following hip fracture can protect against adverse influences of cognitive impairment on ADLs during postoperative recovery. Participants with malnutrition and cognitive impairment had the poorest ADLs. These findings suggest interventions tailored to improving nutritional status may improve recovery for older adults following hip-fracture surgery.

Dialogue is a prerequisite for the nurse-patient relationship in nutritional care: A secondary analysis using the fundamentals of care framework

BACKGROUND

Providing good nutritional care is complex as it goes beyond assessing and ensuring the patients' dietary needs. So far, nutritional research has mainly focused on establishing evidence for the nutritional treatment, while less attention has been on the complexity of providing nutritional care. The Fundamentals of Care (FoC) describes five elements (focus, knowledge, anticipate, evaluate and trust) essential for establishing a nurse-patient relationship as a foundation for quality care. By studying how these elements shape nutritional care and dialogue, we can explore and describe the complexity of nutritional care.

AIM

By using the FoC framework as an analytic framework, this study explores how the nurse-patient relationship shapes the nutritional care of orthopaedic patients.

METHOD

This study is a secondary analysis using deductive content analysis of interviews with patients undergoing major orthopaedic surgery, nursing staff and observations of interactions between nursing staff and patients. The core dimension of the FoC framework, 'Establishment of relationship,' was used as an analytic framework.

RESULT

The nurses perceived serving meals and providing nutritional supplements as an essential part of the nutritional care. Still, the nutritional care was organised as a routine task to be less time-consuming. Appropriate care was initiated when the nursing staff explored patients´ food preferences. When the nursing staff failed to familiarise themselves with the patient's preferences, the patients interpreted nutritional care as unrelated to their needs, resulting in a lack of trust.

CONCLUSION

The need for efficiency within nutritional care must not compromise the patients' need for dialogue with the nurse. Establishing a trusting relationship between nurses and patients prevents nutritional care from becoming a routine task unrelated to the patients' needs.

Theory-driven development of an educative nutritional intervention (ENI) supporting older hospital patients to eat sufficiently, assisted by an eHealth solution: an intervention mapping approach

Background:

Insufficient protein and energy intake is a prevalent and serious problem in older hospital patients. Here, we describe the development of a program consisting of 1) an educative nutritional intervention (ENI) to support older hospital patients to participate in their own nutritional care using the eHealth solution Food’n’Go, and 2) a plan for education and support of healthcare professionals, enabling them to conduct the ENI. Further, we describe the evaluation of the acceptability of the program as perceived by nursing staff and dieticians.

Methods:

The Intervention Mapping (IM) framework was used to design and develop the ENI through six steps: 1) a logic model of the problem was developed; 2) performance objectives and related change objectives were defined for patients, relatives, and healthcare professionals; 3) the intervention was designed using relevant theory-based change methods; 4) program materials were produced; and finally, 5) implementation and maintenance were planned and 6) evaluation of the program was planned. End users (patients, relatives, and healthcare professionals) were involved in the design and development of the ENI.

Results:

Based on the logic model, the personal determinants (knowledge, skills, self-efficacy, outcome expectation, social support, attitude, and awareness) related to the patients and their relatives were addressed in the ENI, and those related to the healthcare professionals were addressed in the plan for their education and support. Theories of behavioral change, technology acceptance, and nutritional management for older persons were applied. A plan for evaluation of the effectiveness (intake of energy and protein) and feasibility of the ENI was conducted. The feasibility measurements were the behaviors and determinants related to the intervention outcome that were identified in the logic model of change. The ENI was perceived as acceptable by the nursing staff and dieticians.

Conclusion:

We developed a theory- and evidence-based intervention guided by the IM framework and a sociotechnical approach, which was perceived as acceptable and ready for use to support older hospital patients to eat sufficiently assisted by eHealth.

Risk factors of mortality and second fracture after elderly hip fracture surgery in Shanghai, China

INTRODUCTION

Hip fracture is one of the leading causes of death and disability in the elderly. We analyzed the risk factors of mortality and second fracture within 2 years after hip fracture surgery in elderly Chinese patients.

MATERIALS AND METHODS

A total of 613 elderly patients after hip fracture surgery were selected, including 181 males and 432 females, and the patients were followed for at least 24 months. Information about patients and surgery was collected from medical records. Information on death, secondary fracture, and postoperative activities of daily living (ADL) was obtained by telephone follow-up. Cox regression was performed to identify risk factors associated with mortality and second fracture, measured by hazard ratio (HR).

RESULTS

The 1-year and 2-year mortality rates after hip fracture were 13.4% and 20.7%, respectively. The second fracture rate within 2 years was 9.5%. Male gender (HR 1.51, P = 0.035), increased age (HR 1.07, P < 0.001), preoperative hypoalbuminemia (HR 1.79, P = 0.004), preoperative pneumonia (HR 2.60, P = 0.005) and poor ADL (P = 0.048) were independent risk factors for 2-year mortality, while high preoperative hemoglobin (HR 0.98, P = 0.002), high preoperative eGFR (HR 0.99, P = 0.031), high preoperative LVEF (HR 0.92, P = 0.048) were protective factors for 2-year mortality. Poor ADL (P = 0.002) was the independent risk factor for second fracture within 2 years.

CONCLUSIONS

The 2-year mortality rate and second fracture rate after hip fracture in elderly remained high, which was related to old age and complications exists. Postoperative rehabilitation and improving ADL were very important to reduce mortality and second fracture.

Hypoalbuminemia is associated with 30-day mortality in hip fracture patients independently of Body Mass Index

The aim of this study was to assess the possible association between P-Albumin and 30-day mortality in hip fracture patients. The study is based on information from a database of hip fracture patients, established and collected at Bispebjerg University Hospital (Copenhagen, Denmark). This database includes all femoral neck (DS720), pertrochanteric (DS721) and subtrochanteric fractures (DS722) admitted to Bispebjerg Hospital between 1996 and 2012. We further identified all surgically treated hip fracture patients aged >60 years with an available P-Albumin at admission. 1856 patients were eligible for inclusion in this study (73.7% female, 26.3% male). 11.8% of these had died within 30 days. Differences between continuous variables were tested using unpaired t-tests while differences in the distribution of categorical variables were tested using chi square tests. After adjusting for co-variates in a logistic regression model, the association between P-Albumin and 30-day mortality remained increased, (OR 1.09, 95% CI 1.05;1.11 (p < 0.0001)). This study shows an increased 30-day mortality risk among surgically treated hip fracture patients with decreasing levels of P-Albumin even after adjusting for age, sex, BMI, CCI and fracture type. Routine screening of patients for hypoalbuminemia at hospital admission may be beneficial in the management of hip fracture patients.

Outcomes After Revision Fixation With Cement Augmentation for Failed Intertrochanteric Fracture Fixation in Older Adult Patients

Introduction

Intertrochanteric (IT) fractures that fail fixation are traditionally treated with arthroplasty, introducing significant risk of morbidity and mortality in frail older adult patients. Revision fixation with cement augmentation is a relatively novel technique that has been reported in several small scale international studies. Here we report a clinical series of 22 patients that underwent revision fixation with cement augmentation for IT fracture fixation failure.

Methods

This retrospective case series identified all patients that underwent revision intramedullary nailing from 2018 to 2021 at two institutions within a large metropolitan healthcare system. Demographics, injury characteristics, Charlson Comorbidity Index score, and surgical characteristics were extracted from the electronic medical record. Outcomes were extracted from the electronic medical record and included radiographic findings, pain, functional outcomes, complications, and mortality.

Results

Average follow-up after revision surgery was 15.2 ± 10.6 months. Twenty patients (90.9%) reported improved pain and achieved union or progressive healing after surgery. Most of these patients regained some degree of independent ambulation (19 patients, 86.4%), with only 5 patients (22.7%) requiring increased assistance for their activities of daily living (ADLs). One-year mortality was 13.6% (3 patients). Of the 5 patients (22.7%) that experienced complications, 2 patients (9.1%) required revision hemiarthroplasty for subsequent fixation failure. The other 3 patients did well when complications resolved.

Conclusions

Revision fixation with cement augmentation can be an effective, safe, cost-effective alternative to arthroplasty for the management of cases involving non-infected failed IT fracture fixation with implant cut-out or cut-through limited to the femoral head in older adult patients that have appropriate acetabular bone stock.

Preliminary Evidence on the Effectiveness of a Multidisciplinary Nutritional Support for Older People with Femur Fracture at an Orthogeriatric Unit in Spain

To describe the nutritional and functional changes that occurred in older patients with a femur fracture following a dietary intervention and oral nutritional support implemented at an orthogeriatric unit in Aragon, Spain. Open-label, prospective study. Patients were consecutively recruited and arranged into three groups based on their CONtrolling NUTritional (CONUT^®) score and nutritional needs. Nutritional status was assessed while in hospital, and at 45-, 100- and 180-days post-hospital discharge. One hundred and sixty-nine patients [mean age: 86 years (SD ± 5.48)] were recruited (July 2017 to January 2020). At admission, 53.3% were at risk of malnutrition; 26.6% were malnourished; 20.1% were well-nourished. Variable proportions of malnourished patients at admission were well-nourished 45-, 100-, and 180-days post-discharge. CONUT^® and Barthel index correlations showed that as nutritional status enhanced, patients gained functionality. Dietary interventions and nutritional support may help restoring the nutritional and functional status of older patients with a femur fracture.

Usefulness of nutritional assessment using Geriatric Nutritional Risk Index as an independent predictor of 30-day mortality after hip fracture surgery

INTRODUCTION

The Geriatric Nutritional Risk Index (GNRI) is an objective nutritional status assessment tool used for predicting mortality risk in hospitalized patients. However, it is unclear whether GNRI reflects short-term mortality for hip fracture patients after surgery. We examined the usefulness of the nutritional status assessed by the GNRI and identified cutoff scores that predict mortality risk. Does GNRI on admission predict the mortality after surgery for hip fracture?

HYPOTHESIS

Evaluation of GNRI could help identify patients at higher risk of 30-day mortality after hip fracture surgery.

MATERIALS AND METHODS

This retrospective study used data from 1040 patients who underwent hip fracture surgery. Fatalities within 30 days after hip fracture surgery were investigated. The GNRI was calculated on admission in all patients as follows: 14.89×serum albumin (g/dL)+41.7×body mass index/22. Receiver operating characteristic (ROC) curves were used to calculate the area under the curve (AUC) and the optimal cutoff score that could predict 30-day mortality after hip fracture surgery. This cutoff score was used for comparing the mortality rates between patient groups with a GNRI higher and lower than the cutoff score using Fisher's exact test. Logistic regression analysis was used to determine risk factors of 30-day mortality.

RESULTS

There were 17 fatalities (1.6%) in the cohort. The ROC-AUC value was 0.811, and the cutoff GNRI was 75.4. Mortality was significantly higher in the group with a GNRI<75.4 compared with the group with a GNRI≥75.4 (odds ratio [OR], 22.99; 95% confidence interval [95% CI], 7.55-78.05; p=0.00000004). A GNRI<75.4 was a significant predictor of mortality within 30-days after hip fracture surgery (OR, 27.1; 95% CI, 8.57-85.9; p≤0.0001).

DISCUSSION

Our results show that nutritional status assessment using GNRI can help predict 30-day mortality among geriatric patients undergoing surgery for hip fracture. The GNRI is a simple and accurate tool for predicting the risk of mortality after hip fracture surgery.

LEVEL OF EVIDENCE

IV; case series study.

Better nutrition trajectory improves recovery following a hip fracture surgery for older persons with diabetes mellitus

BACKGROUND

Influences of nutritional status on hip fractured persons with diabetes mellitus (DM) following surgery have not been reported.

AIMS

To explore the trajectory groups of nutritional status and their influences on post-operative recovery for older persons with hip fracture and DM.

METHODS

A total of 169 patients with DM and hip fracture from a clinical trial were included in this analysis. Mini Nutritional Assessment was used to assess the nutritional status of the participants. Outcome variables included self-care ability, muscle strength, depressive symptoms, health related quality of life, and cognitive function, which were collected before discharge and 1-, 3-, 6-, 12-, 18-, and 24-months following hospital discharge.

RESULTS

Among hip fractured older persons with DM, within two years following surgery there were three nutritional trajectory groups: malnourished (28.3%), at-risk of malnutrition (41.9%) and well-nourished (29.8%). A decline in nutritional status, especially for the malnourished group, was seen in the second year. A better nutritional trajectory was associated with better recovery outcomes, including self-care ability, health related quality of life, cognitive function and less depressive symptoms.

DISCUSSION

Close to 30% of hip fractured persons with DM were considered to have a malnourished trajectory over 2 years following surgery. A poor nutritional trajectory was associated with poor mental health and physical recovery.

CONCLUSIONS

Continuous nutrition assessment during the first 2 years following hip fracture surgery for older persons with DM is important. Development and implementation of interventions targeting the malnourished trajectory group are suggested.

Patient-specific factors affecting survival following hip fractures-a 14-year follow-up study in Finland

The mortality of elderly hip fracture patients is high. Eighty-five percent of all patients were followed until death. The three most protective factors for 1-year survival were ASA class; BMI; and age, and the four most protective factors for 14-year survival were age; BMI; ASA class; and subtrochanteric fracture type.

OBJECTIVE

Hip fractures are associated with increased mortality. The purpose of this study was to evaluate the protective preoperative factors regarding the survival of short-term (1 year) and long-term (14 years) follow-up in a hip fracture cohort in Finland.

METHODS

A total of 486 patients, operated on in 2005 and 2006, were retrospectively evaluated. Survival was analyzed using Bayesian multivariate analysis and relative survival with the life table method. All patients were followed for a minimum of 14 years.

RESULTS

We analyzed 330 women and 156 men, whose mean ages were 82.4 and 72.0 years, respectively. The overall mortality rate was 7% at 1 month, 22% at 12 months, and 87% at 14 years. Protective factors against mortality at 1 year were ASA class (1-3), BMI ≥ 20 kg/m², age < 85 years, alcohol involvement, Alzheimer's disease, no comorbidities, certain operative methods, and female sex. Factors promoting survival at 14 years were age < 75 years, BMI ≥ 20 kg/m², ASA class (1-2), subtrochanteric fracture, certain operative methods, alcohol involvement, and no comorbidities.

CONCLUSIONS

Protective factors for 1-year survival in order of importance were ASA class, BMI, and age, and, correspondingly, for 14-year survival, age, certain operative methods, BMI, and ASA class. The relative survival of hip fracture patients was lower than that of the general population.

Preoperative malnutrition as an independent risk factor for the postoperative mortality in elderly Chinese individuals undergoing hip surgery: a single-center observational study

Objective:

Malnutrition is prevalent in elderly with hip fracture and higher than in community-dwelling older adults. Scarce studies have examined the association between preoperative malnutrition and postoperative mortality in elderly Chinese individuals with hip fracture. This study was designed to explore the effect of preoperative malnutrition on the postoperative long-term mortality in elderly Chinese individuals undergoing hip surgery.

Methods:

As a single-center observational study, this study included 263 consecutive patients above 70 years old with hip fracture and elective surgery. Preoperative nutritional status was evaluated by prognostic nutritional index (PNI). Patients were divided into one group with malnutrition (26 patients with PNI ⩽ 38) and the other group without malnutrition (169 patients with PNI > 38), respectively.

Results:

The overall malnutrition rate was 13.3% (26 patients). The postoperative long-term mortality rates of patients with and without malnutrition had statistically significant difference [10 patients (38.5%) and 32 patients (18.9%), p < 0.05]. Cox regression analysis showed that malnutrition (hazard ratio: 0.269, 95% confidence interval: 0.085–0.859, p < 0.05) and partial pressure of carbon dioxide (hazard ratio: 0.873, 95% confidence interval: 0.790–0.964, p < 0.05) were independent risk factors for the postoperative long-term mortality.

Conclusion:

This study demonstrated that preoperative malnutrition was an independent risk factor for the postoperative long-term mortality and resulted in a more than 2.5-fold increase of the postoperative long-term mortality in elderly Chinese individuals undergoing hip surgery.

Prevalence and factors associated with malnutrition in hospitalized patients with proximal femur fracture: Experience at Hospital Universitari Mutua Terrassa

INTRODUCTION

Malnutrition is commonly associated with elderly patients with femoral fractures. Approximately 50% of hospitalized patients with a femoral fracture are malnourished or at risk of malnourishment. This situation may have a negative impact on outcomes and results for these patients. Malnourishment has been associated with an increased risk of complications, mortality, poor recovery, and delayed length of stay.

METHOD

A retrospective observational study was conducted at our institution to evaluate the prevalence of malnutrition or risk of malnourishment in 766 hospitalized patients from January 2016 to December 2019. Furthermore, we identified factors that are associated with malnutrition. We also compared length of stay and mortality according to the degree of malnutrition.

RESULTS

The mean age for patients included was 84.6 years and 75% of patients were female. The Mini Nutritional Assessment test results showed 7.9% of patients were malnourished and 31.5% at risk of malnourishment.

CONCLUSIONS

Our study results indicate a high prevalence of malnutrition and risk of malnourishment in hospitalized elderly patients with a femoral fracture.

The Aging Features of Thyrotoxicosis Mice: Malnutrition, Immunosenescence and Lipotoxicity

The problem of aging is mainly the increase of age-related diseases, and elderly patients have longer hospitalization and worse prognosis. Poorer nutritional status and immunosenescence may be predisposing and severe factors. The mechanism of the high incidence of diseases and poor prognosis behind aging is complex. Finding suitable aging models is of great significance to find strategies to prevent aging related events. In this study, the relationship between thyrotoxicosis and aging was investigated in mice. The results of routine blood tests and flow cytometry showed that immunosenescence occurred in thyrotoxicosis mice, which was characterized by a significant decrease in neutrophils, lymphocytes, CD4+/CD8+ and CD4+IFN-γ+ lymphocytes. Biochemical examination results showed that there were hypocholesterolemia, hypolipoproteinemia, and hyperlipidemia in thyrotoxicosis mice. Serum proteomics analysis showed that the downregulation of complement and coagulation proteins was another manifestation of declined immunity. Moreover, proteomics analysis showed that many downregulated proteins were related to homeostasis, mainly transport proteins. Their downregulation led to the disturbance of osmotic pressure, ion homeostasis, vitamin utilization, lipid transport, hyaluronic acid processing, and pH maintenance. Serum metabolomics analysis provided more detailed evidence of homeostasis disturbance, especially lipid metabolism disorder, including the downregulation of cholesterol, vitamin D, bile acids, docosanoids, and the upregulation of glucocorticoids, triglycerides, sphingolipids, and free fatty acids. The upregulated lipid metabolites were related to lipotoxicity, which might be one cause of immunosenescence and many aging related syndromes. This study provides evidence for the aging model of thyrotoxicosis mice, which can be used for exploring anti-aging drugs and strategies.

Relationship between Nutritional Status, Body Composition, Muscle Strength, and Functional Recovery in Patients with Proximal Femur Fracture

Sarcopenia is a major issue among the elderly. However, the effects of nutritional status and body composition on functional recovery in patients with proximal femur fractures (PFF) remain unclear. Hence, this study aimed to investigate the effects of nutritional status, body composition (skeletal muscle mass and muscle quality measured by phase angle [PhA] values), and muscle strength on the improvement in activities of daily living (ADL) in patients with PFF. We enrolled patients with PFF admitted to a rehabilitation unit. Nutritional status, body composition, grip strength, and motor Functional Independence Measure (FIM) score were assessed on admission day and at 4 weeks thereafter. Of 148 patients, 84 had femoral neck fractures, and 64 had trochanteric fractures. The mean motor FIM score was 49.2 points at admission and 64.9 points after 4 weeks. In multivariate analysis, higher geriatric nutritional risk index and PhA measured by anthropometry were associated with a significantly higher FIM score after 4 weeks. Muscle strength and quality changes significantly correlated with ADL improvement. Poor nutritional status and decreased muscle strength and quality interfered with ADL recovery. Nutritional management before injury and from the acute phase, and rehabilitation to maintain skeletal muscle status, are important for ADL recovery.

Efficacy of Oral Nutritional Supplements in Patients Undergoing Surgical Intervention for Hip Fracture

Introduction: Malnutrition is considered a risk factor among geriatric individuals with hip fracture, affecting functional healing and recovery, increasing healthcare spending, and associated with high mortality. In this study, we sought to evaluate the clinical efficacy of oral nutritional supplements in geriatric patients undergoing surgery for hip fracture. Material and Methods: We retrospectively analyzed data of 1625 consecutive patients who underwent fixation or arthroplasty for hip fracture in a tertiary medical center between 2017 and 2020. Patients who had no available albumin or body mass index levels were excluded. The study group is of patients who received an advanced formula in the form of an oral nutritional supplement (ONS), and the control group of patients that received no ONS. Peri- and postoperative complications, readmissions, short-term mortality, and albumin levels were compared between the 2 groups. Results: The final cohort included 1123 patients, 298 in the study group and 825 controls, with a follow-up of at least 1-year. Provision of the advanced enriched formula was not associated with 30-day, 90-day, or 1-year mortality (P = .62, P = .52, and P = .72, respectively) or any perioperative complications, such as 30-day or 90-day readmission (P = .37 and P = .1, respectively), revision surgery of any cause (P = .35), and postoperative infection rates (P = .73). Albumin levels on admission and the minimum albumin levels during hospitalization were similar between the groups, but they were significantly higher in the study group before discharge (33.42 g/L vs. 32.79 g/L, P = .01). Discussion: The use of an ONS was not associated with reduced perioperative complications or mortality, although it did affect nutritional status, as indicated by increased albumin levels, a known marker of nutritional status. Conclusions. While current findings do not support ONS use to minimize major postoperative complication after hip fracture surgery, further long-term study is warranted to evaluate subjective and functional outcomes associated with improved nutritional status.

Conditionally Essential Amino Acid Supplementation Reduces Postoperative Complications and Muscle Wasting After Fracture Fixation: A Randomized Controlled Trial

BACKGROUND

Postoperative complications and substantial loss of physical function are common after musculoskeletal trauma. We conducted a prospective randomized controlled trial to assess the impact of conditionally essential amino acid (CEAA) supplementation on complications and skeletal muscle mass in adults after operative fixation of acute fractures.

METHODS

Adults who sustained pelvic and extremity fractures that were indicated for operative fixation at a level-I trauma center were enrolled. The subjects were stratified based on injury characteristics (open fractures and/or polytrauma, fragility fractures, isolated injuries) and randomized to standard nutrition (control group) or oral CEAA supplementation twice daily for 2 weeks. Body composition (fat-free mass [FFM]) was measured at baseline and at 6 and 12 weeks postoperatively. Complications were prospectively collected. An intention-to-treat analysis was performed. The relative risk (RR) of complications for the control group relative to the CEAA group was determined, and linear mixed-effects models were used to model the relationship between CEAA supplementation and changes in FFM.

RESULTS

Four hundred subjects (control group: 200; CEAA group: 200) were enrolled. The CEAA group had significantly lower overall complications than the control group (30.5% vs. 43.8%; adjusted RR = 0.71; 95% confidence interval [CI] = 0.55 to 0.92; p = 0.008). The FFM decreased significantly at 6 weeks in the control subjects (-0.9 kg, p = 0.0205), whereas the FFM was maintained at 6 weeks in the CEAA subjects (-0.33 kg, p = 0.3606). This difference in FFM was not seen at subsequent time points.

CONCLUSIONS

Our results indicate that CEAA supplementation has a protective effect against common complications and early skeletal muscle wasting after operative fixation of extremity and pelvic fractures. Given the potential benefits of this inexpensive, low-risk intervention, multicenter prospective studies in focused trauma populations are warranted.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Oral versus intravenous tranexamic acid in elderly patients with intertrochanteric fracture undergoing proximal femur intramedullary nailing: A prospective cohort study

Objective

Methods

Results

Conclusion

The translational potential of this article

Optimal preoperative timing for prevention of deep vein thrombosis (DVT) in patients over 60 years of age with intertrochanteric fractures

PURPOSE

To investigate the incidence and risk factors of preoperative DVT in elderly patients with intertrochanteric fracture of the femur and determine the optimal preoperative time.

METHODS

Electronic medical records of 358 patients over 60 years of age with intertrochanteric fractures from May 1, 2016, to May 1, 2019, were retrospectively analyzed. The preoperative group was divided into DVT and non-DVT. Univariate analysis was used for preliminary comparison, and multivariate logistic regression analysis was used to identify independent risk factors associated with DVT development. ROC curve was drawn to analyze the specificity and sensitivity of risk factors for DVT diagnosis. The diagnostic value of the model was analyzed by the ROC curve of multivariable combined diagnosis.

RESULTS

A total of 358 patients who met the criteria were enrolled. The total prevalence of DVT before surgery was 8.38%. Multivariate logistic regression analysis showed that smoking status, preoperative time, albumin (ALB), D-dimer level, diabetes mellitus, and hypertension were independent risk factors for preoperative DVT. Preoperative time has the best sensitivity and specificity for diagnosing the occurrence of preoperative DVT. The ROC curve analysis model of multivariable combined diagnosis has a better diagnostic value.

CONCLUSIONS

In this study, elderly patients with intertrochanteric femur fracture had a higher incidence of deep vein thrombosis before surgery. Early identification of DVT-related risk factors may contribute to individualized risk assessment and preventing adverse outcomes in patients with intertrochanteric fractures.

Disease-specific Nutritional Physical Therapy: A Position Paper by the Japanese Association of Rehabilitation Nutrition (Secondary Publication)

Nutritional disorders diminish the effectiveness of physical therapy. The pathogenesis of nutritional disorders, such as sarcopenia, frailty, and cachexia, differs from disease to disease. Disease-specific nutrition can maximize the function, activity, participation, and quality of life for patients undergoing physical therapy, a practice known as nutritional physical therapy. Understanding and practicing disease-specific nutritional physical therapy is essential to meet patients' diverse needs and goals with any disease. Thus, the physical therapist division of the Japanese Association of Rehabilitation Nutrition, with advice from the Japanese Society of Nutrition and Swallowing Physical Therapy, developed this review. It discusses the impact of disease-specific nutritional physical therapy on sarcopenia and frailty in community-dwelling older adults, obesity and metabolic syndrome, critical illness, musculoskeletal diseases, stroke, respiratory diseases, cardiovascular diseases, diabetes, renal disease, cancer, and sports.

Perioperative Nutritional Support: A Review of Current Literature

Since the beginning of the practice of surgery, the reduction of postoperative complications and early recovery have been two of the fundamental pillars that have driven the improvement of surgical techniques and perioperative management. Despite great advances in these fields, the rationalization of antibiotic prophylaxis, and other important innovations, postoperative recovery (especially in elderly patients, oncological pathology or digestive or head and neck surgery) is tortuous. This can be explained by several reasons, among which, malnutrition has a major role. Perioperative nutritional support, included within the ERAS (Enhanced Recovery After Surgery) protocol, has proven to be a main element and a critical step to achieve better surgical results. Starting with the preoperative nutritional assessment and treatment in elective surgery, we can improve nutritional status using oral supplements and immunomodulatory formulas. If we add early nutritional support in the postoperative scenario, we are able to significantly reduce infectious complications, need for intensive care unit (ICU) and hospital stay, costs, and mortality. Throughout this review, we will review the latest developments and the available literature.

Relationship Between Preoperative Hypoalbuminemia and Postoperative Pneumonia Following Geriatric Hip Fracture Surgery: A Propensity-Score Matched and Conditional Logistic Regression Analysis

Background

Pneumonia is a devastating complication following geriatric hip fracture surgery, and preoperative hypoalbuminemia may be a potentially modifiable factor leading to improved outcome. This study aimed to quantify the relationship between preoperative hypoalbuminemia and postoperative pneumonia.

Methods

We retrospectively reviewed the medical records of elderly patients (≥60 years) who underwent surgeries for hip fracture in a tertiary referral center between 2016 and 2020. According to the preoperative serum albumin level, they were divided into two groups: <35 g/ L and ≥35 g/ L. To reduce potential confounding, propensity score matching (PSM) in a 1:1 ratio was performed, with the caliper value set as 0.002; and further conditional logistic regression analysis was used to control the other potential confounders to determine the association strength.

Results

Among 3,147 eligible patients included, PSM yielded 1,318 matched patients, with 659 in each respective group, suggesting significantly improved balance in most variables (standardized mean deviation improvement range, 20.7% to 99.1%), except for basophil count. The conditional logistic regression analysis, adjusted for PS and other intra- or post-operative variables, showed 6.18-fold (relative ratio, 6.18; 95% CI, 3.15–11.98; P<0.001) increased risk of postoperative pneumonia associated with preoperative hypoalbuminemia.

Conclusion

Preoperative hypoalbuminemia was identified to be independently and highly associated with development of postoperative pneumonia in elderly patients undergoing hip fracture surgeries. However, whether the patients who had such condition may benefit from preoperative targeted nutritional support needs to be clarified by more prospective studies.

Low serum levels of vitamin D significantly increase the risk of death in older adults with hip fractures: a prospective cohort

OBJECTIVE

to evaluate the relationship between 25(OH)D3 levels and fatal outcome in patients over 60 years of age undergoing surgical repair of hip fractures.

METHODS

prospective cohort of patients undergoing surgical repair of hip fractures. At admission, 25(OH)D3 levels were measured, among other parameters. Patients were followed for at least 1 year, and incident mortality was recorded.

RESULTS

209 patients were included in the study, with a mean age of 79.5 ± 7.6 years among survivors and 80.7 ± 8.2 years among those who died in the first postoperative year (p=0.346). The 25(OH)D3 levels of survivors were significantly higher than those of patients who died (p=0.003). After adjusting for confounding variables, 25(OH)D3 levels below 12.5ng/mL were significant risk factors regardless of mortality (adjusted OR: 7.6; 95% CI: 2.35 to 24.56).

CONCLUSIONS

our data show that serum 25(OH)D3 levels below 12.5ng/mL significantly and independently increased the risk of mortality in the first year after surgical repair of low-energy hip fracture in patients over 60 years of age in the geographic region where this study was conducted. Low albumin also showed a significant association with mortality in these patients. All other factors had no significant associations.

Patient-specific risk factors for adverse outcomes following geriatric proximal femur fractures

BACKGROUND

Proximal femur fractures (PFFs) occur frequently among geriatric patients due to diverse risk factors, such as a lower bone mineral density and the increased risk of falls.

METHODS

In this review, we focus on recent literature of patient-specific risk factors and their impact on common complications and outcome parameters in patients with PFF.

RESULTS

Patient- and treatment related factors have a significant impact on outcome and are associated with an increased risk of mortality, impairments in functional rehabilitation and complicative courses.

CONCLUSION

Geriatric patients at high risk for complications are nursing home inhabitants suffering from severe osteoporosis, dementia and sarcopenia. The early and ongoing assessment for these individual risk factors is crucial. Strategies including interdisciplinary approaches, addressing comorbidities and facilitating an optimal risk factor evaluation result in a beneficial outcome. The ongoing ambulant assessment and therapy of complicating factors (e.g., malnutrition, sarcopenia, frailty or osteoporosis) have to be improved.

The global approach to rehabilitation following an osteoporotic fragility fracture: A review of the rehabilitation working group of the International Osteoporosis Foundation (IOF) committee of scientific advisors

PURPOSE

To conduct a review of the current state of the evidence for rehabilitation strategies post-fragility fracture.

METHODS

Narrative review conducted by the Rehabilitation Working Group of the International Osteoporosis Foundation Committee of Scientific Advisors characterizing the range of rehabilitation modalities instrumental for the management of fragility fractures.

RESULTS

Multi-modal exercise post-fragility fracture to the spine and hip is strongly recommended to reduce pain, improve physical function, and improve quality of life. Outpatient physiotherapy post-hip fracture has a stronger evidence base than outpatient physiotherapy post-vertebral fracture. Appropriate nutritional care after fragility fracture provides a large range of improvement in morbidity and mortality. Education increases understanding of osteoporosis which in turn increases utilization of other rehabilitation services. Education may improve other health outcomes such as pain and increase a patient's ability for self-advocacy.

CONCLUSION

Rehabilitation interventions are inter-reliant, and research investigating the interaction of exercise, nutrition, and other multi-modal therapies may increase the relevance of rehabilitation research to clinical care.

Profile of Patients with Dementia or Cognitive Impairment Hospitalized with a Proximal Femur Fracture Requiring Surgery

This study reports the characteristics of patients with dementia or cognitive impairment hospitalized with a proximal femur fracture requiring surgery. Methods: Multicentric descriptive longitudinal study conducted in three traumatology units, representing high-technology public hospitals across Spain. Data collection took place between August 2018 and December 2019 upon admission to hospital, discharge, one month and three months after discharge. Results: Study participants (n = 174) were mainly women (81.6%), and the mean age was 90.7± 6.3 years old. Significant statistical differences were noted in the decline of functional capacity at baseline and one month later, and after three months they had still not recovered. Malnutrition increased from baseline to the one-month follow-up. The use of physical restraints increased during hospitalization, especially bilateral bedrails and a belt in the chair/bed. After one month, 15.2% of patients had pressure ulcers. Although pain decreased, it was still present after three months. Conclusion: Hospitalization after hip surgery for elderly people with dementia or cognitive impairment negatively impacted their global health outcomes such as malnutrition and the development of pressure ulcers, falls, functional impairment and the use of physical restraints and pain management challenges. Hospitals should implement policy-makers’ strategic dementia care plans to improve their outcomes.

Prevalence of Sarcopenia and Its Association with Quality of Life, Postural Stability, and Past Incidence of Falls in Postmenopausal Women with Osteoporosis: A Cross-Sectional Study

In this cross-sectional analysis of 61 postmenopausal osteoporosis patients who regularly visited an osteoporosis outpatient clinic, we aimed to clarify the prevalence of sarcopenia and its related clinical factors. Of 61 patients (mean age 77.6 ± 8.1 years), 24 (39.3%) had osteosarcopenia and 37 (60.7%) had osteoporosis alone. Age, nutritional status, and the number of prescribed drugs were associated with the presence of sarcopenia (p = 0.002, <0.001, and 0.001, respectively), while bone mineral density (BMD) and % young adult mean BMD were not (p = 0.119 and 0.119, respectively). Moreover, patients with osteosarcopenia had lower quality of life (QOL) scores, greater postural instability, and a higher incidence of falls in the past year than patients with osteoporosis alone. In contrast, BMD status showed no correlation with the nutritional status, QOL score, postural instability, or incidence of falls in the past year. In conclusion, the incidence of sarcopenia was relatively high among postmenopausal osteoporosis female patients in an osteoporosis outpatient clinic. Our results suggest that in addition to routine BMD evaluation, assessment and management of sarcopenia may be promoted at osteoporosis outpatient clinics to limit the risk of falls and prevent consequent fragility fractures in osteoporosis patients.

Risk factors of hospitalization costs and length of stay for tibial plateau fractures

PURPOSE

This study aimed to analyze the factors influencing the length of stay (LOS) and the cost of hospital stay in patients with tibial plateau fractures (TPFs).

METHODS

We enrolled 233 patients with TPFs in this retrospective study. The general conditions, hematological indicators, and imaging data of hospitalized patients were collected. The factors influencing the cost and LOS were determined by a multivariate logistic regression model controlling confounding factors. Receiver operating characteristic (ROC) curve is used to determine the sensitivity and specificity of risk factors.

RESULTS

The hospitalization cost of hypoproteinemia was significantly higher than that of the standard group (OR 3.07; 95% CI 1.23-7.69; P = 0.017); Low hemoglobin levels in the male will significantly affect patient hospitalization costs (OR 8.32; 95% CI 2.82-24.57; P = 0.015), will also extend the LOS (OR 3.02; 95% CI 1.15-7.89; P = 0.024). Among Schatzker classification of the tibial plateau, hospitalization costs of type V, VI above fractures were significantly higher than those of class I, II, III, and IV fractures (OR 8.78; 95% CI 3.34-23.09; P < 0.001).

CONCLUSION

In this study, hypoproteinemia and the Schatzker classification appeared to be a useful indicator for predicting hospitalization costs for TPFs patients; Male hemoglobin level appears to be an independent risk factor for hospital cost and LOS.

Development and validation of a model for predicting mortality in patients with hip fracture

OBJECTIVE

to develop a user-friendly prediction tool of 1-year mortality for patients with hip fracture, in order to guide clinicians and patients on appropriate targeted preventive measures.

DESIGN

population-based cohort study from 2011 to 2017 using nationwide data from the Danish Hip Fracture Registry.

SUBJECTS

a total of 28,791 patients age 65 and above undergoing surgery for a first-time hip fracture.

METHODS

patient-related prognostic factors at the time of admission were assessed as potential predictors: Nursing home residency, comorbidity (Charlson Comorbidity Index [CCI] Score), frailty (Hospital Frailty Risk Score), basic mobility (Cumulated Ambulation Score), atrial fibrillation, fracture type, body mass index (BMI), age and sex. Association with 1-year mortality examined by determining the cumulative incidence, applying univariable logistic regression and assessing discrimination (area under the receiver operating characteristics curve [AUROC]). The final model (logistic regression) was utilised on a development cohort (70% of patients). Discrimination and calibration were assessed on the validation cohort (remaining 30% of patients).

RESULTS

all predictors showed an association with 1-year mortality, but discrimination was moderate. The final model included nursing home residency, CCI Score, Cumulated Ambulation Score, BMI and age. It had an acceptable discrimination (AUROC 0.74) and calibration, and predicted 1-year mortality risk spanning from 5 to 91% depending on the combination of predictors in the individual patient.

CONCLUSIONS

using information obtainable at the time of admission, 1-year mortality among patients with hip fracture can be predicted. We present a user-friendly chart for daily clinical practice and provide new insight regarding the interplay between prognostic factors.

Influence of Nutritional Status on a Family-Centered Care Intervention for Older Adults with Cognitive Impairment following Hip-Fracture Surgery: Secondary Data Analysis of a Randomized Controlled Trial

OBJECTIVES

In Taiwan, older adults with cognitive impairment who undergo hip-fracture surgery are routinely cared for by family members. This study aimed to determine if nutritional status influenced the effects of a family-centered intervention for older adults with cognitive impairment recovering from hip-fracture surgery.

DESIGN

Secondary data analysis of data from a randomized controlled trial was conducted to examine the influences of nutritional status 1 month after hospital discharge on the effects of a family-centered care intervention model, which was designed for older adults with hip fracture and cognitive impairment. Outcomes were compared among participants according to nutrition status (well-nourished/poorly-nourished) and treatment approach (control/intervention).

SETTING

The original study was conducted at a 3000-bed medical center from July 2015 to October 2019.

PARTICIPANTS

Participants were older adults with cognitive impairment who had undergone hip-fracture surgery. Participants were assessed as poorly-nourished or well-nourished with the Mini-Nutritional Assessment (MNA) 1-month post-discharge and were then randomly assigned to either the intervention group or control group.

INTERVENTION

A family-centered intervention model for family caregivers of older adults with cognitive impairment recovering from hip-fracture surgery was implemented. The intervention was delivered by geriatric nurses, which included instructions for family caregivers in overseeing exercises for strengthening the hip, understanding dietary requirements, and managing behavioral problems associated with cognitive impairment.

MEASUREMENTS

Outcome measures included activities of daily living (ADLs), instrumental ADLs, hip range of motion, hip muscle strength, depression, measured with the Geriatric Depressive Scale, and physical and mental health related quality of life, measured with the Short Form Survey (SF-36), Taiwanese version. Participants were assessed at 1-, 3-, 6-, and 12-months post-discharge.

RESULTS

Most of the 134 participants were assessed as poorly nourished (n = 122); 57 were the control group and 65 received the intervention. For the well-nourished participants (n = 12), four were in the intervention group and eight were controls. There were no significant differences in any outcome variables for poorly nourished participants who received the intervention compared with controls. For the sample of well-nourished participants, those who received the intervention performed significantly better in outcomes of IADLs (b = 1.74, p < .05), hip muscle strength (b = 9.64, p < .01), and physical health related quality of life (b = 10.47, p < .01).

CONCLUSION

The family-centered care intervention was only effective for older adults with cognitive impairment recovering from hip-fracture surgery who were well-nourished at 1 month following hospital discharge, but not for those at risk of malnutrition. Interventions should focus on enhancing nutritional status following hip surgery which could allow the family-centered in-home intervention to be beneficial for more older adults with cognitive impairment recovering from hip-fracture surgery.

Association between Neutrophil Levels on Admission and All-Cause Mortality in Geriatric Patients with Hip Fractures: A Prospective Cohort Study of 2,589 Patients

OBJECTIVE

To evaluate the association between neutrophil levels and all-cause mortality in geriatric hip fractures.

METHODS

Elderly patients with hip fractures were screened between January 2015 and September 2019. Demographic and clinical characteristics of the patients were collected. Linear and nonlinear multivariate Cox regression models were used to identify the association between neutrophil levels and mortality. Analyses were performed using Empower Stats and R software.

RESULTS

A total of 2,589 patients were included in this study. The mean follow-up period was 38.95 months. During the study period, 875 (33.80%) patients died due to various causes. Linear multivariate Cox regression models showed that neutrophil levels were associated with mortality after adjusting for confounding factors, when neutrophil concentration increased by 1∗10⁹/L, the mortality risk increased by 3% (HR = 1.03, 95% CI: 1.00-1.06, and P=0210). Neutrophil concentration was used as a categorical variable; we only found statistically significant differences when neutrophil levels were high (HR = 1.27, 95% CI:1.05-1.52, and P=0.0122). In addition, the results are stable in P for trend and propensity score matching sensitivity analysis.

CONCLUSIONS

Neutrophil levels are associated with mortality in geriatric hip fractures and could be considered a predictor of death risk in the long-term. This study is registered with the Chinese Clinical Trial Registry (ChiCTR) as number ChiCTR2200057323.

Effect of nutritional status before femoral neck fracture surgery on postoperative outcomes: a retrospective study

Background

Although nutritional status is crucial in gait recovery after femoral neck fracture surgery, the relationship between preoperative nutritional status and postoperative outcomes remains unknown. This study examined the effects of preoperative nutritional status on postoperative outcomes in patients undergoing femoral neck fracture surgery.

Methods

Data regarding the joints of 137 patients (29 men, 108 women) who underwent bipolar hemiarthroplasty for femoral neck fractures at our hospital from January 2015 to December 2019 were retrospectively examined. The Geriatric Nutritional Risk Index (GNRI), an index of nutritional status, was used to classify patients into two groups: a normal group (GNRI ≥92; n = 62) and an undernourished group (GNRI < 92; n = 75). The study endpoints included age at surgery, sex, Mini Mental State Examination (MMSE), American Society of Anesthesiologists Physical Status (ASA) classification, preoperative waiting period, intraoperative blood loss, surgery time, perioperative hemoglobin levels, blood transfusion rate, complication rate, 6-month mortality rate, transfer rate, percentage of patients unable to walk at discharge or transfer, and inability to walk 6 months postoperatively.

Results

The patients in the undernourished group was significantly older at surgery (p < 0.01) and had a lower perioperative hemoglobin levels (p < 0.01), a higher blood transfusion rate (p < 0.01), a lower MMSE (p < 0.01), a longer preoperative waiting period (p < 0.05), a higher transfer rate (p < 0.05), were more likely to be unable to walk 6 months postoperatively (p < 0.01), a higher complication rate (p < 0.05), and a higher 6-month mortality rate (p < 0.01) than the normal group. Patients in the undernourished group had worse rates of postoperative complications, transfer, mortality, and inability to walk 6-month after surgery than those in the normal group.

Conclusions

A poor nutritional status affects the gait function and systemic condition of patients undergoing femoral neck fracture surgery; therefore, early nutritional interventions may reduce mortality rates and shorten rehabilitation. These results suggest that the GNRI effectively predicts postoperative complications, mortality, and gait function.

The Pathologic Fracture Mortality Index: A Novel Externally Validated Tool for Predicting 30-day Postoperative Mortality

INTRODUCTION

Current mortality predictive tools, in the setting of completed or impending pathologic fractures, are nonspecific. Clinical decision making and mortality prediction in research would benefit from creation of a high-fidelity scoring system for calculating the risk of 30-day postoperative mortality. The purpose of this study is to develop a validated research and clinical tool that is superior to existing methods in estimating postoperative mortality risk after fixation of pathologic fractures.

METHODS

One thousand two hundred nineteen patients who underwent fixation for either completed or impending pathologic fractures in the National Surgical Quality Improvement Program (2012 to 2018) database were analyzed. Multivariable logistic regression with diagnostics was used to develop a predictive model in a derivation cohort and then validated in a validation cohort. Area under the curve (AUC) from receiver operator curve analysis was used to assess accuracy. A score was derived and compared with the American Society of Anesthesiologists classification and modified five-component frailty index (mF-I5). The score was validated in an exclusive cohort of patients who underwent fixation for pathologic fractures at a tertiary care center.

RESULTS

Of 1,219, a total of 177 (15%) patients did not survive beyond 30 days postoperatively. AUC for our predictive model was 0.76 in the derivation and 0.75 in the validation National Surgical Quality Improvement Program cohorts. The derived Pathologic Fracture Morbidity Index included seven data points: anemia, alkaline phosphatase > 150 U/L, albumin < 3.5 mg/dL, pulmonary disease, recent weight loss, functional dependence, and white blood cell count >12,000. The PFMI (AUC = 0.75) was more accurate than ASA (AUC = 0.60) or mF-5 (AUC = 0.58) (P < 0.01). The AUC for PFMI in predicting 30-day mortality in the exclusive cohort (N = 39) was 0.74.

CONCLUSION

The PFMI is a validated tool that may be used for predicting postoperative 30-day mortality after fixation of pathologic fractures, with higher level of accuracy compared with ASA or mF-I5.

Prevalence and prognostic significance of malnutrition in diabetic patients with coronary artery disease: a cohort study

Background

Malnutrition is associated with poor prognosis in cardiovascular disease patients or in diabetic patients. However, the relationship between malnutrition and clinical outcomes in diabetic patients with coronary artery disease (CAD) is not well known. The aim of this study is to report the prevalence and prognostic consequences of malnutrition in diabetic patients with CAD.

Methods

In this retrospective observational study, the Controlling Nutritional Status (CONUT) score applied to 12,898 consecutive diabetic patients with CAD. The association between malnutrition and long-term all-cause mortality was examined using Cox proportional hazards regression analysis.

Results

According to CONUT score, 60.5% patients suffered from malnutrition; 46.4%, 13.2%, and 0.9% patients had mild, moderate, and severe malnutrition, respectively. During a median follow-up of 4.88 (2.83–7.51) years, 1973 (15.3%) patients died. After adjustment for confounders, malnutrition was associated with significantly increased risk for long-term all-cause mortality (adjusted hazard ratio for mild malnutrition and moderate to severe malnutrition, respectively: 1.38 [95% confidence interval (CI) 1.07–1.77]; P value = 0.012 and 1.63 [95% CI 1.18–2.24]; P value = 0.003). A similar association was observed around subgroups.

Conclusions

Malnutrition is common in diabetic patients with CAD and is strongly associated with increased mortality. It is necessary to adequately assess the nutritional status and take the effective nutritional guidance to improve the prognosis of diabetic patients with CAD.

Beneficial effects of preoperative oral nutrition supplements on postoperative outcomes in geriatric hip fracture patients: A PRISMA-compliant systematic review and meta-analysis of randomized controlled studies

BACKGROUND

Geriatric hip fracture patients often present malnutrition during admission, which leads to higher morbidity and mortality. Protein-based oral nutrition supplements may improve nutritional status. We conducted this systematic review and meta-analysis of randomized controlled trials (RCTs) according to the PRISMA guidelines to elucidate whether preoperative nutrition supplements can improve postoperative outcomes in geriatric hip fracture patients.

METHODS

Only RCTs conducted to compare postoperative outcomes between geriatric hip fracture patients (>60 years old) receiving preoperative oral protein-based nutrition supplement (ONS group) and those who receiving regular diet (Control group) were included. PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched from inception until August, 2021. Postoperative outcomes, including complications, length of hospital stay, and in-hospital mortality, were assessed.

RESULTS

A total of 5 RCTs with 654 geriatric hip fracture patients (ONS group: 320 subjects; Control group 334 subjects) were included. Our data revealed that postoperative complications risk in the ONS group was significantly lower than in the Control group (odd's ratio: 0.48, 95% confidence intervals [CI]: 0.26-0.89, P = .02, I2 = 64%). However, no significant differences in the length of hospital stay (standardized mean difference: -0.35 days, 95% CI: -1.68 to 0.98 days, P = .61, I2 = 0%) and the risk of having postoperative in-hospital mortality (odd's ratio: 1.07, 95% CI: 0.43-2.63, P = .89, I2 = 54%) between these 2 groups were observed. Quality assessment revealed high risk of bias and significant data heterogeneity (I2>50%) in most included RCTs.

CONCLUSION

Preoperative protein-based oral nutrition supplements exert beneficial, but limited, effects on postoperative outcomes in geriatric patients with hip fracture undergoing surgery.

Do we care about nutritional support in patients hospitalized with a diagnosis of femoral neck fracture?

Aim:Femoral neck fractures (FNF) occur in the intracapsular region of the proximal femur. The incidence of fractures in the proximal femur increases with age. FNF's cause high mortality and morbidity. Malnutrition is also one of the problems of these patients. In this study, it was aimed to reveal the importance of necessary nutritional follow-up in patients hospitalized in our hospital for FNF. Methods:XXXX Health Sciences University XXXXX Training and Research Hospital data of hospitalized patients with a diagnosis of FNF between 2017-2018 were retrospectively scanned from the patient file and the hospital automation system. 229 patients with a diagnosis of FNF were included in the study. Hospitalization diagnosis, age and gender, albumin, C-reactive protein (crp), and lymphocyte values of the patients were measured. The nutritional risk score (NRS-2002) made for each patient in the automation system of our hospital was checked. For nutritional support, it was checked whether a consultation was requested from the nutrition support team (NST). Results:The mean age of the patients included in the study was found to be 74 years. 79.3% were over 65 years old, while 20.97% were under 65. Albumin, lymphocyte and CRP values of the patients were examined and found that 65.1% albumin, 24.5% lymphocyte and 88.2% CRP values outside the normal range. There was a statistically significant negative correlation of 41% between the patients' albumin and age variable. (p

Malnutrition in elective shoulder arthroplasty: a multi-institutional retrospective study of preoperative albumin and adverse outcomes

BACKGROUND

Malnutrition is associated with poor postoperative outcomes after knee, hip, and spine surgery. However, whether albumin labs should be part of the routine preoperative workup for shoulder arthroplasty remains understudied. This study investigated the role of preoperative albumin levels in predicting common postoperative adverse outcomes in patients undergoing shoulder arthroplasty.

METHODS

All shoulder arthroplasty cases performed at 2 tertiary referral centers between July 2013 and May 2019 (institution 1) and between June 2007 and Feb 2020 (institution 2) were reviewed. A total of 421 primary and 71 revision elective shoulder arthroplasty cases had preoperative albumin levels recorded. Common demographic variables and relevant Elixhauser comorbidities were pulled. Outcomes gathered included extended (>3 days) postoperative inpatient length of stay (eLOS), 90-day readmission, and discharge to rehab or skilled nursing facility (SNF).

RESULTS

The prevalence of malnutrition (albumin <3.5 g/dL) was higher in the revision group compared with the primary group (36.6% vs. 19.5%, P = .001). Reverse shoulder arthroplasty (P = .013) and increasing American Society of Anesthesiologists score (P = .016) were identified as independent risk factors for malnutrition in the primary group. In the revision group, liver disease was associated with malnutrition (P = .046). Malnourished primary shoulder arthroplasty patients had an increased incidence of eLOS (26.8% vs. 13.6%, P = .003) and discharge to rehab/SNF (18.3% vs. 10.3%, P = .045). On univariable analysis, low albumin had an odds ratio (OR) of 2.34 for eLOS (P = .004), which retained significance in a multivariable model including age, American Society of Anesthesiologists score, sex, and body mass index (OR 2.11, P = .03). On univariable analysis, low albumin had an OR of 1.94 for discharge to SNF/rehab (P = .048), but this did not reach significance in the multivariable model. Among revisions, malnourished patients had an increased incidence of eLOS (30.8% vs. 6.7%, P = .014) and discharge to rehab/SNF (26.9% vs. 4.4%, P = .010). In both the primary and revision groups, there was no difference in 90-day readmission rate between patients with low or normal albumin.

CONCLUSION

Malnutrition is more prevalent among revision shoulder arthroplasty patients compared with those undergoing a primary procedure. Primary shoulder arthroplasty patients with low preoperative albumin levels have an increased risk of eLOS and may have an increased need for postacute care. Low albumin was not associated with a risk of 90-day readmissions. Albumin level merits further investigation in large, prospective cohorts to clearly define its role in preoperative risk stratification.