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Spoladore D, Colombo V, Fumagalli A, Tosi M, Lorenzini EC, Sacco M. An Ontology-Based Decision Support System for Tailored Clinical Nutrition Recommendations for Patients With Chronic Obstructive Pulmonary Disease: Development and Acceptability Study. JMIR Med Inform 2024; 12:e50980. [PMID: 38922666 PMCID: PMC11237782 DOI: 10.2196/50980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 02/01/2024] [Accepted: 04/23/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a chronic condition among the main causes of morbidity and mortality worldwide, representing a burden on health care systems. Scientific literature highlights that nutrition is pivotal in respiratory inflammatory processes connected to COPD, including exacerbations. Patients with COPD have an increased risk of developing nutrition-related comorbidities, such as diabetes, cardiovascular diseases, and malnutrition. Moreover, these patients often manifest sarcopenia and cachexia. Therefore, an adequate nutritional assessment and therapy are essential to help individuals with COPD in managing the progress of the disease. However, the role of nutrition in pulmonary rehabilitation (PR) programs is often underestimated due to a lack of resources and dedicated services, mostly because pneumologists may lack the specialized training for such a discipline. OBJECTIVE This work proposes a novel knowledge-based decision support system to support pneumologists in considering nutritional aspects in PR. The system provides clinicians with patient-tailored dietary recommendations leveraging expert knowledge. METHODS The expert knowledge-acquired from experts and clinical literature-was formalized in domain ontologies and rules, which were developed leveraging the support of Italian clinicians with expertise in the rehabilitation of patients with COPD. Thus, by following an agile ontology engineering methodology, the relevant formal ontologies were developed to act as a backbone for an application targeted at pneumologists. The recommendations provided by the decision support system were validated by a group of nutrition experts, whereas the acceptability of such an application in the context of PR was evaluated by pneumologists. RESULTS A total of 7 dieticians (mean age 46.60, SD 13.35 years) were interviewed to assess their level of agreement with the decision support system's recommendations by evaluating 5 patients' health conditions. The preliminary results indicate that the system performed more than adequately (with an overall average score of 4.23, SD 0.52 out of 5 points), providing meaningful and safe recommendations in compliance with clinical practice. With regard to the acceptability of the system by lung specialists (mean age 44.71, SD 11.94 years), the usefulness and relevance of the proposed solution were extremely positive-the scores on each of the perceived usefulness subscales of the technology acceptance model 3 were 4.86 (SD 0.38) out of 5 points, whereas the score on the intention to use subscale was 4.14 (SD 0.38) out of 5 points. CONCLUSIONS Although designed for the Italian clinical context, the proposed system can be adapted for any other national clinical context by modifying the domain ontologies, thus providing a multidisciplinary approach to the management of patients with COPD.
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Affiliation(s)
- Daniele Spoladore
- Institute of Intelligent Industrial Technologies and Systems for Advanced Manufacturing, National Research Council of Italy, Lecco, Italy
- Department of Pure and Applied Sciences, Computer Science Division, Insubria University, Varese, Italy
| | - Vera Colombo
- Institute of Intelligent Industrial Technologies and Systems for Advanced Manufacturing, National Research Council of Italy, Lecco, Italy
| | - Alessia Fumagalli
- Unit of Pulmonary Rehabilitation, IRCCS, Italian National Research Center on Aging, Casatenovo, Italy
| | - Martina Tosi
- Institute of Agricultural Biology and Biotechnology, National Research Council of Italy, Milan, Italy
- Department of Health Science, University of Milan, Milan, Italy
| | - Erna Cecilia Lorenzini
- Institute of Agricultural Biology and Biotechnology, National Research Council of Italy, Milan, Italy
- Department of Biomedical Sciences for Health, Chair of Clinical Pathology, University of Milan, Milan, Italy
| | - Marco Sacco
- Institute of Intelligent Industrial Technologies and Systems for Advanced Manufacturing, National Research Council of Italy, Lecco, Italy
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Conway V, Hukins C, Sharp S, Collins PF. Nutritional Support in Malnourished Outpatients with Chronic Obstructive Pulmonary Disease (COPD): A Randomized Controlled Pilot Study. Nutrients 2024; 16:1696. [PMID: 38892629 PMCID: PMC11174753 DOI: 10.3390/nu16111696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/29/2024] [Accepted: 05/26/2024] [Indexed: 06/21/2024] Open
Abstract
(1) Background: The evidence for nutritional support in COPD is almost entirely based on ready-to-drink oral nutritional supplements (ONSs). This study aimed to explore the effectiveness of powdered ONSs alongside individualized dietary counseling in the management of malnutrition. (2) Methods: Malnourished outpatients with COPD were randomized to receive either routine care (Group A: counseling + recommended to purchase powdered ONSs) or an enhanced intervention (Group B: counseling + provision of powdered ONSs at no cost to the patient) for 12 weeks. Outcomes of interest were nutritional intake, weight status, and quality of life. (3) Results: A total of 33 outpatients were included, categorized as follows: Group A (n = 21); Group B (n = 12); severely malnourished (n = 9), moderately malnourished (n = 24), mean BMI 18.0 SD 2.5 kg/m2. No differences were observed between groups at baseline or at week 12; however, analysis of the whole cohort (Group A + B) revealed nutrition intervention resulted in significant improvements in protein intake (+25.4 SD 53.4 g/d; p = 0.040), weight (+1.1 SD 2.6 kg; p = 0.032) and quality of life (-4.4 SD 10.0; p = 0.040). Only 41.2% of Group A and 58.3% of Group B reported consuming ONSs at week 12. Adherence to ONSs was associated with weight gain (+1.9 SD 2.5 kg vs. +0.4 SD 2.5 kg; p = 0.098). (4) Conclusions: Nutritional support results in significant improvements in nutrition status and quality of life in malnourished outpatients with COPD. However, improvements are associated with adherence to ONSs, suggesting the type of ONSs and how they are provided are important considerations in clinical practice and future studies.
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Affiliation(s)
- Valerie Conway
- Nutrition and Dietetics, Brisbane South Chronic Disease Service, Metro South Hospital and Health Service, Wynnum, QLD 4178, Australia;
| | - Craig Hukins
- Department of Respiratory and Sleep Medicine, Princess Alexandra Hospital, Brisbane, QLD 4102, Australia;
| | - Stacey Sharp
- Department of Nutrition and Dietetics, Logan Hospital, Meadowbrook, QLD 4131, Australia;
| | - Peter F. Collins
- Nutrition and Dietetics, Sydney Nursing School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, NSW 2006, Australia
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Yang M, Liu Y, Zhao Y, Wang Z, He J, Wang Y, Anme T. Association of Frailty with Patient-Report Outcomes and Major Clinical Determinants in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2024; 19:907-919. [PMID: 38628984 PMCID: PMC11020290 DOI: 10.2147/copd.s444580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 04/07/2024] [Indexed: 04/19/2024] Open
Abstract
Purpose This study aimed to explore the correlation of frailty status with disease characteristics and patient-reported outcomes (PROs) in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and determine the sensitivity and specificity of modified COPD PRO scale (mCOPD-PRO) for detecting frailty. Patients and Methods This cross-sectional study surveyed 315 inpatients with AECOPD from a tertiary hospital in China from August 2022 to June 2023. Patient frailty and PROs were assessed using the validated FRAIL scale and mCOPD-PRO, respectively. Spearman's ρ was used to assess the relevance of lung disease indicators commonly used in clinical practice, and ordinal logistic regression analyses were used to identify the variables associated with frailty status. The validity of mCOPD-PRO in discriminating frail or non-frail individuals was determined using the receiver operating characteristic curve. Results The participants (N=302, mean age 72.4±9.1 years) were predominantly males (73.2%). Among them, 43 (14.3%) patients were not frail, whereas 123 (40.7%) and 136 (45.0%) patients were pre-frail and frail, respectively. The FRAIL scale was moderately correlated with the mCOPD-PRO scores (Spearman's rank correlation coefficient [Rs]=0.52, P<0.01) for all dimensions (Rs=0.43-0.49, P<0.01). Patients residing in rural areas (odds ratio [OR], 1.67; 95% confidence interval [95% CI], 1.01-2.76) and with higher mCOPD-PRO scores (OR, 4.78; 95% CI, 2.75-8.32) were more likely to be frail. Physically active patients (OR, 0.42; 95% CI, 0.21-0.84) were less likely to be frail. In addition, mCOPD-PRO had good discriminate validity for detecting frailty (area under the curve=0.78), with a sensitivity and specificity of 84.6% and 60.8%, respectively. The optimal probability threshold for mCOPD-PRO was ≥1.52 points. Conclusion In patients with AECOPD, frailty is closely related to PROs and disease characteristics. Additionally, the mCOPD-PRO score can distinguish well between frail and non-frail patients. Our findings provide support for interventions targeting frail populations with AECOPD.
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Affiliation(s)
- Mengjiao Yang
- Graduate School of Comprehensive Human Science, University of Tsukuba, Tsukuba, Japan
- Department of Cardiovascular Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong City, Sichuan Province, People’s Republic of China
| | - Yang Liu
- Graduate School of Comprehensive Human Science, University of Tsukuba, Tsukuba, Japan
| | - Yangyang Zhao
- Department of Blood Transfusion, Affiliated Hospital of North Sichuan Medical College, Nanchong City, Sichuan Province, People’s Republic of China
| | - Ziwei Wang
- Department of Respiratory and Critical Care Medicine, Affiliated Hospital of North Sichuan Medical College, Nanchong City, Sichuan Province, People’s Republic of China
| | - Jie He
- Department of Nursing, Affiliated Hospital of North Sichuan Medical College, Nanchong City, Sichuan Province, People’s Republic of China
| | - Yali Wang
- Department of Cardiovascular Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong City, Sichuan Province, People’s Republic of China
| | - Tokie Anme
- Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Yde SK, Mikkelsen S, Brath MSG, Holst M. Unintentional weight loss is reflected in worse one-year clinical outcomes among COPD outpatients. Clin Nutr 2023; 42:2173-2180. [PMID: 37778301 DOI: 10.1016/j.clnu.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/17/2023] [Accepted: 09/07/2023] [Indexed: 10/03/2023]
Abstract
RATIONALE Unintentional weight loss (UWL) is prevalent among patients with chronic obstructive pulmonary disease (COPD). However, little research has been done on UWL as an independent variable in terms of clinical outcome. The aim of this study was to investigate the association between BMI, UWL, and clinical outcome in terms of hospitalization, length of stay, exacerbations, mortality, and quality of life (QoL) within six months and one year in a hospital outpatient setting. METHODS A prospective single-center cohort study enrolled 200 patients from the COPD outpatient clinic between October 2020 and May 2021 at a Danish Hospital. At baseline, data was collected using patients' electronic journals and a quantitative questionnaire was gathered with a patient-reported UWL of 5% of body weight within three months. At six months and one-year follow-ups, data was collected using the patients' medical journals and a telephonic interview with the EQ-5D-5L and SARC-F questionnaire and the number of non-hospitalization exacerbations since inclusion. Data were analyzed using logistic and Cox hazard regression analysis. RESULTS A total of 187 patients were eligible for follow-up (mean age 69.2 years, 43.9% males, median BMI 26.8 kg/m2), and the prevalence of UWL was 13.4%. UWL was associated with an almost trifold risk of >five days stay (OR = 2.94, p = 0.021). Additionally, UWL was associated with a worse QoL. A higher risk of exacerbation was found in the underweight patients (OR = 4.94, p = 0.014). No significant difference in mortality was found. CONCLUSION UWL as a solitary factor is associated with increased hospital length of stay and a worse QoL. The results provide further evidence that implementation of regular screening for UWL in addition to BMI might be beneficial to include in international COPD guidelines for outpatient settings.
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Affiliation(s)
- Søren Kveiborg Yde
- Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000 Aalborg, Denmark
| | - Sabina Mikkelsen
- Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000 Aalborg, Denmark; Centre for Nutrition and Intestinal Failure, Department of Gastroenterology, Aalborg University Hospital, Sdr. Skovvej 5.1, 9000 Aalborg, Denmark
| | - Mia Solholt Godthaab Brath
- Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000 Aalborg, Denmark; Department of Respiratory Diseases, Aalborg University Hospital, Mølleparkvej 4, 9000 Aalborg, Denmark
| | - Mette Holst
- Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000 Aalborg, Denmark; Centre for Nutrition and Intestinal Failure, Department of Gastroenterology, Aalborg University Hospital, Sdr. Skovvej 5.1, 9000 Aalborg, Denmark.
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Miravitlles M, Bhutani M, Hurst JR, Franssen FME, van Boven JFM, Khoo EM, Zhang J, Brunton S, Stolz D, Winders T, Asai K, Scullion JE. Implementing an Evidence-Based COPD Hospital Discharge Protocol: A Narrative Review and Expert Recommendations. Adv Ther 2023; 40:4236-4263. [PMID: 37537515 PMCID: PMC10499689 DOI: 10.1007/s12325-023-02609-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/06/2023] [Indexed: 08/05/2023]
Abstract
Discharge bundles, comprising evidence-based practices to be implemented prior to discharge, aim to optimise patient outcomes. They have been recommended to address high readmission rates in patients who have been hospitalised for an exacerbation of chronic obstructive pulmonary disease (COPD). Hospital readmission is associated with increased morbidity and healthcare resource utilisation, contributing substantially to the economic burden of COPD. Previous studies suggest that COPD discharge bundles may result in fewer hospital readmissions, lower risk of mortality and improvement of patient quality of life. However, evidence for their effectiveness is inconsistent, likely owing to variable content and implementation of these bundles. To ensure consistent provision of high-quality care for patients hospitalised with an exacerbation of COPD and reduce readmission rates following discharge, we propose a comprehensive discharge protocol, and provide evidence highlighting the importance of each element of the protocol. We then review care bundles used in COPD and other disease areas to understand how they affect patient outcomes, the barriers to implementing these bundles and what strategies have been used in other disease areas to overcome these barriers. We identified four evidence-based care bundle items for review prior to a patient's discharge from hospital, including (1) smoking cessation and assessment of environmental exposures, (2) treatment optimisation, (3) pulmonary rehabilitation, and (4) continuity of care. Resource constraints, lack of staff engagement and knowledge, and complexity of the COPD population were some of the key barriers inhibiting effective bundle implementation. These barriers can be addressed by applying learnings on successful bundle implementation from other disease areas, such as healthcare practitioner education and audit and feedback. By utilising the relevant implementation strategies, discharge bundles can be more (cost-)effectively delivered to improve patient outcomes, reduce readmission rates and ensure continuity of care for patients who have been discharged from hospital following a COPD exacerbation.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Vall d'Hebron University Hospital/Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Barcelona Hospital Campus, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Mohit Bhutani
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Frits M E Franssen
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Job F M van Boven
- Department of Clinical Pharmacy & Pharmacology, Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ee Ming Khoo
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- International Primary Care Respiratory Group, Leicester, UK
| | - Jing Zhang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | | | - Daiana Stolz
- Clinic of Respiratory Medicine and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tonya Winders
- Global Allergy and Airways Patient Platform, Vienna, Austria
| | - Kazuhisa Asai
- Department of Respiratory Medicine, Osaka Metropolitan University, Osaka, Japan
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Yuan FZ, Xing YL, Xie LJ, Yang DL, Shui W, Niu YY, Zhang X, Zhang CR. The Relationship Between Prognostic Nutritional Indexes and the Clinical Outcomes of Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2023; 18:1155-1167. [PMID: 37332836 PMCID: PMC10275318 DOI: 10.2147/copd.s402717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 05/30/2023] [Indexed: 06/20/2023] Open
Abstract
Purpose Nutritional status is related to the clinical outcomes of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The aim of this study was to investigate the association between nutritional status, measured by the prognostic nutritional index (PNI), and adverse hospitalization outcomes in patients with AECOPD. Methods Consecutive AECOPD patients admitted to the First Affiliated Hospital of Sun Yat-sen University between January 1, 2015 to October 31, 2021 were enrolled. We collected the clinical characteristics and laboratory data of patients. Multivariable logistic regression models were developed to assess the relationship between the baseline PNI and adverse hospitalization outcomes. A generalized additive model (GAM) was used to identify any non-linear relationship. In addition, we performed a subgroup analysis to tested the robustness of the results. Results A total of 385 AECOPD patients were involved in this retrospective cohort study. Based on the tertiles of PNI, patients in the lower tertiles of PNI showed more worse outcome incidence (30 [23.6%] versus 17 [13.2%] versus 8 [6.2%]; p < 0.001). Multivariable logistic regression analysis revealed that the PNI were independently associated with adverse hospitalization outcomes after adjustment for confounding factors (Odds ratio [OR] = 0.94, 95% CI: 0.91 to 0.97, P < 0.0001). After adjusting for confounders, smooth curve fitting showed a saturation effect, suggesting that the relationship between the PNI and adverse hospitalization outcomes was nonlinear. Two-piecewise linear regression model suggested that the incidence of adverse hospitalization outcomes significantly decreased with PNI level up to the inflection point (PNI = 42), and PNI was not associated with adverse hospitalization outcome after that point. Conclusion Decreased PNI levels at admission were determined to be associated with adverse hospitalization outcomes in patients with AECOPD. The results obtained in this study may potentially assist clinicians optimize risk evaluations and clinical management processes.
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Affiliation(s)
- Fu-Zhen Yuan
- Department of General Practice Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, People’s Republic of China
| | - Yan-Li Xing
- Department of General Medicine, East Hospital, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510700, People’s Republic of China
| | - Liang-Jie Xie
- Department of General Practice Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, People’s Republic of China
| | - Dong-Ling Yang
- Department of General Practice Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, People’s Republic of China
| | - Wei Shui
- Department of General Medicine, East Hospital, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510700, People’s Republic of China
| | - Yuan-Yuan Niu
- Department of General Medicine, East Hospital, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510700, People’s Republic of China
| | - Xin Zhang
- Department of General Medicine, East Hospital, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510700, People’s Republic of China
| | - Chang-Ran Zhang
- Department of General Medicine, East Hospital, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510700, People’s Republic of China
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Deng M, Lu Y, Zhang Q, Bian Y, Zhou X, Hou G. Global prevalence of malnutrition in patients with chronic obstructive pulmonary disease: Systemic review and meta-analysis. Clin Nutr 2023; 42:848-858. [PMID: 37084471 DOI: 10.1016/j.clnu.2023.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 02/22/2023] [Accepted: 04/05/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND Malnutrition is a significant comorbidity among chronic obstructive pulmonary disease (COPD), but it has been often ignored. To date, the prevalence of malnutrition and its association with clinical parameters in the patients with COPD have not been well described. We aimed to investigate the prevalence of malnutrition and the prevalence of at-risk for malnutrition among COPD and the clinical impact of malnutrition on patients with COPD in a systematic review and meta-analysis. METHODS PubMed, Embase, Cochrane Library, and Web of Science were searched for articles describing the prevalence of malnutrition and/or at-risk for malnutrition from January 2010 to December 2021. Eligibility screening, data extraction, and quality assessment of the retrieved articles were conducted independently by two reviewers. Meta-analyses were performed to determine the prevalence of malnutrition and at-risk for malnutrition and the clinical impact of malnutrition on patients with COPD. Meta-regression and subgroup analyses were performed to explore the sources of heterogeneity. Comparisons were made between individuals with and without malnutrition according to pulmonary function, degree of dyspnea, exercise capacity, and mortality risk. RESULTS Out of the 4156 references identified, 101 were read full-text, of which 36 studies were included. The total number of involved patients included in this meta-analysis was 5289. The prevalence of malnutrition was 30.0% (95% CI 20.3 to 40.6), compared with an at-risk prevalence of 50.0% (95% CI 40.8 to 59.2). Both prevalences were associated with regions and measurement tools. The prevalence of malnutrition was associated with COPD phase (acute exacerbations and stable). COPD with malnutrition showed lower forced expiratory volume 1 s % predicted (mean difference (MD) -7.19, 95% CI -11.86 to -2.52), higher modified Medical Research Council dyspnea scores (MD 0.38, 95% CI 0.12 to 0.64), poorer exercise tolerance (standardized mean difference -0.29, 95% CI -0.54 to -0.05), and higher mortality risk (hazard ratio 2.24, 95% CI 1.23 to 4.06) compared to COPD without malnutrition. CONCLUSION Malnutrition and at-risk for malnutrition are common among COPD. Malnutrition negatively impacts important clinical outcomes of COPD.
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Affiliation(s)
- Mingming Deng
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Ye Lu
- Department of Respiratory and Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Qin Zhang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Yiding Bian
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Xiaoming Zhou
- Respiratory Department, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Gang Hou
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China.
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Wang Y, Li Z, Li F. Impact of Previous Pulmonary Tuberculosis on Chronic Obstructive Pulmonary Disease: Baseline Results from a Prospective Cohort Study. Comb Chem High Throughput Screen 2023; 26:93-102. [PMID: 35388750 DOI: 10.2174/1386207325666220406111435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 12/30/2021] [Accepted: 01/05/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Pulmonary tuberculosis (PTB) is a significant risk factor for COPD, and Xinjiang, China, has a high incidence of pulmonary tuberculosis. The effects of tuberculosis history on airflow restriction, clinical symptoms, and acute episodes in COPD patients have not been reported in the local population. Besides, the exact relationship between lung function changes in people with a history of tuberculosis and COPD risk is not clear. METHODS This study is based on the Xinjiang baseline survey data included in the Natural Population Cohort Study in Northwest China from June to December, 2018. Subjects' questionnaires, physical examination, and lung function tests were performed through a face-to-face field survey to analyze the impact of previous pulmonary tuberculosis on local COPD. Furthermore, we clarified the specific relationship between pulmonary function decline and the probability of developing COPD in people with a history of tuberculosis. RESULTS A total of 3249 subjects were eventually enrolled in this study, including 87 with a history of tuberculosis and 3162 non-TB. The prevalence of COPD in the prior TB group was significantly higher than that in the control group (p-value = 0.005). First, previous pulmonary tuberculosis is an essential contributor to airflow limitation in the general population and patients with COPD. In all subjects included, pulmonary function, FEV1% predicted (p-value < 0.001), and FEV1/FVC (%) (p-value < 0.001) were significantly lower in the prior TB group than in the control group. Compared to non-TB group, FEV1% prediction (p-value = 0.019) and FEV1/FVC (%) (p-value = 0.016) were found to be significantly reduced, and airflow restriction (p-value = 0.004) was more severe in prior TB group among COPD patients. Second, COPD patients in the prior TB group had more severe clinical symptoms. Compared with no history of tuberculosis, mMRC (p-value = 0.001) and CAT (p-value = 0.002) scores were higher in the group with a history of tuberculosis among COPD patients. Third, compared with the non-TB group, the number of acute exacerbations per year (p-values=0.008), the duration of each acute exacerbation (p-values=0.004), and hospitalization/ patient/year (p-values<0.001) were higher in the group with a history of tuberculosis among COPD patients. Finally, a dose-response relationship between FEV1/FVC (%) and the probability of developing COPD in people with previous pulmonary TB was observed; when FEV1/FVC (%) was < 80.8, the risk of COPD increased by 13.5% per unit decrease in lung function [0.865(0.805, 0.930)]. CONCLUSION COPD patients with previous pulmonary tuberculosis have more severe airflow limitations and clinical symptoms and are at higher risk for acute exacerbations. Furthermore, lung function changes in people with a history of tuberculosis were associated with a dose-response relationship with the probability of developing COPD.
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Affiliation(s)
- Yide Wang
- Department of Integrated Pulmonology, The Traditional Chinese Medicine Hospital Affiliated to Xinjiang Medical University, Urumqi, 830000, P.R. China
- National Clinical Research Base of Traditional Chinese Medicine in Xinjiang, Urumqi, 830000, P.R. China
| | - Zheng Li
- Department of Integrated Pulmonology, The Traditional Chinese Medicine Hospital Affiliated to Xinjiang Medical University, Urumqi, 830000, P.R. China
- National Clinical Research Base of Traditional Chinese Medicine in Xinjiang, Urumqi, 830000, P.R. China
| | - Fengsen Li
- Department of Integrated Pulmonology, The Traditional Chinese Medicine Hospital Affiliated to Xinjiang Medical University, Urumqi, 830000, P.R. China
- National Clinical Research Base of Traditional Chinese Medicine in Xinjiang, Urumqi, 830000, P.R. China
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Bernardes S, Teixeira PJZ, Silva FM. Association of reduced BMI, length of hospital stay, mortality, and malnutrition diagnosis in patients with acute exacerbation COPD: A secondary analysis of a cohort study. JPEN J Parenter Enteral Nutr 2023; 47:101-108. [PMID: 35511699 DOI: 10.1002/jpen.2390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/19/2022] [Accepted: 04/23/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Body mass index (BMI) presents prognostic value in chronic obstructive pulmonary disease (COPD), and despite its limitations in capturing malnutrition, its use is common to assess nutritional status. We aimed to confirm the association between BMI and in-hospital outcomes in acute exacerbation of COPD (AECOPD) and its inaccuracy in diagnosing malnutrition. METHODS We diagnosed malnutrition using the Subjective global assessment (SGA), Academy of Nutrition and Dietetics-American Society for Parenteral and Enteral Nutrition (AND-ASPEN), and two cutoff values for reduced BMI (age-related and ≤ 21.0). BMI accuracy was assessed using the area under the receiver operating characteristic (AUC-ROC) curve and SGA and AND-ASPEN as references. We evaluated in-hospital mortality and hospital stay outcomes and constructed logistic regression models. RESULTS The median hospital stay was 11 (7-18) days, and 7.5% of patients died. Malnutrition prevalence according to BMI, SGA, and AND-ASPEN was 21.4% (mean of both cutoff values), 50%, and 54%, respectively. Reduced BMI presented low agreement (κ = 0.315-0.383) and unsatisfactory accuracy (AUC-ROC curve = 0.333-0.679) with reference methods for malnutrition diagnosis. Age-related reduced BMI (odds ratio [OR] = 2.11; 95% CI, 1.10-4.04) and BMI ≤ 21.0 (OR = 2.25; 95% CI, 1.13-4.48) were associated with hospital stays longer than the median in adjusted models, but not in-hospital mortality. CONCLUSION BMI was inaccurate in identifying malnutrition in hospitalized patients with AECOPD and was associated with hospital stays longer than ten days.
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Affiliation(s)
- Simone Bernardes
- Health Sciences Graduate Program from Federal University of Health Sciences of Porto Alegre, RS, Brazil
| | - Paulo José Zimermann Teixeira
- Pulmonary Rehabilitation Program, Hospital Pavilhão Pereira Filho, Santa Casa de Misericordia of Porto Alegre Hospital Complex, Undergraduate Medicine Program and Health Sciences Graduate Program from Federal University of Health Sciences of Porto Alegre, RS, Brazil.,Undergraduate Medicine Program and Health Sciences Graduate Program from Federal University of Health Sciences of Porto Alegre, RS, Brazil
| | - Flávia Moraes Silva
- Nutrition Department and Nutrition Science Graduate Program from Federal University of Health Sciences of Porto Alegre, RS, Brazil
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10
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McCray S, Barsha L, Maunder K. Implementation of an electronic solution to improve malnutrition identification and support clinical best practice. J Hum Nutr Diet 2022; 35:1071-1078. [PMID: 35510388 DOI: 10.1111/jhn.13026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/25/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Routine malnutrition risk screening of patients is critical for optimal care and comprises part of the National Australian Hospital Standards. Identification of malnutrition also ensures reimbursement for hospitals to adequately treat these high-risk patients. However, timely, accurate screening, assessment and coding of malnutrition remains suboptimal. The present study aimed to investigate manual and digital interventions to overcome barriers to malnutrition identification for improvements in the hospital setting. METHODS Retrospective reporting on malnutrition identification processes was conducted through two stages: (1) manual auditing intervention and (2) development of a digital solution - the electronic malnutrition management solution (eMS). Repeated process audits were completed at approximately 6-monthly intervals through both stages between 2016 and 2019 and the results were analysed. In Stage 2, time investment and staff adoption of the digital solution were measured. RESULTS Overall, the combined effect of both regular auditing and use of the eMS resulted in statistically significant improvements across all six key measures: patients identified (97%-100%; p < 0.001), screened (68%-95%; p < 0.001), screened within 24 h (51%-89%; p < 0.001), assessed (72%-95%; p < 0.001), assessed within 24 h (66%-93%; p < 0.001) and coded (81%-100%; p = 0.017). The eMS demonstrated a reduction in screening time by over 60% with user adoption 100%. Data analytics enabled automated, real-time auditing with a 95% reduction in time taken to audit. CONCLUSIONS A single digital solution for management of malnutrition and automation of auditing demonstrated significant improvements where manual or combinations of manual and electronic systems continue to fall short.
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Affiliation(s)
- Sally McCray
- Dept of Dietetics and Foodservices, Mater Group, Raymond Terrace, South Brisbane, QLD, Australia.,Mater Research Institute, University of Queensland Brisbane, QLD, Australia
| | - Laura Barsha
- Dept of Dietetics and Foodservices, Mater Group, Raymond Terrace, South Brisbane, QLD, Australia.,Mater Research Institute, University of Queensland Brisbane, QLD, Australia
| | - Kirsty Maunder
- The CBORD Group, Sydney, NSW, Australia.,University of Wollongong, Faculty of Science, Medicine and Health, Wollongong, NSW, Australia
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11
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Shirai Y, Momosaki R, Kokura Y, Kato Y, Okugawa Y, Shimizu A. Validation of Asian Body Mass Index Cutoff Values for the Classification of Malnutrition Severity According to the Global Leadership Initiative on Malnutrition Criteria in Patients with Chronic Obstructive Pulmonary Disease Exacerbations. Nutrients 2022; 14:nu14224746. [PMID: 36432433 PMCID: PMC9698554 DOI: 10.3390/nu14224746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/02/2022] [Accepted: 11/08/2022] [Indexed: 11/12/2022] Open
Abstract
Low body mass index (BMI) is an independent predictor of prolonged hospital stay and mortality in patients with chronic obstructive pulmonary disease (COPD). However, to the best of our knowledge, no studies have examined the validity of Asian BMI cutoff values for classifying severity based on the Global Leadership Initiative on Malnutrition (GLIM) criteria in patients with acute COPD exacerbations. This study sought to validate whether Asian BMI cutoff values can accurately predict 30-day in-hospital mortality, length of stay, and 90-day readmission outcomes for patients with acute COPD exacerbations. The present retrospective cohort study was conducted using a large claims database created by the JMDC. Patients were classified into three groups according to the severity of low BMI assessed using Asian BMI cutoff values. As a result, 624 (29.4%) had severely low BMI, and 444 (20.9%) had moderately low BMI. The severity of low BMI, as assessed by the Asian BMI cutoff values used in the GLIM criteria, was independently associated with 30-day in-hospital mortality (moderately low BMI: HR, 1.87; 95% CI, 1.13−3.08; p = 0.014 and severely low BMI: HR, 2.55; 95% CI, 1.66−3.92; p < 0.001). The Asian BMI cutoff values used to classify the severity of malnutrition in the GLIM criteria are clinically functional for predicting the prognosis of patients with acute COPD exacerbations.
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Affiliation(s)
- Yuka Shirai
- Department of Rehabilitation Medicine, Mie University Graduate School of Medicine, Tsu 514-8507, Mie, Japan
- Clinical Nutrition Unit, Hamamatsu University Hospital, 1-20-1 Handayama, Higashi-ku, Hamamatsu 431-3192, Shizuoka, Japan
| | - Ryo Momosaki
- Department of Rehabilitation Medicine, Mie University Graduate School of Medicine, Tsu 514-8507, Mie, Japan
| | - Yoji Kokura
- Department of Nutritional Management, Keiju Hatogaoka Integrated Facility for Medical and Long-Term Care, Hosu 927-0023, Ishikawa, Japan
| | - Yuki Kato
- Department of Rehabilitation Medicine, Mie University Graduate School of Medicine, Tsu 514-8507, Mie, Japan
| | - Yoshinaga Okugawa
- Department of Genomic Medicine, Mie University Hospital, Tsu 514-8507, Mie, Japan
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Tsu 514-8507, Mie, Japan
| | - Akio Shimizu
- Department of Health Science, Faculty of Health and Human Development, The University of Nagano, 8-49-7, Nagano 380-8525, Nagano, Japan
- Correspondence: ; Tel.: +81-26-462-1463
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12
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Owusuaa C, Dijkland SA, Nieboer D, van der Rijt CCD, van der Heide A. Predictors of mortality in chronic obstructive pulmonary disease: a systematic review and meta-analysis. BMC Pulm Med 2022; 22:125. [PMID: 35379214 PMCID: PMC8978392 DOI: 10.1186/s12890-022-01911-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/10/2022] [Indexed: 11/10/2022] Open
Abstract
Background Better insight in patients’ prognosis can help physicians to timely initiate advance care planning (ACP) discussions with patients with chronic obstructive pulmonary disease (COPD). We aimed to identify predictors of mortality. Methods We systematically searched databases Embase, PubMed, MEDLINE, Web of Science, and Cochrane Central in April 2020. Papers reporting on predictors or prognostic models for mortality at 3 months and up to 24 months were assessed on risk-of-bias. We performed a meta-analysis with a fixed or random-effects model, and evaluated the discriminative ability of multivariable prognostic models. Results We included 42 studies (49–418,251 patients); 18 studies were included in the meta-analysis. Significant predictors of mortality within 3–24 months in the random-effects model were: previous hospitalization for acute exacerbation (hazard ratio [HR] 1.97; 95% confidence interval [CI] 1.32–2.95), hospital readmission within 30 days (HR 5.01; 95% CI 2.16–11.63), cardiovascular comorbidity (HR 1.89; 95% CI 1.25–2.87), age (HR 1.48; 95% CI 1.38–1.59), male sex (HR 1.68; 95% CI 1.38–1.59), and long-term oxygen therapy (HR 1.74; 95% CI 1.10–2.73). Nineteen previously developed multicomponent prognostic models, as examined in 11 studies, mostly had moderate discriminate ability. Conclusion Identified predictors of mortality may aid physicians in selecting COPD patients who may benefit from ACP. However, better discriminative ability of prognostic models or development of a new prognostic model is needed for further large-scale implementation. Registration: PROSPERO (CRD42016038494), https://www.crd.york.ac.uk/prospero/. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-01911-5.
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Affiliation(s)
- Catherine Owusuaa
- Department of Medical Oncology, Erasmus MC Cancer Institute, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Simone A Dijkland
- Department of Public Health, Erasmus MC, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus MC, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Carin C D van der Rijt
- Department of Medical Oncology, Erasmus MC Cancer Institute, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, Erasmus University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
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13
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Pereira TG, Lima J, Silva FM. Undernutrition is associated with mortality, exacerbation and poorer quality of life in COPD patients: a systematic review with meta‐analysis of observational studies. JPEN J Parenter Enteral Nutr 2022; 46:977-996. [DOI: 10.1002/jpen.2350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 01/22/2022] [Accepted: 02/10/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Thainá Gattermann Pereira
- Nutrition Science Postgraduation Program of Federal University of Health Science of Porto Alegre Porto Alegre Rio Grande do Sul Brazil
| | - Júlia Lima
- Federal University of Health Science of Porto Alegre Porto Alegre Rio Grande do Sul Brazil
| | - Flávia Moraes Silva
- Nutrition Department and Nutrition Science Postgraduation Program of Federal University of Health Science of Porto Alegre Porto Alegre Rio Grande do Sul Brazil
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14
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Cardoso J, Ferreira AJ, Guimarães M, Oliveira AS, Simão P, Sucena M. Treatable Traits in COPD - A Proposed Approach. Int J Chron Obstruct Pulmon Dis 2021; 16:3167-3182. [PMID: 34824530 PMCID: PMC8609199 DOI: 10.2147/copd.s330817] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/03/2021] [Indexed: 12/20/2022] Open
Abstract
The well-recognized individual heterogeneity within COPD patients has led to a growing interest in greater personalization in the approach of these patients. Thus, the treatable traits strategy has been proposed as a further step towards precision medicine in the management of chronic airway disease, both in stable phase and acute exacerbations. The aim of this paper is to perform a critical review on the treatable traits strategy and propose a guide to approach COPD patients in the light of this new concept. An innovative stepwise approach is proposed - a multidisciplinary model based on two distinct phases, with the potential to be implemented in both primary care and hospital settings. The first phase is the initial and focused assessment of a selected subset of treatable traits, which should be addressed in all COPD patients in both settings (primary care and hospital). As some patients may present with advanced disease at diagnosis or may progress despite this initial treatment requiring a more specialized assessment, they should progress to a second phase, in which a broader approach is recommended. Beyond stable COPD, we explore how the treatable traits strategy may be applied to reduce the risk of future exacerbations and improve the management of COPD exacerbations. Since many treatable traits have already been related to exacerbation risk, the strategy proposed here represents an opportunity to be proactive. Although it still lacks prospective validation, we believe this is the way forward for the future of the COPD approach.
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Affiliation(s)
- João Cardoso
- Pulmonology Department, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal.,NOVA Medical School, Nova University Lisbon, Lisboa, Portugal
| | - António Jorge Ferreira
- Pulmonology Department, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Miguel Guimarães
- Pulmonology Department, Centro Hospitalar Vila Nova de Gaia/Espinho EPE, Vila Nova de Gaia, Portugal
| | - Ana Sofia Oliveira
- Pulmonology Department, Centro Hospitalar Universitário de Lisboa Norte EPE, Lisboa, Portugal
| | - Paula Simão
- Pulmonology Department, Unidade Local de Saúde de Matosinhos EPE, Matosinhos, Portugal
| | - Maria Sucena
- Pulmonology Department, Centro Hospitalar Universitário do Porto EPE, Porto, Portugal.,Lung Function and Ventilation Unit, Centro Hospitalar Universitário do Porto EPE, Porto, Portugal
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15
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AND-ASPEN and ESPEN consensus, and GLIM criteria for malnutrition identification in AECOPD patients: a longitudinal study comparing concurrent and predictive validity. Eur J Clin Nutr 2021; 76:685-692. [PMID: 34702965 DOI: 10.1038/s41430-021-01025-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 09/09/2021] [Accepted: 10/01/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND/OBJECTIVES Malnutrition in chronic obstructive pulmonary disease (COPD) patients is prevalent and usually assessed by body mass index (BMI), which can lead to misdiagnosis. The subjective global assessment (SGA) is the reference method for this diagnose in hospitalized patients. In the last decade, new tools have emerged Academy of Nutrition and Dietetics-American Society for Parenteral and Enteral Nutrition [AND-ASPEN], European Society for Clinical Nutrition and Metabolism [ESPEN], and Global Leadership Initiative on Malnutrition [GLIM]). Therefore, this study aimed to assess the concurrent and predictive validity of these tools in acute exacerbated COPD (AECOPD) patients. SUBJECTS/METHODS Prospective cohort study with hospitalized AECOPD patients. Malnutrition was diagnosed by SGA (reference method), AND-ASPEN, ESPEN, and GLIM consensus. Hospital length of stay (LOS) and mortality were the outcomes evaluated. RESULTS In 241 patients (46.5% males; 68.3 ± 10.2 years), malnutrition was found in 50.0% by SGA, 54.4% by AND-ASPEN, 20.2% by ESPEN, and 47.8% by GLIM. AND-ASPEN had the best accuracy (AUC = 0.837; 95% CI 0.783-0.841) and concordance (kappa = 0.674) with SGA and it was an independent predictor of prolonged LOS (OR = 1.73; 95% CI 1.01-3.37). ESPEN consensus did not agree with SGA, but was associated with prolonged LOS (OR = 2.57 95% CI, 1.27-5.20). The GLIM had good concordance (kappa = 0.533) and accuracy with SGA (AUC = 0.768; 95% CI 0.701-0.835), but was not associated with outcomes. CONCLUSIONS The AND-ASPEN was the most accurate tool for diagnosing malnutrition in AECOPD patients and was an independent predictor of prolonged LOS.
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16
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Dávalos-Yerovi V, Marco E, Sánchez-Rodríguez D, Duran X, Meza-Valderrama D, Rodríguez DA, Muñoz E, Tejero-Sánchez M, Muns MD, Guillén-Solà A, Duarte E. Malnutrition According to GLIM Criteria Is Associated with Mortality and Hospitalizations in Rehabilitation Patients with Stable Chronic Obstructive Pulmonary Disease. Nutrients 2021; 13:nu13020369. [PMID: 33530364 PMCID: PMC7911981 DOI: 10.3390/nu13020369] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/16/2021] [Accepted: 01/20/2021] [Indexed: 12/16/2022] Open
Abstract
Malnutrition has a negative impact on patients with chronic pulmonary obstructive disease (COPD). The purpose of this study was to assess the prevalence of malnutrition, defined by the Global Leadership Initiative for Malnutrition (GLIM), in stable COPD patients referred to pulmonary rehabilitation, and to explore potential associations of malnutrition according to GLIM, and its components, with increased risk of mortality and hospitalizations in 2 years. In a post-hoc analysis of a prospective cohort of 200 rehabilitation patients with stable COPD, main outcome variables were hospital admissions, length of stay, and mortality during a 2-year follow-up. Covariates were malnutrition according to GLIM and its phenotypic criteria: unintentional weight loss, low body mass index (BMI), and low fat-free mass (FFM). Univariate and multivariate analysis were performed using logistic and proportional hazard Cox regression. Malnutrition according to GLIM showed 45% prevalence and was associated with increased mortality risk. Low age-related BMI and FFM were independently associated with mortality, which persisted after adjustment for age and lung function. Malnutrition and low BMI were also associated with increased risk of hospitalization. Malnutrition according to GLIM criteria was highly prevalent in rehabilitation patients with COPD and was associated with nearly 3 times greater mortality and hospitalization risk.
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Affiliation(s)
- Vanesa Dávalos-Yerovi
- Physical Medicine and Rehabilitation Department, Parc Salut Mar (Hospital del Mar Hospital de l’Esperança), Passeig Maritim de la Barceloneta 25-29, 08003 Barcelona, Spain; (V.D.-Y.); (M.T.-S.); (A.G.-S.); (E.D.)
- Rehabilitation Research Group, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Carrer del Doctor Aiguader 88, 08003 Barcelona, Spain; (D.S.-R.); (D.M.-V.); (E.M.); (M.D.M.)
| | - Ester Marco
- Physical Medicine and Rehabilitation Department, Parc Salut Mar (Hospital del Mar Hospital de l’Esperança), Passeig Maritim de la Barceloneta 25-29, 08003 Barcelona, Spain; (V.D.-Y.); (M.T.-S.); (A.G.-S.); (E.D.)
- Rehabilitation Research Group, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Carrer del Doctor Aiguader 88, 08003 Barcelona, Spain; (D.S.-R.); (D.M.-V.); (E.M.); (M.D.M.)
- School of Medicine, Universitat Autònoma de Barcelona (UAB), Campus Universitari Mar, Carrer del Doctor Aiguader 80, 08003 Barcelona, Spain;
- School of Medicine, Universitat Internacional de Catalunya, Carrer Josep Trueta s/n, Sant Cugat del Vallès, 08195 Barcelona, Spain
- Correspondence: ; Tel.: +34-603-622-596
| | - Dolores Sánchez-Rodríguez
- Rehabilitation Research Group, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Carrer del Doctor Aiguader 88, 08003 Barcelona, Spain; (D.S.-R.); (D.M.-V.); (E.M.); (M.D.M.)
- Geriatrics Department, Centre Fòrum-Hospital del Mar, Carrer Llull 410, 08019 Barcelona, Spain
- Department of Health Sciences (CEXS), Universitat Pompeu i Fabra, Carrer del Doctor Aiguader 80, 08003 Barcelona, Spain
| | - Xavier Duran
- Methodology and Biostatistics Support Unit, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Carrer del Doctor Aiguader 88, 08003 Barcelona, Spain;
| | - Delky Meza-Valderrama
- Rehabilitation Research Group, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Carrer del Doctor Aiguader 88, 08003 Barcelona, Spain; (D.S.-R.); (D.M.-V.); (E.M.); (M.D.M.)
- Physical Medicine and Rehabilitation Department, National Institute of Physical Medicine and Rehabilitation (INMFER), Panama City 0819, Panama
- Physical Medicine and Rehabilitation Department, Caja de Seguro Social (C.S.S.), Panama City 0824, Panama
| | - Diego A. Rodríguez
- School of Medicine, Universitat Autònoma de Barcelona (UAB), Campus Universitari Mar, Carrer del Doctor Aiguader 80, 08003 Barcelona, Spain;
- Department of Health Sciences (CEXS), Universitat Pompeu i Fabra, Carrer del Doctor Aiguader 80, 08003 Barcelona, Spain
- Respiratory Medicine Department, Hospital del Mar, Passeig Maritim de la Barceloneta 25-29, 08003 Barcelona, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Avenida Monforte de Lemos 3-5, Pabellón 11, 28019 Madrid, Spain
| | - Elena Muñoz
- Rehabilitation Research Group, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Carrer del Doctor Aiguader 88, 08003 Barcelona, Spain; (D.S.-R.); (D.M.-V.); (E.M.); (M.D.M.)
| | - Marta Tejero-Sánchez
- Physical Medicine and Rehabilitation Department, Parc Salut Mar (Hospital del Mar Hospital de l’Esperança), Passeig Maritim de la Barceloneta 25-29, 08003 Barcelona, Spain; (V.D.-Y.); (M.T.-S.); (A.G.-S.); (E.D.)
- Rehabilitation Research Group, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Carrer del Doctor Aiguader 88, 08003 Barcelona, Spain; (D.S.-R.); (D.M.-V.); (E.M.); (M.D.M.)
| | - Maria Dolors Muns
- Rehabilitation Research Group, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Carrer del Doctor Aiguader 88, 08003 Barcelona, Spain; (D.S.-R.); (D.M.-V.); (E.M.); (M.D.M.)
- Endocrinology and Nutrition Department, Hospital del Mar-Parc de Salut Mar. Passeig Marítim de la Barceloneta, 25, 29, 08003 Barcelona, Spain
| | - Anna Guillén-Solà
- Physical Medicine and Rehabilitation Department, Parc Salut Mar (Hospital del Mar Hospital de l’Esperança), Passeig Maritim de la Barceloneta 25-29, 08003 Barcelona, Spain; (V.D.-Y.); (M.T.-S.); (A.G.-S.); (E.D.)
- Rehabilitation Research Group, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Carrer del Doctor Aiguader 88, 08003 Barcelona, Spain; (D.S.-R.); (D.M.-V.); (E.M.); (M.D.M.)
- School of Medicine, Universitat Autònoma de Barcelona (UAB), Campus Universitari Mar, Carrer del Doctor Aiguader 80, 08003 Barcelona, Spain;
| | - Esther Duarte
- Physical Medicine and Rehabilitation Department, Parc Salut Mar (Hospital del Mar Hospital de l’Esperança), Passeig Maritim de la Barceloneta 25-29, 08003 Barcelona, Spain; (V.D.-Y.); (M.T.-S.); (A.G.-S.); (E.D.)
- Rehabilitation Research Group, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Carrer del Doctor Aiguader 88, 08003 Barcelona, Spain; (D.S.-R.); (D.M.-V.); (E.M.); (M.D.M.)
- School of Medicine, Universitat Autònoma de Barcelona (UAB), Campus Universitari Mar, Carrer del Doctor Aiguader 80, 08003 Barcelona, Spain;
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17
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Detection of nutritional risk and hospital stay in the hospitalized elderly adult. NUTR HOSP 2021; 38:464-469. [PMID: 33887948 DOI: 10.20960/nh.03200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Introduction Background and aims: a high nutritional risk can independently be associated with a longer hospital stay in elderly patients. This study aims to establish the prevalence of the risk of malnutrition and its associated factors in a high-complexity level hospital in Bogotá, Colombia, during 2018. Methods: a cross-sectional study. The prevalence of the risk of malnutrition was measured using a malnutrition-screening tool (MST), and the association with hospital stage, age, and patient diagnoses was assessed. Results: a total of 7,192 patients comprised the cohort. Age range was 61 to 108 years, with an average of 77.1 ± 9.2 years, and subjects were mostly female (55.5 %). We identified as main conditions urinary tract infections (8.4 %), congestive heart failure (5.4 %), and chronic obstructive pulmonary disease with an acute exacerbation (4.6 %). The prevalence of the risk of malnutrition was 41.4 %, significantly associated with longer hospital stays (p < 0.001), older age (p < 0.001), and a diagnosis of delirium (OR = 5.98, 95 % CI: 2.78 to 12.86), diarrhea and gastroenteritis (OR = 5.01, 95 % CI: 2.44 to 10.32), gastrointestinal hemorrhage (OR = 4.44, 95 % CI: 2.38 to 8.28), specified pneumonia (OR = 4.43, 95% CI: 2.11 to 9.30), and high blood pressure (3.94, 95 % CI: 2.07 to 7.50). Other diagnoses included abdominal pain (other) (OR = 3.80, 95 % CI: 1.81 to 7.99), urinary tract infections (OR = 3.64, 95 % CI: 2.07 to 6.24), acute bronchitis (OR = 3.22, 95 % CI: 1.56 to 6.65), and bacterial pneumonia (OR = 3.02, 95 % CI: 1.65 to 5.55). Conclusion: the prevalence of the risk of malnutrition in our institution is approximately one in two patients, with a significant association to increased hospital stay ≥ 8 days, patient age ≥ 80 years, and mainly diagnoses of delirium, diarrhea, and gastroenteritis of suspected infectious etiology.
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18
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Keogh E, Mark Williams E. Managing malnutrition in COPD: A review. Respir Med 2020; 176:106248. [PMID: 33253970 DOI: 10.1016/j.rmed.2020.106248] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/18/2020] [Indexed: 12/31/2022]
Abstract
In the UK approximately 1.2 million people have COPD with around 25-40% being underweight and 35% have a severely low fat-free mass index. Measuring their body mass index is recommended and Health care professionals should endeavour to ensure that COPD patients are achieving their nutritional requirements. A narrative review summarizes evidence from 28 original articles identified through a systematic searches of databases, grey literature and hand searches covering 15 years, focusing on two themes, on the impact of malnutrition on COPD, and the management of malnutrition in COPD. Malnutrition causes negative effects on exercise and muscle function and lung function as well as increasing exacerbations, mortality and cost. Management options include nutritional supplementation which may increase weight and muscle function. Nutritional education has short-term improvements. Malnutrition affects multiple aspects of COPD, but treatment is of benefit. Clinical practice should include nutrition management.
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Affiliation(s)
- Emma Keogh
- Respiratory Medicine, University of Cambridge Hospitals, Cambridge, UK
| | - E Mark Williams
- Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK.
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Teixeira PP, Kowalski VH, Valduga K, de Araújo BE, Silva FM. Low Muscle Mass Is a Predictor of Malnutrition and Prolonged Hospital Stay in Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Longitudinal Study. JPEN J Parenter Enteral Nutr 2020; 45:1221-1230. [PMID: 32794593 DOI: 10.1002/jpen.1998] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/31/2020] [Accepted: 08/07/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Malnutrition in chronic obstructive pulmonary disease (COPD) patients is more prevalent during times of exacerbation. Fat-free mass index (FFMI), calf circumference (CC), and adductor muscle pollicis thickness (AMPT) can be used to identify reduced muscle mass and have been found to be good predictors of clinical outcomes in other conditions, but they have not been investigated in COPD. Therefore, this study evaluated low muscle mass as predictor of malnutrition, prolonged length of stay (LOS), and in-hospital death in COPD patients. METHODS This prospective cohort study was carried out in hospitalized patients with COPD exacerbation. Malnutrition diagnosis was performed by Subjective Global Assessment, and muscle mass was assessed by FFMI, calculated using fat-free mass from bioelectrical impedance, CC, and AMPT. Clinical outcomes (LOS and in-hospital death) were collected from records. RESULTS One hundred seventy-six patients were included (68.2 ± 10.4 years old, 56.2% women); 74.2% were classified as Global Initiative of Chronic Obstructive Lung Disease 2 or 3 and 58.2% as malnourished. The median LOS was 11 (7-19) days, and the incidence of death was 9.1%. Low FFMI and CC predicted malnutrition (low CC: odds ratio [OR], 4.6; 95% CI, 2.2-9.7 and low FFMI: OR, 8.8; 95% CI, 3.7-20.8) and were associated with prolonged LOS (low CC: OR, 2.3; 95% CI, 1.1-4.6 and low FFMI: OR, 2.5; 95% CI, 1.3-4.8). CONCLUSION Simple, inexpensive, and noninvasive parameters of muscle mass-FFMI and CC-are good predictors of malnutrition and prolonged LOS in COPD patients experiencing exacerbation.
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Affiliation(s)
- Paula Portal Teixeira
- Federal University of Health Science of Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Kamila Valduga
- Endocrine Postgraduation Program of Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Bruna Espíndola de Araújo
- Nutrition Science Postgraduation Program of Federal University of Health Science of Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Flávia Moraes Silva
- Nutrition Department and Nutrition Science Postgraduation Program in Federal University of Health Science of Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
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20
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McCauley SM, Barrocas A, Malone A. Hospital Nutrition Care Betters Patient Clinical Outcomes and Reduces Costs: The Malnutrition Quality Improvement Initiative Story. J Acad Nutr Diet 2020; 119:S11-S14. [PMID: 31446938 DOI: 10.1016/j.jand.2019.05.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Indexed: 11/18/2022]
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21
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Abstract
Due to growing recognition of comorbidities, COPD is no longer considered a disease affecting only the respiratory system. Its management now entails the early diagnosis and treatment of comorbidities. However, although many studies have examined the impact of comorbidities on the evolution of COPD and patients' quality of life, very few have explored the means to systematically identify and manage them. The aims of this article are to summarise the state of current knowledge about comorbidities associated with COPD and to propose a possible screening protocol in the outpatient setting, emphasising the areas needing further research.
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Affiliation(s)
- Delphine Natali
- Respiratory Medicine Dept, Hanoi French Hospital, Hanoi, Vietnam
| | | | | | - Belinda Cochrane
- Dept of Respiratory and Sleep Medicine, Campbelltown Hospital, Sydney, Australia
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22
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Tyler R, Barrocas A, Guenter P, Araujo Torres K, Bechtold ML, Chan L, Collier B, Collins NA, Evans DC, Godamunne K, Hamilton C, Hernandez BJD, Mirtallo JM, Nadeau WJ, Partridge J, Perugini M, Valladares A. Value of Nutrition Support Therapy: Impact on Clinical and Economic Outcomes in the United States. JPEN J Parenter Enteral Nutr 2020; 44:395-406. [DOI: 10.1002/jpen.1768] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 11/21/2019] [Accepted: 12/10/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Renay Tyler
- University of Maryland Medical Center Baltimore Maryland USA
| | | | - Peggi Guenter
- Clinical Practice, Quality, and AdvocacyAmerican Society for Parenteral Nutrition Silver Spring Maryland USA
| | | | - Matthew L. Bechtold
- Division of Gastroenterology & HepatologyDepartment of Medicine University Hospital & Clinics Columbia Missouri USA
| | - Lingtak‐Neander Chan
- Department of PharmacyInterdisciplinary FacultyNutritional Sciences ProgramUniversity of Washington Seattle Washington USA
| | - Bryan Collier
- Virginia Tech Carilion School of Medicine Roanoke Virginia USA
| | - Nilsa A. Collins
- Clinical Integration ProgramsWellStar Clinical Partners Marietta Atlanta Georgia USA
| | - David C. Evans
- Ohio Health Trauma and Surgical Services Columbus Ohio USA
| | | | - Cindy Hamilton
- Digestive Disease and Surgery Institute Cleveland Clinic Cleveland Ohio USA
| | | | - Jay M. Mirtallo
- Clinical Practice, Quality, and AdvocacyAmerican Society for Parenteral Nutrition Silver Spring Maryland USA
- The Ohio State UniversityCollege of Pharmacy Columbus Ohio USA
| | | | - Jamie Partridge
- Field Health Economics and Outcomes ResearchBayer Pharmaceuticals Whippany New Jersey USA
| | - Moreno Perugini
- Global Head of Medical Affairs & Marketing AccessNestlé Health Science Bridgewater New Jersey USA
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23
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Shepherd AB, Bowell K. ‘Mind the gap’: the importance of managing malnutrition in chronic obstructive pulmonary disease. ACTA ACUST UNITED AC 2019; 28:1442-1449. [DOI: 10.12968/bjon.2019.28.22.1442] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Malnutrition is linked to poor outcomes in patients with chronic obstructive pulmonary disease (COPD), and reduced fat free mass and low BMI are independent risk factors for increased mortality. However, weight loss is not inevitable and can be prevented or reversed so screening for malnutrition is essential. The latest guidelines for managing malnutrition in COPD recommend first-line nutritional support. In particular, patients with a BMI <20 kg/m2 should be prescribed oral nutritional supplements (ONS), which have been shown to significantly improve outcomes. However, this guidance is often not implemented locally, increasing the likelihood of malnutrition, hospital admission and increased healthcare costs. Ready-prepared, low-volume, high-protein, high-energy drinks can improve compliance with ONS, particularly in people who are unable to tolerate high volumes. ONS therefore play an important role in managing malnutrition in COPD, helping to reduce its physiological and economic effects.
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Affiliation(s)
| | - Karen Bowell
- Senior Medical Affairs Manager, Nutricia Advanced Medical Nutrition, Trowbridge, UK
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24
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Nguyen HT, Pavey TG, Collins PF, Nguyen NV, Pham TD, Gallegos D. Effectiveness of Tailored Dietary Counseling in Treating Malnourished Outpatients with Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial. J Acad Nutr Diet 2019; 120:778-791.e1. [PMID: 31786177 DOI: 10.1016/j.jand.2019.09.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 09/06/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Malnutrition in patients with chronic obstructive pulmonary disease (COPD) is common and associated with poor prognosis. Nutrition interventions are necessary, but there is a lack of evidence regarding the effectiveness of tailored nutrition advice. OBJECTIVE This study investigated whether tailored nutrition counseling could improve dietary intake, nutritional status, functional outcomes, and health-related quality of life (QoL) of malnourished outpatients with COPD. DESIGN We conducted a randomized controlled trial in which participants were randomly assigned to either the intervention group (IG) or the control group (CG). PARTICIPANTS/SETTING One hundred and twenty malnourished outpatients with COPD participated in the study between May and November 2017 at the National Lung Hospital, Hanoi, Vietnam. INTERVENTION The IG received tailored nutrition counseling once per month for 3 months based on a specifically developed written nutrition resource for COPD. The CG received the same educational resource at baseline without any discussion. MAIN OUTCOME MEASURES The main outcome measures were energy and protein intakes, body weight change, nutritional status (Subjective Global Assessment score), muscle strength, and QoL. STATISTICAL ANALYSES Differences between groups before and after the intervention were assessed using two-way repeated measures analysis of variance. Generalized estimating equation modeling was used to investigate the differences between groups over time. RESULTS At baseline, there were no significant differences in outcomes of interest between the two groups. After 3 months of intervention, time-intervention interactions for energy intake, protein intake, and body weight change were significant (945 kcal/day, 95% CI 792 to 1,099 kcal/day, P<0.001; 50.0 g protein/day, 95% CI 43.9 to 56.1 g protein/day, P<0.001; and 1.0 kg, 95% CI 0.5 to 1.5 kg, P<0.001, respectively). Subjective Global Assessment scores improved in the IG and worsened in the CG. Significant improvements were found in inspiratory muscle strength in the IG (5.4 cmH2O, 95% CI 2.3 to 8.6 cmH2O, P=0.001) and significant decreases in handgrip strength were found in the CG after 3 months of the intervention (1.4 kg, 95% CI 0.4 to 2.4 kg, P=0.007). There was a significant interaction effect for all QoL scores (analysis of variance two-way repeated, P≤0.003). The IG also significantly improved all QoL scores from baseline to 3 months (P<0.004). CONCLUSIONS Tailored nutritional counseling has the potential to improve dietary intakes, nutritional status, functional outcomes, and QoL in malnourished outpatients with COPD.
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25
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Lackoff AS, Hickling D, Collins PF, Stevenson KJ, Nowicki TA, Bell JJ. The association of malnutrition with falls and harm from falls in hospital inpatients: Findings from a 5-year observational study. J Clin Nurs 2019; 29:429-436. [PMID: 31715045 DOI: 10.1111/jocn.15098] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 09/01/2019] [Accepted: 10/20/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Inpatient falls continue to be a significant clinical issue, and while malnutrition is a known risk factors for falls, few studies have investigated its association with inpatient falls. This study aimed to explore the independent association between malnutrition and fall risk as well as harm from falls in hospital inpatients. METHODS Malnutrition identified in annual malnutrition audits was combined with inpatient fall data captured through the electronic patient incident reporting system in the 12 months following audit days. Audit data were available for 1,849 inpatients across 2011-2015, and covariate associations between age, gender, BMI, malnutrition, falls and harmful falls were analysed. The reporting of this paper is in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations (see Appendix S1). RESULTS The prevalence of malnutrition was 32.4% (n = 543), and 171 (9.2%) inpatients experienced a fall with 0.7% (n = 13) categorised as harmful. In bivariate analysis, patients who fell were more likely to be older (median 79.0 vs. 70.0 years; p < .0001) or malnourished (40.9% vs. 31.5%; p = .021). Malnutrition (p < .0001) and having a lower BMI (p = .026) were significant predictors of harmful falls. Regression modelling demonstrated that only increasing age increased the likelihood of having an inpatient fall (OR 1.022 95% CI 1.021-1.046; p < .0001). Malnourished inpatients were almost 8 times more likely to have a harmful fall than those not malnourished (OR 7.94 95% CI 1.457-43.338; p = .017), independent of age and BMI. CONCLUSIONS Malnourished patients are more likely to experience a harmful fall. Assessment of malnutrition should be incorporated into fall risk assessments as a way of highlighting those patients at greater risk and to link to nutritional care pathways.
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Affiliation(s)
- Ariel S Lackoff
- Nutrition and Dietetics, Faculty of Health, School of Exercise and Nutrition Sciences, QUT, Brisbane, Qld, Australia.,Department of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane, Qld, Australia
| | | | - Peter F Collins
- Faculty of Health and Behavioural Sciences, School of Human Movement and Nutrition Sciences, The University of Queensland, St Lucia, Qld, Australia
| | | | | | - Jack J Bell
- The Prince Charles Hospital, Brisbane, Qld, Australia.,Faculty of Health and Behavioural Sciences, School of Human Movement and Nutrition Sciences, The University of Queensland, St Lucia, Qld, Australia
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26
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Collins PF, Yang IA, Chang YC, Vaughan A. Nutritional support in chronic obstructive pulmonary disease (COPD): an evidence update. J Thorac Dis 2019; 11:S2230-S2237. [PMID: 31737350 DOI: 10.21037/jtd.2019.10.41] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) primarily affects the lungs but due to the accompanying chronic systematic inflammation and the symptoms associated with the disease there are many extrapulmonary effects which include complex physical and metabolic adaptations. These changes have been associated with reduced exercise capacity, increased nutritional requirements, altered metabolic processes and compromised nutritional intake. As a result, nutritional depletion in COPD is multi-faceted and can involve imbalances of energy (weight loss), protein (sarcopenia), and periods of markedly increased inflammation (pulmonary cachexia) which can increase nutritional losses. As a result, depletion of both fat-mass (FM) and fat-free mass (FFM) can occur. There is good evidence that nutritional support, in the form of oral nutritional supplements (ONS), can overcome energy and protein imbalances resulting in improved nutritional status and functional capacity. However, in order to treat the aetiology of sarcopenia, frailty and cachexia, it is likely that targeted multi-modal interventions are required to address energy and protein imbalance, specific nutrient deficiencies, reduced androgens and targeted exercise training. Furthermore, interventions taking a disease-course approach, are likely to hold the key to effectively managing the common and costly problem of nutritional depletion in COPD.
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Affiliation(s)
- Peter F Collins
- School of Human Movement and Nutrition Science, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Ian A Yang
- University of Queensland Thoracic Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, Australia
| | - Yuan-Chin Chang
- University of Queensland Thoracic Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, Australia
| | - Annalicia Vaughan
- University of Queensland Thoracic Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, Australia
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27
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Saussereau J, Guillien A, Soumagne T, Laplante JJ, Laurent L, Bouhaddi M, Rocchi S, Annesi-Maesano I, Roche N, Dalphin JC, Degano B. Dietary Patterns and Prevalence of Post-bronchodilator Airway Obstruction in Dairy Farmers Exposed to Organic Dusts. COPD 2019; 16:118-125. [PMID: 31298600 DOI: 10.1080/15412555.2019.1631775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Exposure to organic dusts is an independent causative factor of chronic obstructive pulmonary disease (COPD). Unhealthy dietary patterns have been associated with poor lung function in smokers. This study investigated whether dietary patterns were associated with post-bronchodilator airway obstruction, a hallmark of COPD, in dairy farmers exposed to organic dusts. All subjects were identified by screening programs and patients with airflow obstruction were matched with subjects with normal spirometry. Six groups were compared, defined by their exposures (non-smoking dairy farmers, smokers ≥ 10 pack-years with no occupational exposure, and smoking dairy farmers) and the presence or absence of post-bronchodilator airflow obstruction, resulting in 321 study subjects. The Alternative Healthy Eating Index (AHEI) score was calculated based on an adapted food frequency questionnaire. Mean total AHEI scores were similar in all groups. Comparison between smokers with post-bronchodilator airway obstruction and subjects with post-bronchodilator airway obstruction related to occupational exposure found minimal differences in dietary patterns: dairy farmers had lower scores for the ratio of white to red meat and higher scores for cereal fiber consumption. As in previous studies, smokers with post-bronchodilator airway obstruction exhibited higher lipid intakes and lower carbohydrate intakes than their counterparts with normal spirometry. No evidence of any meaningful difference in dietary patterns was found between subjects with post-bronchodilator airway obstruction detected by screening and healthy controls, either in dairy farmers or in smokers with no occupational exposure.
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Affiliation(s)
- Julien Saussereau
- a Service d'Explorations Fonctionnelles Respiratoires, Centre Hospitalier Régional Universitaire (CHRU) , Besançon , France.,b Service de Pneumologie, CHRU , Besançon , France
| | - Alicia Guillien
- a Service d'Explorations Fonctionnelles Respiratoires, Centre Hospitalier Régional Universitaire (CHRU) , Besançon , France.,c EA 3920, Université de Franche-Comté , Besançon , France
| | | | | | - Lucie Laurent
- a Service d'Explorations Fonctionnelles Respiratoires, Centre Hospitalier Régional Universitaire (CHRU) , Besançon , France.,b Service de Pneumologie, CHRU , Besançon , France
| | - Malika Bouhaddi
- a Service d'Explorations Fonctionnelles Respiratoires, Centre Hospitalier Régional Universitaire (CHRU) , Besançon , France.,c EA 3920, Université de Franche-Comté , Besançon , France
| | - Steffi Rocchi
- e UMR/CNRS 6249 Chrono-Environnement, UFR Sciences médicales et pharmaceutiques, University of Bourgogne Franche-Comté , Besançon , France.,f Department of Parasitology-Mycology, University Hospital , Besancon , France
| | - Isabella Annesi-Maesano
- g Epidémiologie des Maladies Respiratoires et Allergiques (EPAR), i-PLESP INSERM and UPMC, Medical School Saint-Antoine , Paris , France
| | - Nicolas Roche
- h Service de Pneumologie et Soins Intensifs Respiratoires, Groupe Hospitalier Cochin, AP-HP and Université Paris Descartes (EA2511), Sorbonne-Paris-Cité , Paris , France
| | - Jean-Charles Dalphin
- b Service de Pneumologie, CHRU , Besançon , France.,e UMR/CNRS 6249 Chrono-Environnement, UFR Sciences médicales et pharmaceutiques, University of Bourgogne Franche-Comté , Besançon , France
| | - Bruno Degano
- i Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes , Grenoble , France.,j Laboratoire HP2, INSERM U1042, Université Grenoble Alpes , Grenoble , France
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28
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Jerng JS, Tang CH, Cheng RWY, Wang MYH, Hung KY. Healthcare utilization, medical costs and mortality associated with malnutrition in patients with chronic obstructive pulmonary disease: a matched cohort study. Curr Med Res Opin 2019; 35:1265-1273. [PMID: 30676096 DOI: 10.1080/03007995.2019.1574460] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Objective: Although disease-related malnutrition has prognostic implications for patients with chronic obstructive pulmonary disease (COPD), its health-economic impact and clinical burdens are uncertain. We conducted a population-level study to investigate these questions. Methods: We excerpted data relevant to malnutrition, prolonged mechanical ventilation and medications from claims by 1,197,098 patients which were consistent with COPD and registered by the Taiwan National Health Insurance Administration between 2009 and 2013. These patients were separated into cohorts with or without respiratory failure requiring long-term mechanical ventilation, and each cohort was divided to compare cases who developed malnutrition after their first diagnosis consistent with COPD, versus non-malnourished propensity-score matched controls. Results: The prevalence of malnutrition was 3.8% overall (10,259/287,000 non-ventilator-dependent; 1198/15,829 ventilator-dependent). Propensity-score matched non-ventilator-dependent patients who became malnourished (N = 10,242) had comparatively more hospitalizations, emergency room and outpatient visits, longer hospitalization (all p < .01), and higher mortality (HR = 2.26, 95% CI 2.18-2.34) than non-malnourished controls (N = 40,968). Malnourished ventilator-dependent patients (N = 1197) had higher rates of hospitalization, emergency room and outpatient visits, but shorter hospitalization (all p < .001) and lower mortality (HR = 0.85, 95% CI 0.80-0.93) than matched non-malnourished controls (N = 4788). Total medical expenditure on malnourished non-ventilator-dependent COPD patients was 75% higher than controls (p < .001), whereas malnourished ventilator-dependent patients had total costs 7% lower than controls (p < .001). Conclusions: Malnourishment among COPD patients who were not dependent on mechanical ventilation was associated with greater healthcare resource utilization and higher aggregate medical costs.
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Affiliation(s)
- Jih-Shuin Jerng
- a Department of Internal Medicine , National Taiwan University Hospital , Taipei , Taiwan
| | - Chao-Hsiun Tang
- b School of Health Care Administration, College of Management , Taipei Medical University , Taipei , Taiwan
| | | | | | - Kuan-Yu Hung
- d Department of Internal Medicine , National Taiwan University Hospital Hsin-Chu Branch , Hsinchu , Taiwan
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29
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Spruit MA, Rochester CL, Pitta F, Kenn K, Schols AMWJ, Hart N, Wouters EFM, Nava S, Dreher M, Janssen DJA, Johnson MJ, Curtis RJ, Sastry M, Franssen FME. Pulmonary rehabilitation, physical activity, respiratory failure and palliative respiratory care. Thorax 2019; 74:693-699. [PMID: 30872364 DOI: 10.1136/thoraxjnl-2018-212044] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 02/07/2019] [Accepted: 02/11/2019] [Indexed: 12/13/2022]
Abstract
The CIRO Academy in Horn (the Netherlands) organised a 2-day meeting to present and discuss the studies published in 2017 pertaining to key priority areas of respiratory and critical care medicine. This review summarises studies focussing on pulmonary rehabilitation and exercise training, physical activity, chronic respiratory failure and palliative respiratory care published in 2017.
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Affiliation(s)
- Martijn A Spruit
- REVAL - Rehabilitation Research Center, BIOMED - Biomedical Research Institute, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium .,Department of Research and Education, CIRO, Horn, The Netherlands.,Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), NUTRIMSchool of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
| | - Carolyn L Rochester
- Section of Pulmonary and Critical Care, Yale University School of Medicine, New Haven, Connecticut, USA.,VA Connecticut Healthcare System, West Haven, CT, United States
| | - Fabio Pitta
- Department of Physiotherapy, Laboratory of Research in Respiratory Physiotherapy, Londrina, Brazil
| | - Klaus Kenn
- Department of Respiratory Medicine and Pulmonary Rehabilitation, Schoen Klinik Berchtesgadener Land, Schoenau am Koenigssee, Germany.,Department of Pulmonary Rehabilitation, University of Marburg, Marburg, Germany
| | - Annemie M W J Schols
- Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), NUTRIMSchool of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
| | - Nicholas Hart
- Lane Fox Respiratory Service, Guy's & St Thomas' NHS Foundation Trust, London, UK.,Lane-Fox Clinical Respiratory Physiology Research Centre, Guy's and St Thomas' NHS Trust, St Thomas' Hospital, London, United Kingdom
| | - Emiel F M Wouters
- Department of Research and Education, CIRO, Horn, The Netherlands.,Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), NUTRIMSchool of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
| | - Stefano Nava
- Alma Mater University, Dept. of Clinical, Integrated and Experimental Medicine (DIMES), Respiratory and Critical Care Unit, S. Orsola-Malpighi Hospital Bologna, Bologna, Italy
| | - Michael Dreher
- Pneumology, Universitatsklinikum Aachen, Aachen, Germany
| | - Daisy J A Janssen
- Department of Research and Education, CIRO, Horn, The Netherlands.,Centre of Expertise for Palliative Care, MUMC+, Maastricht, The Netherlands
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, The University of Hull, Hull, UK
| | - Randall J Curtis
- Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, United States
| | | | - Frits M E Franssen
- Department of Research and Education, CIRO, Horn, The Netherlands.,Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), NUTRIMSchool of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
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30
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Nguyen HT, Collins PF, Pavey TG, Nguyen NV, Pham TD, Gallegos DL. Nutritional status, dietary intake, and health-related quality of life in outpatients with COPD. Int J Chron Obstruct Pulmon Dis 2019; 14:215-226. [PMID: 30666102 PMCID: PMC6336029 DOI: 10.2147/copd.s181322] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Malnutrition is common in patients with COPD; however, little is known about its impacts on health-related quality of life (QoL) among patients with COPD. This study aimed to explore the nutritional status and dietary intake among outpatients with COPD in Vietnam and its possible associations with QoL. Methods A cross-sectional study was carried out in COPD outpatients visiting the COPD management unit at the National Lung Hospital, Hanoi, Vietnam between May 2017 and July 2017. Consecutive outpatients with a confirmed diagnosis of COPD were recruited with written inform consent. The nutritional status of participants was assessed using Subjective Global Assessment (SGA), and dietary intake via a 24-hour recall interview. The St George Respiratory Questionnaire (SGRQ) for COPD was used to investigate the participants’ QoL. Sociodemographic and clinical data were extracted from hospital records. Results Of 168 COPD outpatients involved in the study, three-quarters (74.4%) were diagnosed as malnourished (SGA B/C) and 81.5% reported unintentional weight loss. Most of the patients did not meet their estimated energy and protein requirements (85.7% and 89.9%, respectively). Malnutrition was significantly associated with disease severity (P=0.039) and ratio of protein intake to estimated requirement (P=0.005). QoL was low for all levels of malnutrition or disease severity, with well-nourished participants and those with less disease severity having better QoL (P=0.006 and P<0.001, respectively). With an extra meal per day, the odds of having malnutrition decreased 5.6 times (P<0.05) and the total SGRQ reduced 3.61 scores (P<0.05) indicating a better QoL. Conclusion Malnutrition and weight loss are prevalent among COPD outpatients. Most of the patients had inadequate dietary intake and low QoL. Nutrition counselling including increasing the number of meals per day with a focus on energy- and protein-rich foods may help improving nutritional status and QoL of patients with COPD in Vietnam.
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Affiliation(s)
- Ha Thanh Nguyen
- School of Exercise and Nutrition Sciences, Faculty of Health Queensland University of Technology, Kelvin Grove, QLD, Australia, .,Department of Nutrition and Food Safety, Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam,
| | - Peter F Collins
- School of Exercise and Nutrition Sciences, Faculty of Health Queensland University of Technology, Kelvin Grove, QLD, Australia, .,Department of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane, Australia
| | - Toby G Pavey
- School of Exercise and Nutrition Sciences, Faculty of Health Queensland University of Technology, Kelvin Grove, QLD, Australia,
| | | | - Tuong Duy Pham
- Department of Nutrition and Food Safety, Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam,
| | - Danielle L Gallegos
- School of Exercise and Nutrition Sciences, Faculty of Health Queensland University of Technology, Kelvin Grove, QLD, Australia,
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31
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Ingadottir AR, Beck AM, Baldwin C, Weekes CE, Geirsdottir OG, Ramel A, Gislason T, Gunnarsdottir I. Oral nutrition supplements and between-meal snacks for nutrition therapy in patients with COPD identified as at nutritional risk: a randomised feasibility trial. BMJ Open Respir Res 2019; 6:e000349. [PMID: 30687503 PMCID: PMC6326325 DOI: 10.1136/bmjresp-2018-000349] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 11/07/2018] [Accepted: 11/27/2018] [Indexed: 12/24/2022] Open
Abstract
Introduction Intervention studies have mainly used oral nutritional supplements (ONS) for the management of patients with chronic obstructive pulmonary disease (COPD) identified as at nutritional risk. In this 12-month randomised feasibility trial, we assessed the (1) feasibility of the recruitment, retention and provision of two interventions: ONS and between-meal snacks (snacks) and (2) the potential impact of the provision of snacks and ONS on body weight and quality of life in patients with COPD. Methods Hospitalised patients with COPD, at nutritional risk, were randomised to ONS (n=19) or snacks (n=15) providing 600 kcal and 22 g protein a day in addition to regular daily diet. The intervention started in hospital and was continued for 12 months after discharge from the hospital. Results Study recruitment rate was n=34 (45%) and retention rate at 12 months was similar for both groups: n=13 (68%) in the ONS group and n=10 (67%) in the Snacks group. Both groups gained weight from baseline to 12 months (2.3±4.6 kg (p=0.060) in the ONS group and 4.4±6.4 kg (p=0.030) in the Snacks group). The St George’s Respiratory Questionnaire total score improved from baseline to 12 months in both groups (score 3.9±11.0 (p=0.176) in the ONS group and score 8.9±14.1 (p=0.041) in the Snacks group). Discussion In patients with COPD who are at nutritional risk snacks are at least as feasible and effective as ONS, however, adequately powered trials that take account of the difficulties in recruiting this patient group are required to confirm this effect.
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Affiliation(s)
- Arora Ros Ingadottir
- Unit for Nutrition Research, Landspitali University Hospital and Faculty of Food Science and Nutrition, University of Iceland, Reykjavik, Iceland.,Department of Clinical Nutrition, Landspitali University Hospital, Reykjavik, Iceland
| | - Anne Marie Beck
- Faculty of Health, Copenhagen University College, Copenhagen, Denmark.,Research Unit for Nutrition, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Christine Baldwin
- Department of Nutritional Sciences, King's College London, London, UK
| | | | - Olof Gudny Geirsdottir
- Unit for Nutrition Research, Landspitali University Hospital and Faculty of Food Science and Nutrition, University of Iceland, Reykjavik, Iceland.,The Icelandic Gerontological Research Institute, Landspitali University Hospital and University of Iceland, Reykjavik, Iceland
| | - Alfons Ramel
- Unit for Nutrition Research, Landspitali University Hospital and Faculty of Food Science and Nutrition, University of Iceland, Reykjavik, Iceland
| | - Thorarinn Gislason
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Sleep, Landspitali University Hospital, Reykjavik, Iceland
| | - Ingibjorg Gunnarsdottir
- Unit for Nutrition Research, Landspitali University Hospital and Faculty of Food Science and Nutrition, University of Iceland, Reykjavik, Iceland.,Department of Clinical Nutrition, Landspitali University Hospital, Reykjavik, Iceland
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32
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McDonald VM, Osadnik CR, Gibson PG. Treatable traits in acute exacerbations of chronic airway diseases. Chron Respir Dis 2019; 16:1479973119867954. [PMID: 31409129 PMCID: PMC6696844 DOI: 10.1177/1479973119867954] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 07/09/2019] [Indexed: 01/06/2023] Open
Abstract
Acute exacerbations of chronic airway disease are common occurrences that cause a major burden of illness. Acute exacerbations are associated with impaired health status, increased lung function decline, hospitalization and increased risk of death. Exacerbation avoidance is a major priority. Despite this goal, exacerbations continue to occur and the need for effective models of care that optimize patient outcomes are urgently needed. 'Treatable Traits' is an approach to personalized medicine that has been proposed for the management of airway diseases. The treatable traits approach allows for the recognition of clinically important, identifiable and treatable disease characteristics, followed by targeted and individualized treatment interventions to address each trait. We review the literature relating to treatable traits in airway diseases; in particular, those traits that can predict exacerbations and approaches to management that aim to prevent exacerbations by using a treatable traits model of care. We propose this approach as a potentially useful model of care to both prevent and manage acute exacerbations.
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Affiliation(s)
- Vanessa M McDonald
- Priority Research Centre for Healthy Lungs and Centre of Excellence
in Severe Asthma, Faculty of Health and Medicine, University of Newcastle, New South
Wales, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital,
Newcastle, Australia
| | - Christian R Osadnik
- Department of Physiotherapy, Monash University, Melbourne,
Australia
- Monash Lung and Sleep, Monash Health, Melbourne, Australia
| | - Peter G Gibson
- Priority Research Centre for Healthy Lungs and Centre of Excellence
in Severe Asthma, Faculty of Health and Medicine, University of Newcastle, New South
Wales, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital,
Newcastle, Australia
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33
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Ng WL, Collins PF, Hickling DF, Bell JJ. Evaluating the concurrent validity of body mass index (BMI) in the identification of malnutrition in older hospital inpatients. Clin Nutr 2018; 38:2417-2422. [PMID: 30501917 DOI: 10.1016/j.clnu.2018.10.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 09/28/2018] [Accepted: 10/31/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Nutrition screening and assessment tools often include body mass index (BMI) as a component in identifying malnutrition risk. However, rising obesity levels will impact on the relevancy and applicability of BMI cut-off points which may require re-evaluation. This study aimed to explore the relationship between commonly applied BMI cut-offs and diagnosed malnutrition. METHODS Data (age, gender, BMI and Subjective Global Assessment (SGA) ratings) were analysed for 1152 inpatients aged ≥65 years across annual malnutrition audits (2011-2015). The receiver operation characteristic (ROC) curve analysed the optimal BMI cut-off for malnutrition and concurrent validity of commonly applied BMI cut-offs in nutritional screening and assessment tools. RESULTS Malnutrition prevalence was 36.0% (n = 372) using SGA criteria (not malnourished, moderate or severe malnutrition). Median age was 78.7 (IQR 72-85) years, median BMI 25.4 (IQR 21.8-29.7) kg/m2; 52.1% male and 51.2% overweight/obese. ROC analysis identified an optimal BMI cut-off of <26 kg/m2, 80.8% sensitivity and 61.5% specificity (AUC 0.802, 95% CI 0.773, 0.830; p < 0.0001). Commonly applied BMI cut-offs (between 18.5 and 23 kg/m2) failed to meet the alpha-priori requirement of 80% sensitivity and 60% specificity. However, BMI <23 kg/m2 had the highest agreement (κ = 0.458) with malnutrition diagnosed using the SGA. CONCLUSIONS Both malnutrition and overweight/obesity are common in older inpatients. Continuing increases in the prevalence of overweight and obesity will impact on the sensitivity of BMI as a screening component for malnutrition risk. The current study suggests tools developed over a decade ago may need to be revisited in future.
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Affiliation(s)
- W L Ng
- Nutrition and Dietetics, School of Exercise and Nutrition Sciences, Faculty of Health, QUT, Brisbane, Queensland 4059, Australia; Department of Dietetics, Sengkang General Hospital, Singapore Health Services, Singapore 544886, Singapore
| | - P F Collins
- Nutrition and Dietetics, School of Exercise and Nutrition Sciences, Faculty of Health, QUT, Brisbane, Queensland 4059, Australia; Department of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane, Queensland 4102, Australia
| | - D F Hickling
- Nutrition and Dietetics Department, The Prince Charles Hospital, Brisbane, Chermside, Queensland 4032, Australia
| | - J J Bell
- Nutrition and Dietetics Department, The Prince Charles Hospital, Brisbane, Chermside, Queensland 4032, Australia; School of Human Movement and Nutrition Sciences, The University of Queensland, St Lucia, Queensland 4072, Australia.
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Marco E, Sánchez-Rodríguez D, Dávalos-Yerovi VN, Duran X, Pascual EM, Muniesa JM, Rodríguez DA, Aguilera-Zubizarreta A, Escalada F, Duarte E. Malnutrition according to ESPEN consensus predicts hospitalizations and long-term mortality in rehabilitation patients with stable chronic obstructive pulmonary disease. Clin Nutr 2018; 38:2180-2186. [PMID: 30342931 DOI: 10.1016/j.clnu.2018.09.014] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 08/09/2018] [Accepted: 09/13/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Nutritional disorders are frequent in patients with chronic pulmonary obstructive disease (COPD) and have negative health impacts. This study aimed to explore the value of the European Society of Clinical Nutrition and Metabolism (ESPEN) definition of malnutrition (and/or its individual components) to predict hospitalizations and mortality at 2 years, and to determine the prevalence of malnutrition in COPD patients referred to pulmonary rehabilitation. METHODS The study was a prospective analysis of 118 patients with COPD free of exacerbations and/or hospital admissions in the previous two months. Main outcome variables were mortality, hospital admissions, and length of stay at 2-year follow-up; main covariates were malnutrition assessment according to the ESPEN definition and its components: unintentional weight loss, body mass index, and fat-free mass index (FFMI). Body composition was assessed by bioimpedance analysis. Kaplan-Meier survival curves and linear regression analyses were performed, adjusting for age and airflow obstruction as potential confounders. RESULTS The observed prevalence of malnutrition was 24.6%. Malnutrition was associated with increased mortality risk (HR = 3.9 [95% CI: 1.4-10.62]). FFMI was independently associated with increased mortality (HR = 17.0 [95% CI: 2.24-129.8]), which persisted after adjustment for age and lung function (adjusted HR = 13.0 [95% CI: 1.67-101.7]). Low age-related body mass index was associated with increased risk of hospital admissions. CONCLUSIONS Malnutrition according to ESPEN criteria, highly prevalent in patients with stable COPD referred to pulmonary rehabilitation, was associated with 4 times greater mortality risk after 2 years. Low FFMI was associated with a 17-fold increase in mortality risk, suggesting independent predictive value.
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Affiliation(s)
- Ester Marco
- Physical Medicine and Rehabilitation Department, Parc Salut Mar (Hospital del Mar - Hospital de l'Esperança), Barcelona, Catalonia, Spain; Rehabilitation Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Catalonia, Spain; School of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Catalonia, Spain; School of Medicine, Universitat Internacional de Catalunya, Barcelona, Catalonia, Spain.
| | - Dolores Sánchez-Rodríguez
- Rehabilitation Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Catalonia, Spain; School of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Catalonia, Spain; Geriatrics Department, Parc de Salut Mar (Centre Fòrum - Hospital del Mar), Barcelona, Catalonia, Spain; Department of Health Sciences (CEXS), Universitat Pompeu i Fabra, Barcelona, Catalonia, Spain
| | - Vanesa N Dávalos-Yerovi
- Physical Medicine and Rehabilitation Department, Parc Salut Mar (Hospital del Mar - Hospital de l'Esperança), Barcelona, Catalonia, Spain
| | - Xavier Duran
- Methodology & Biostatistics Support Unit, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Catalonia, Spain
| | - Eva M Pascual
- Physical Medicine and Rehabilitation Department, Parc Salut Mar (Hospital del Mar - Hospital de l'Esperança), Barcelona, Catalonia, Spain
| | - Josep M Muniesa
- Physical Medicine and Rehabilitation Department, Parc Salut Mar (Hospital del Mar - Hospital de l'Esperança), Barcelona, Catalonia, Spain; Rehabilitation Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Catalonia, Spain; School of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Catalonia, Spain
| | - Diego A Rodríguez
- School of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Catalonia, Spain; Department of Health Sciences (CEXS), Universitat Pompeu i Fabra, Barcelona, Catalonia, Spain; Respiratory Medicine Department, Parc Salut Mar (Hospital del Mar - Centre Fòrum del Hospital del Mar), Barcelona, Catalonia, Spain; Muscle and Respiratory System Research Unit (URMAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Catalonia, Spain; Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Ana Aguilera-Zubizarreta
- Hospital Home-care Unit, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Ferran Escalada
- Physical Medicine and Rehabilitation Department, Parc Salut Mar (Hospital del Mar - Hospital de l'Esperança), Barcelona, Catalonia, Spain; Rehabilitation Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Catalonia, Spain; School of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Catalonia, Spain
| | - Esther Duarte
- Physical Medicine and Rehabilitation Department, Parc Salut Mar (Hospital del Mar - Hospital de l'Esperança), Barcelona, Catalonia, Spain; Rehabilitation Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Catalonia, Spain; School of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Catalonia, Spain
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Shi M, Wang J, Zhang L, Yan Y, Miao YD, Zhang X. Effects of Integrated Case Payment on Medical Expenditure and Readmission of Inpatients with Chronic Obstructive Pulmonary Disease: A Nonrandomized, Comparative Study in Xi County, China. Curr Med Sci 2018; 38:558-566. [PMID: 30074226 DOI: 10.1007/s11596-018-1914-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 11/07/2017] [Indexed: 01/05/2023]
Abstract
In the past few decades, Chinese government attempted to reduce the economic burden of chronic diseases and lower family financial risk of patients by establishing a nationwide coverage of Social Health Insurance system. However, the payment mode of Social Health Insurance varies across Chinese healthcare settings, and the effectiveness of each mode differs. This study aimed to evaluate the effects of integrated case payment on medical expenditure and readmission of inpatients with chronic obstructive pulmonary disease (COPD), a complex, multicomponent, chronic condition. A nonrandomized, comparative method was used in this study. Inpatients with COPD before (n=1569) and after the integrated case payment reform (n=4764) were selected from the inpatient information database of the New Cooperative Medical Scheme Agency of Xi County. The integrated case payment comprises the case payment (including price-cap case payment and fixed-reimbursement case payment) and clinical pathway (including clinical pathway A, clinical pathway B and clinical pathway C). Effects of integrated case payment were evaluated with indicators of per capita total medical expense and readmission within 30 days. A multivariate linear regression and a binary logistic regression were used to conduct statistical analysis. The results showed that case payment, comprising price-cap case payment β=2382.988, P<0.001) and fixed-reimbursement case payment β=2613.564, P<0.001), and clinical pathway C β=1996.467, P<0.001) were risk factors of per capita total medical expenses. Clinical pathway A β=1443.409, P<0.001) and clinical pathway B β=1583.791, P<0.001) were protective factors. The interactive effects of case payment with hospital level β=0.710, P<0.001) lowered the readmission rate within 30 days. Meanwhile, clinical pathways A β=18.949, P<0.001), B (β=19.152, PO.OOl) and C β=1.882, P<0.001) were associated with the rate increase. The findings revealed that integrated case payment ensured the quality of care for inpatients with COPD to some extent. However, this payment mode increased the per capita total medical expense. Further, policy-makers should set reasonable reimbursement standards of case payment, unify the type of case payment, and strengthen the supervision of the reform to enhance its function on medical cost control.
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Affiliation(s)
- Meng Shi
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Research Center for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan, 430030, China
| | - Jing Wang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Research Center for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan, 430030, China
| | - Liang Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Research Center for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan, 430030, China
| | - Yan Yan
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Research Center for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan, 430030, China
| | - Yu-Dong Miao
- School of Health Policy and Management, Nanjing Medical University, Nanjing, 211166, China
| | - Xiang Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China. .,Research Center for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan, 430030, China.
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36
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Collins PF, Stratton RJ, Kurukulaaratchy RJ, Elia M. Influence of deprivation on health care use, health care costs, and mortality in COPD. Int J Chron Obstruct Pulmon Dis 2018; 13:1289-1296. [PMID: 29719384 PMCID: PMC5914553 DOI: 10.2147/copd.s157594] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background and aim Deprivation is associated with the incidence of COPD, but its independent impact on clinical outcomes is still relatively unknown. This study aimed to explore the influence of deprivation on health care use, costs, and survival. Methods A total of 424 outpatients with COPD were assessed for deprivation across two hospitals. The English Index of Multiple Deprivation (IMD) was used to establish a deprivation score for each patient. The relationship between deprivation and 1-year health care use, costs, and mortality was examined, controlling for potential confounding variables (age, malnutrition risk, COPD severity, and smoking status). Results IMD was significantly and independently associated with emergency hospitalization (β-coefficient 0.022, SE 0.007; p=0.001), length of hospital stay, secondary health care costs (β-coefficient £101, SE £30; p=0.001), and mortality (HR 1.042, 95% CI 1.015–1.070; p=0.002). IMD was inversely related to participation in exercise rehabilitation (OR 0.961, 95% CI 0.930–0.994; p=0.002) and secondary care appointments. Deprivation was also significantly related to modifiable risk factors (smoking status and malnutrition risk). Conclusion Deprivation in patients with COPD is associated with increased emergency health care use, health care costs, and mortality. Tackling deprivation is complex; however, strategies targeting high-risk groups and modifiable risk factors, such as malnutrition and smoking, could reduce the clinical and economic burden.
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Affiliation(s)
- Peter F Collins
- NIHR Nutrition Biomedical Research Centre, Faculty of Medicine, University of Southampton, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK.,Nutrition and Dietetics, School of Exercise and Nutrition Sciences, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia.,Department of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Rebecca J Stratton
- NIHR Nutrition Biomedical Research Centre, Faculty of Medicine, University of Southampton, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Ramesh J Kurukulaaratchy
- NIHR Respiratory Biomedical Research Centre, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK.,Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, Hampshire, UK
| | - Marinos Elia
- NIHR Nutrition Biomedical Research Centre, Faculty of Medicine, University of Southampton, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
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37
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Association of energy and protein intakes with length of stay, readmission and mortality in hospitalised patients with chronic obstructive pulmonary disease. Br J Nutr 2018; 119:543-551. [DOI: 10.1017/s0007114517003919] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
AbstractLow energy and protein intakes have been associated with an increased risk of malnutrition in outpatients with chronic obstructive pulmonary disease (COPD). We aimed to assess the energy and protein intakes of hospitalised COPD patients according to nutritional risk status and requirements, and the relative contribution from meals, snacks, drinks and oral nutritional supplements (ONS), and to examine whether either energy or protein intake predicts outcomes. Subjects were COPD patients (n 99) admitted to Landspitali University Hospital in 1 year (March 2015–March 2016). Patients were screened for nutritional risk using a validated screening tool, and energy and protein intake for 3 d, 1–5 d after admission to the hospital, was estimated using a validated plate diagram sheet. The percentage of patients reaching energy and protein intake ≥75 % of requirements was on average 59 and 37 %, respectively. Malnourished patients consumed less at mealtimes and more from ONS than lower-risk patients, resulting in no difference in total energy and protein intakes between groups. No clear associations between energy or protein intake and outcomes were found, although the association between energy intake, as percentage of requirement, and mortality at 12 months of follow-up was of borderline significance (OR 0·12; 95 % CI 0·01, 1·15; P=0·066). Energy and protein intakes during hospitalisation in the study population failed to meet requirements. Further studies are needed on how to increase energy and protein intakes during hospitalisation and after discharge and to assess whether higher intake in relation to requirement of hospitalised COPD patients results in better outcomes.
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38
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Collins P, Elia M, Kurukulaaratchy R, Stratton R. The influence of deprivation on malnutrition risk in outpatients with chronic obstructive pulmonary disease (COPD). Clin Nutr 2018; 37:144-148. [DOI: 10.1016/j.clnu.2016.11.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Revised: 10/31/2016] [Accepted: 11/01/2016] [Indexed: 11/30/2022]
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39
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Chao CT, Tang CH, Cheng RWY, Wang MYH, Hung KY. Protein-energy wasting significantly increases healthcare utilization and costs among patients with chronic kidney disease: a propensity-score matched cohort study. Curr Med Res Opin 2017; 33:1705-1713. [PMID: 28699849 DOI: 10.1080/03007995.2017.1354823] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Disease-related malnutrition is highly prevalent, and has prognostic implications for patients with chronic kidney disease (CKD); however, few studies have investigated the impact of malnutrition, or protein-energy wasting (PEW), on healthcare utilization and medical expenditure among CKD patients. METHODS Using claim data from the National Health Insurance in Taiwan, this study identified patients with CKD between 2009-2013 and categorized them into those with mild, moderate, or severe CKD. Cases with PEW after CKD was diagnosed were propensity-score matched with controls in a 1:4 ratio. Healthcare resource utilization metrics were compared, including outpatient and emergency department visits, frequency and duration of hospitalization, and the cumulative costs associated with different CKD severity. RESULTS From among 347,501 CKD patients, eligible cohorts of 66,872 with mild CKD (49.2%), 27,122 with moderate CKD (19.9%), and 42,013 with severe CKD (30.9%) were selected. Malnourished CKD patients had significantly higher rates of hospitalization (p < .001 for all severities) and re-admission (p = .015 for mild CKD, p = .002 for severe CKD) than non-malnourished controls. Cumulative medical costs for outpatient and emergency visits, and hospitalization, were significantly higher among all malnourished CKD patients than non-malnourished ones (p < .001); total medical costs were also higher among malnourished patients with mild (62.9%), moderate (59.6%), or severe (43.6%) CKD compared to non-malnourished patients (p < .001). CONCLUSIONS In a nationally-representative cohort, CKD patients with PEW had significantly more healthcare resource utilization and higher aggregate medical costs than those without, across the spectrum of CKD: preventing PEW in CKD patients should receive high priority if we would like to reduce medical costs.
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Affiliation(s)
- Chia-Ter Chao
- a Department of Medicine , National Taiwan University Hospital Jin-Shan branch , Wuhu Village, Jinshan Dist. , New Taipei City , Taiwan
- b Department of Internal Medicine , National Taiwan University Hospital , Taipei , Taiwan
| | - Chao-Hsiun Tang
- c School of Health Care Administration, College of Management , Taipei Medical University , Taipei , Taiwan
| | | | | | - Kuan-Yu Hung
- b Department of Internal Medicine , National Taiwan University Hospital , Taipei , Taiwan
- e Department of Internal Medicine , National Taiwan University Hospital Hsin-Chu branch , Hsinchu City , Taiwan
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40
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Marques-Vidal P, Khalatbari-Soltani S, Sahli S, Coti Bertrand P, Pralong F, Waeber G. Undernutrition is associated with increased financial losses in hospitals. Clin Nutr 2017; 37:681-686. [PMID: 28258776 DOI: 10.1016/j.clnu.2017.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 01/27/2017] [Accepted: 02/12/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND & AIMS Undernutrition is associated with increased hospital costs. Whether these increased costs are totally compensated by third payer systems has not been assessed. We aimed to assess the differences between actual and reimbursed hospital costs according to presence/absence of nutritional risk, defined by a Nutritional risk screening-2002 (NRS-2002) score ≥3. METHODS Retrospective study. Administrative data for years 2013 and 2014 of the department of internal medicine of the Lausanne university hospital. The data included total and specific costs (i.e. clinical biology, treatments, pathology). Reimbursed costs were based on the Swiss Diagnosis Related Group (DRG) system. RESULTS 2200 admissions with NRS-2002 data were included (mean age 76 years, 53.9% women), 1398 (63.6%) of which were considered nutritionally 'at-risk'. After multivariate adjustment, patients nutritionally 'at-risk' had higher costs (multivariate-adjusted difference ± standard error: 34,206 ± 1246 vs. 22,214 ± 1666 CHF, p < 0.001) and higher reimbursements (26,376 ± 1105 vs. 17,783 ± 1477 CHF, p < 0.001). Still, the latter failed to cover the costs, leading to a deficit between costs and reimbursements of 7831 ± 660 CHF in patients 'at-risk' vs. 4431 ± 881 in patients 'not at-risk' (p < 0.003). Being nutritionally 'at-risk' also led to a lower likelihood of complete coverage of costs: multivariate-adjusted odds ratio and 95% confidence interval 0.77 (0.62-0.97). Patients 'at-risk' had lower percentage of total costs in medical interventions, food, imaging and "other", but the absolute differences were less than 2%. CONCLUSION Hospital costs of patients nutritionally 'at-risk' are less well reimbursed than of patients 'not at-risk'. Better reporting of undernutrition in medical records and better reimbursement of undernourished patients is needed.
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Affiliation(s)
- Pedro Marques-Vidal
- Department of Medicine, Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland.
| | - Saman Khalatbari-Soltani
- Department of Medicine, Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland; Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland.
| | - Sahbi Sahli
- Department of Medicine, Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland.
| | - Pauline Coti Bertrand
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital, Lausanne, Switzerland.
| | - François Pralong
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital, Lausanne, Switzerland.
| | - Gérard Waeber
- Department of Medicine, Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland.
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