Unresolved inflammation during hospitalization is associated with post-discharge institutionalization and mortality in geriatric rehabilitation inpatients: The RESORT cohort

Criterion validity of the Global Leadership Initiative on Malnutrition criteria for malnutrition diagnosis compared with the Subjective Global Assessment: Results from a large observational study

AIM

The aim of this study was to assess the criterion validity of the Global Leadership Initiative on Malnutrition criteria compared to the subjective global assessment in a diverse inpatient population.

METHODS

This cross-sectional study was a retrospective analysis of point prevalence audit data. The prevalence of malnutrition determined by the Global Leadership Initiative on Malnutrition criteria was compared to the Subjective Global Assessment. Validity statistics were determined using all of the Global Leadership Initiative on Malnutrition criteria concurrently as well as each pair that could be used to diagnose malnutrition. Subgroup analysis was undertaken based on severe malnutrition, treatment group, age and body mass index.

RESULTS

Nine hundred and eighty-one patients were included (65.1 ± 18.6 years, 54.8% male). The prevalence of malnutrition was 36.7% using the Subjective Global Assessment and 36.1% using the Global Leadership Initiative on Malnutrition criteria. More patients were classified as severely malnourished using the Global Leadership Initiative on Malnutrition criteria (9.8% vs. 6.0%), whilst more rehabilitation patients were classified as malnourished using the Subjective Global Assessment (42.2% vs. 33.6%). The criterion validity of the Global Leadership Initiative on Malnutrition criteria was good, with a sensitivity of 92.5% (95% CI 90.9-94.2) and specificity of 96.6% (95% CI 95.5-97.8). There was a downward trend in sensitivity with increasing body mass index and a lower sensitivity in the rehabilitation population. The criterion validity was fair at best when each pair of the Global Leadership Initiative on Malnutrition criteria was considered independently of other criteria.

CONCLUSIONS

When all criteria are considered concurrently, the Global Leadership Initiative on Malnutrition criteria present good criterion validity and can be applied in clinical practice to diagnose malnutrition.

Inflammatory subphenotypes previously identified in ARDS are associated with mortality at intensive care unit discharge: a secondary analysis of a prospective observational study

BACKGROUND

Intensive care unit (ICU)-survivors have an increased risk of mortality after discharge compared to the general population. On ICU admission subphenotypes based on the plasma biomarker levels of interleukin-8, protein C and bicarbonate have been identified in patients admitted with acute respiratory distress syndrome (ARDS) that are prognostic of outcome and predictive of treatment response. We hypothesized that if these inflammatory subphenotypes previously identified among ARDS patients are assigned at ICU discharge in a more general critically ill population, they are associated with short- and long-term outcome.

METHODS

A secondary analysis of a prospective observational cohort study conducted in two Dutch ICUs between 2011 and 2014 was performed. All patients discharged alive from the ICU were at ICU discharge adjudicated to the previously identified inflammatory subphenotypes applying a validated parsimonious model using variables measured median 10.6 h [IQR, 8.0-31.4] prior to ICU discharge. Subphenotype distribution at ICU discharge, clinical characteristics and outcomes were analyzed. As a sensitivity analysis, a latent class analysis (LCA) was executed for subphenotype identification based on plasma protein biomarkers at ICU discharge reflective of coagulation activation, endothelial cell activation and inflammation. Concordance between the subphenotyping strategies was studied.

RESULTS

Of the 8332 patients included in the original cohort, 1483 ICU-survivors had plasma biomarkers available and could be assigned to the inflammatory subphenotypes. At ICU discharge 6% (n = 86) was assigned to the hyperinflammatory and 94% (n = 1397) to the hypoinflammatory subphenotype. Patients assigned to the hyperinflammatory subphenotype were discharged with signs of more severe organ dysfunction (SOFA scores 7 [IQR 5-9] vs. 4 [IQR 2-6], p < 0.001). Mortality was higher in patients assigned to the hyperinflammatory subphenotype (30-day mortality 21% vs. 11%, p = 0.005; one-year mortality 48% vs. 28%, p < 0.001). LCA deemed 2 subphenotypes most suitable. ICU-survivors from class 1 had significantly higher mortality compared to class 2. Patients belonging to the hyperinflammatory subphenotype were mainly in class 1.

CONCLUSIONS

Patients assigned to the hyperinflammatory subphenotype at ICU discharge showed significantly stronger anomalies in coagulation activation, endothelial cell activation and inflammation pathways implicated in the pathogenesis of critical disease and increased mortality until one-year follow up.

Associations of 25-Hydroxyvitamin D Status and Supplementation with Adverse Outcomes in Geriatric Rehabilitation Inpatients: RESORT

OBJECTIVES

Geriatric rehabilitation inpatients are at a higher risk of 25-hydroxyvitamin D (25(OH)D) deficiency due to poor nutrition and low sunlight exposure. This study aimed to evaluate the prevalence of 25-hydroxyvitamin (25(OH)D) deficiency and supplementation and to investigate their association with adverse health outcomes in geriatric rehabilitation inpatients.

DESIGN

Prospective, observational and longitudinal study.

SETTING AND PARTICIPANTS

Geriatric rehabilitation inpatients admitted to geriatric rehabilitation wards at the Royal Melbourne Hospital (Melbourne, Australia) from 16th, October 2017 and discharged until 18th, March 2020 in the REStORing health of acutely unwell adulTs (RESORT) study were included.

METHODS

25(OH)D levels measured close to rehabilitation admission were classified as sufficiency (>54 nmol/L), insufficiency (26-54 nmol/L), or deficiency (<26 nmol/L). The usage of vitamin D supplementation was extracted from medication records. Outcomes included incidence of institutionalization at three-month post-discharge, in-hospital mortality and post-discharge mortality.

RESULTS

The median age of 1328 geriatric rehabilitation inpatients was 83.9 years (IQR: 78.1-88.7, 58.6% female). 25(OH)D deficiency and insufficiency were present in 8.1% and 26.4% of inpatients, respectively; 74.2% used vitamin D supplementation. 25(OH)D deficiency was associated with higher odds of institutionalization (odds ratio (OR): 1.88, 95% confidence interval (CI): 1.14-3.11), in-hospital mortality (OR: 3.30, 95% CI: 1.54-7.07) and higher risks of one-year mortality (hazard ratio (HR): 1.77, 95% CI: 1.17-2.69) compared to 25(OH)D sufficiency but not with three-month mortality. 25(OH)D insufficiency was not associated with outcomes. Patients who did not use supplementation and had 25(OH)D insufficiency or deficiency had significantly higher in-hospital mortality compared to those who used supplementation.

CONCLUSIONS

Among geriatric rehabilitation inpatients, 25(OH)D deficiency was associated with institutionalization, in-hospital mortality and one-year mortality. Attention to monitor the vitamin D status is of upmost importance during hospitalization.

Albumin and C-reactive protein relate to functional and body composition parameters in patients admitted to geriatric rehabilitation after acute hospitalization: findings from the RESORT cohort

PURPOSE

Albumin and C-reactive protein (CRP) are non-specific markers of inflammation, which could affect muscle tissue during acute hospitalization. We investigated the association between albumin and CRP during acute hospitalization with functional and body composition parameters in patients admitted to geriatric rehabilitation.

METHODS

The REStORing Health of Acutely Unwell AdulTs (RESORT) cohort includes geriatric rehabilitation patients assessed for change in activities of daily living (ADL, using the Katz index) during acute hospitalization, and subsequently for Katz ADL, gait speed (GS), handgrip strength (HGS) and skeletal muscle mass index (SMI) at geriatric rehabilitation admission. Albumin and CRP average (median), variation (interquartile range), and maximum or minimum were collected from serum samples, and were examined for their association with functional and body composition parameters using multivariable linear regression analysis adjusted for age, sex and length of acute hospital stay.

RESULTS

1769 Inpatients were included for analyses (mean age 82.6 years ± 8.1, 56% female). Median length of acute hospitalization was 7 [IQR 4, 13] days and median number of albumin and CRP measurements was 5 [IQR 3, 12] times. ADL declined in 89% of patients (median - 3 points, IQR - 4, - 2). Lower average albumin, higher albumin variation and lower minimum albumin were associated with larger declines in ADL and with lower ADL, GS, HGS and SMI at geriatric rehabilitation admission. Higher average and maximum CRP were associated with lower GS.

CONCLUSION

Inflammation, especially lower albumin concentrations, during acute hospitalization is associated with lower physical function at geriatric rehabilitation admission.