The effect of the nutritional status and dietary inflammatory index on frailty and activities of daily living in geriatric outpatients

BACKGROUND

It has been reported that the inflammatory process plays a role in the pathophysiology of frailty in elderly individuals and that diet is effective in regulating chronic inflammation.

OBJECTIVE

This study aims to evaluate the effects of nutritional status and dietary inflammatory index on frailty and activities of daily living in the elderly.

METHOD

A cross-sectional study in a hospital in Turkey has been carried out with 187 over the age of 65 who presented to the geriatric outpatient clinic participants. Anthropometric measurements of the patients were recorded, and the dietary inflammatory index (DII) was calculated using the 24-h dietary recall method. Mini Nutritional Assessment (MNA) was used to determine the malnutrition risk, the FRAIL scale was used for frailty assessment, and Katz and Lawton & Brody scales were used for daily living activities.

RESULTS

The mean age of the elderly is 70.83 ± 4.98 years. The frailty rate was determined to be 28.3%. The DII score was determined as 4.41 ± 5.16 in frail patients and 1.62 ± 4.39 in non-frail patients (p < 0.05). While DII showed a negative correlation with the Lawton & Brody scale score (r =  - 0.353), MNA was positively correlated to the Katz score (r = 0.386, p = 0.000) and the Lawton & Brody score (r = 0.475). In addition, one-unit increase in the MNA score was associated with a 29% decrease in the risk of frailty.

CONCLUSIONS

The dietary inflammatory index was found to be high in frail and malnourished individuals. It was determined that the quality of life of individuals with malnutrition decreased.

Assessment of quadriceps muscle mass by ultrasound in the postoperative period of cardiac surgery

BACKGROUND

Patients undergoing cardiac surgery are exposed to many factors that activate catabolic and inflammatory pathways, which affect skeletal muscle and are, therefore, related to unfavorable hospital outcomes. Given the limited information on the behavior of muscle mass in critically ill patients, the objective of this study was to evaluate the impact on quantitative and qualitative measurements of quadriceps muscle mass using ultrasound after cardiac surgery. To accomplish this, a prospective, descriptive, and correlational study was conducted at a tertiary care hospital. Quadriceps muscle mass was evaluated via ultrasound in 31 adult patients in the postoperative period of cardiac surgery, with daily follow-up until postoperative day 7, as well as an assessment of associations with negative outcomes at 28 days.

RESULTS

A 16% reduction in the cross-sectional area of the rectus femoris was found (95% CI 4.2-3.5 cm2; p 0.002), as well as a 24% reduction in the pennation angle of the rectus femoris (95% CI 11.1-8.4 degrees; p: 0.025). However, changes in the thickness of the rectus femoris, vastus internus, vastus lateralis, the length of the fascicle of the vastus lateralis, the pennation angle of the vastus lateralis, the sarcopenia index, and the Hekmat score were not statistically significant. There was no significant association between quadriceps muscle mass measurements and Intensive Care Unit (ICU) length stay or 28-day mortality.

CONCLUSIONS

Patients in the postoperative period of cardiac surgery evaluated by ultrasound exhibit both quantitative and qualitative changes in quadriceps muscle mass. A significant reduction in muscle mass is observed but this is not associated with unfavorable outcomes.

Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio as Predictive Factors for Mortality and Length of Hospital Stay after Cardiac Surgery

Background: Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are widely accepted indices positively correlated with disease severity, progression, and mortality. In this study, we tested whether NLR and PLR could predict mortality and length of hospital stay (LOS) after cardiac surgery. Methods: NLR and PLR were calculated on days 0, 3, 5, and 7 postoperatively. A ROC curve was generated to assess their prognostic value; multivariate logistic analysis identified independent risk factors for 90-day mortality. Results: Analysis was performed on 179 patients’ data, 11 of whom (6.15%) died within 90 days. The discriminatory performance for predicting 90-day mortality was better for NLR7 (AUC = 0.925, 95% CI:0.865–0.984) with the optimal cut-off point being 7.10. NLR5 and PLR3 also exhibited a significant strong discriminative performance. Similarly, a significant discriminative performance was prominent for PLR3, NLR5, and NLR7 with respect to LOS. Moreover, NLR7 (OR: 2.143, 95% CI: 1.076–4.267, p = 0.030) and ICU LOS (OR:1.361, 95% CI: 1.045–1.774, p = 0.022) were significant independent risk factors for 90-day mortality. Conclusions: NLR and PLR are efficient predictive factors for 90-day mortality and LOS in cardiac surgery patients. Owing to the simplicity of determining NLR and PLR, their postoperative monitoring may offer a reliable predictor of patients’ outcomes in terms of LOS and mortality.

Heart Disease and Ageing: The Roles of Senescence, Mitochondria, and Telomerase in Cardiovascular Disease

During ageing molecular damage leads to the accumulation of several hallmarks of ageing including mitochondrial dysfunction, cellular senescence, genetic instability and chronic inflammation, which contribute to the development and progression of ageing-associated diseases including cardiovascular disease. Consequently, understanding how these hallmarks of biological ageing interact with the cardiovascular system and each other is fundamental to the pursuit of improving cardiovascular health globally. This review provides an overview of our current understanding of how candidate hallmarks contribute to cardiovascular diseases such as atherosclerosis, coronary artery disease and subsequent myocardial infarction, and age-related heart failure. Further, we consider the evidence that, even in the absence of chronological age, acute cellular stress leading to accelerated biological ageing expedites cardiovascular dysfunction and impacts on cardiovascular health. Finally, we consider the opportunities that modulating hallmarks of ageing offer for the development of novel cardiovascular therapeutics.

Endothelial Damage and Muscle Wasting in Cardiac Surgery Patients

This is a post-hoc analysis to assess the effect of anesthesia, surgical trauma, and extracorporeal circuit on endothelial integrity, microvascular permeability, and extracellular fluid balance, as well as on skeletal muscle catabolism, in patients undergoing elective cardiac surgery. We included 127 well-nourished patients undergoing “on-pump” elective cardiac surgery. One day prior to surgery (D0) and again on postoperative day 7 (POD7), body mass index, body composition assessment, hand-grip strength (HGS), and mid-upper arm muscle circumference (MAMC) were measured. Patients were assigned to early recovery (ER) and late recovery (LR) groups, depending on the duration of ICU stay (cut-off 48 hours). The magnitude of change (Δ) in all parameters studied was assessed in ER versus LR groups, regarding (i) epithelial tissue dysfunction (Δ-Extra-Cellular Water percentage (Δ-ECW%), Δ-Phase Angle (Δ-PhA)), (ii) skeletal muscle mass catabolism (Δ-Skeletal muscle mass reduction%, Δ-Hand Grip Strength (Δ-HGS) and Δ-Mid Upper-Arm Muscle Circumference (Δ-MAMC)). Baseline measurements were similar in both groups. A significant difference was observed in all Δ-parameters studied (Δ-ECW%, Δ-PhA and muscle catabolism, Δ-HGS, Δ-MAMC), the worse results being correlated to the LR group. The results raise the issue that patients with early recovery may silently have pathological conditions, continuing even on the day of discharge - further research should be planned.

Preoperative red cell distribution width to lymphocyte ratio as biomarkers for prolonged intensive care unit stay among older patients undergoing cardiac surgery: a retrospective longitudinal study

Introduction: Our aim was to use the red cell distribution width-lymphocyte ratio (RLR) as a novel biomarker to predict prolonged intensive care unit (ICU) length of stay (LOS) among older patients undergoing cardiovascular surgery. Methods: This longitudinal study included older patients admitted to a tertiary cardiovascular surgery hospital between January 2017 and January 2022. Results: A total of 574 patients were studied, including 83 patients (14.5%) who had prolonged ICU LOS and 471 (85.5%) control subjects. After adjustment for the European System for Cardiac Operative Risk Evaluation 2, the RLR score showed a 10% increased risk of prolonged ICU LOS (odds ratio: 1.10; CI: 1.05-1.16; p = 0.01). Conclusion: Preoperative RLR can be used to predict the risk of long-term intensive care stay in older cardiac surgery patients.

Anti-inflammatory effect of tranexamic acid on adult cardiac surgical patients: A PRISMA-compliant systematic review and meta-analysis

Objective

This study aims to evaluate the anti-inflammatory effect of tranexamic acid (TXA) on adult cardiac surgical patients.

Methods

PubMed, Embase, Ovid, Web of Science, CNKI, VIP, and WANFANG databases were systematically searched using the related keywords for cardiac surgical randomized controlled trials (RCTs) published from their inception to February 1, 2022. The primary outcomes were postoperative inflammatory biomarkers levels. The secondary outcomes were postoperative systemic inflammatory response syndrome and other major postoperative outcomes. The odds ratios and/or the weighted mean difference (WMD) with a 95% confidence interval (CI) were used to pool the data.

Results

Ten RCTs with 770 adult cardiac surgical patients were included. Compared with placebo, TXA achieved statistically significant inhibition of the postoperative interleukin (IL)-6 level (postoperative 6 h: n = 6 trials; WMD -31.66; 95% CI: -45.90, -17.42; p < 0.0001; I ²= 93%; postoperative 24 h: n =  8 trials; WMD, -44.06; 95% CI: -69.21, -18.91; p = 0.006; I ²= 100%); IL-8 level postoperative 24 h, TNF-α level postoperative 24 h, NE level postoperative 6 h: n = 3 trials; WMD, -36.83; 95% CI: -68.84, -4.83; p = 0.02; I ²= 95%); tissue necrosis factor alpha (TNF-α) level (postoperative 6 h: n = 3 trials; WMD, -7.21; 95% CI: -12.41, -2.01; p = 0.007; I ²= 47%; postoperative 24 h: n = 5 trials; WMD, -10.02; 95% CI: -14.93, -5.12; p < 0.0001; I ²= 94%); and neutrophil elastase (NE) level (postoperative 6 h: n = 3 trials; WMD, -66.93; 95% CI: -111.94, -21.92; p = 0.004; I ²= 86%). However, TXA achieved no statistically significant influence on the postoperative 24 h NE level.

Conclusions

TXA had a significant anti-inflammatory effect in adult cardiac surgical patients, as evidenced by the reduction of multiple postoperative proinflammatory biomarkers levels, but these results should be interpreted carefully and cautiously, as only a limited number of studies were included and there was high heterogeneity between them.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/#recordDetails, identifier: CRD42022312919.

Effects of early rehabilitation on functional outcomes in patients after coronary artery bypass graft surgery: a randomized controlled trial

Objective

This study evaluated the effectiveness, feasibility, and safety of early rehabilitation for patients after coronary artery bypass graft (CABG) surgery.

Methods

In a three-arm randomized controlled trial, patients who underwent CABG from January 2018 to June 2018 were randomly assigned to one of three groups: (i) usual care (UC group); (ii) UC + single general ward rehabilitation (SGR group); and (iii) UC + general ward rehabilitation and intensive care unit (ICU) rehabilitation (IGR group). The primary outcome was the Barthel Index scores.

Results

The Barthel Index score for UC (75.3 ± 12.1) was significantly lower than that of both SGR (86.2 ± 14.1) and IGR (89.1 ± 15.5). There was no significant difference in the Barthel Index scores between the SGR and IGR groups. Statistically significant differences were found in the length of ICU stay and post-operative hospital stay but not in post-operative pulmonary complications (PPC) or atrial fibrillation between the three groups.

Conclusion

Early rehabilitation implemented during ICU stay and on the general ward resulted in significant improvements in functional independence and could be a safe part of routine care post-CABG.

Acute changes in handgrip strength, lung function and health-related quality of life following cardiac surgery

Background

Handgrip strength (HGS), lung function and health-related quality of life (HRQoL) are relevant indicators of future cardiovascular risk and mortality. The impact of cardiac surgery on these predictive variables has been under-explored. The aim of this study was to determine the acute (within hospital) changes in HGS, lung function and HRQoL, and their relationships, in adults undergoing elective cardiac surgery. Further, the study examined the relationship between these variables and the predictors for lung function and HRQoL in these patients.

Methods

The study was a prospective cohort study that involved 101 patients who completed pre-operative (1–2 days before surgery) and physiotherapy discharge (5–7 days after surgery) assessments. Handgrip strength, lung function and HRQoL were assessed using JAMAR dynamometers, Vitalograph-Alpha or EasyOne spirometer, and Short-Form 36 questionnaire, respectively. Changes in these variables and their relationships were analysed using paired t-test and Pearson correlation coefficients, respectively. Prediction of lung function and HRQoL using HGS and other co-variates was conducted using regression analysis.

Results

At the time of physiotherapy discharge, lung function, HGS and the physical component of HRQoL were significantly (<0.001) reduced compared to their pre-operative values. Significant (<0.001) and moderate correlations were identified between HGS and lung function at pre-operation and physiotherapy discharge. Handgrip strength was a significant predictor of lung function pre-operatively but not at physiotherapy discharge. Pre-operative lung function and HRQoL, as well as other variables, were significant predictors of lung function and HRQoL during physiotherapy discharge.

Conclusions

Undergoing cardiac surgery acutely and significantly reduced lung function, HGS and physical component of HRQoL in adults with cardiac disease. Assessment of HGS at physiotherapy discharge may be a poor indicator of operative changes in lung function and HRQoL. Clinicians may consider HGS as an inadequate tool in predicting lung function and HRQoL following cardiac surgery.

Restoration of Continence after Prostatectomy is Associated With Weight Loss: A Pilot Study

OBJECTIVES

To examine association between post-prostatectomy incontinence (PPI) severity and weight changes before and after restoration of continence via artificial urinary sphincter (AUS).

METHODS

Single surgeon, retrospective review of urologic prosthetic surgery (UPS) after radical prostatectomy (RP). A cohort of post-RP inflatable penile prosthesis (IPP) patients served as a surgical control. Body Mass Index (BMI) and total body weight were assessed pre and post-UPS. Multivariable linear regression was utilized to assess BMI changes post-UPS.

RESULTS

187 AUS and 63 IPP patients met selection criteria. Greater PPI severity was associated with faster BMI gain after RP (coeff. 0.14 kg/m2, P = 0.03, per pad used) and magnitude of incontinence improvement (mean reduction in daily pad use) after AUS insertion was associated with greater BMI reduction at 12 months post-UPS (coeff. - 0.13 kg/m2, P = 0.04). On multivariable regression, AUS insertion was associated with a decrease in BMI by - 2.83 kg/m2 12 months post-UPS (P = 0.02). Twelve months post-UPS, men with AUS exhibited a mean BMI reduction of -1.0 kg/m² compared to a mean BMI increase in the IPP cohort of 0.4 kg/m² (P < 0.01). Compared to IPP, AUS patients experienced absolute body weight reduction by 6 kg [Median(IQR): 90.4 (80.3-100.1) vs 96.4 (87.1-108.8) kg, P = 0.03], with nearly one-third having clinically significant weight loss (>5% body weight) at 12 months post-UPS (31.8% vs 8.3%, P < 0.01).

CONCLUSION

Severe PPI appears to be associated with weight gain and correction of PPI via AUS insertion with weight loss.

Tranexamic acid attenuates early post-operative systemic inflammatory response and nutritional loss and avoids reduction of fibrinogen in total hip arthroplasty within an enhanced recovery after surgery pathway

PURPOSE

Total hip arthroplasty (THA) is an intervention with significant inflammatory response. The impact of additional doses of tranexamic acid (TXA) on inflammatory response, trauma and nutrition parameters, and coagulation and fibrinolysis changes has rarely been reported.

METHODS

A prospective double-blind randomized trial was performed on elective primary THA. Ninety-nine adult patients were recruited consecutively from 2019 to 2020. They were randomized to receive single-dose of TXA before incision, another dose of TXA at three hours post-operatively, or another two doses of TXA at three and six hours  post-operatively. The primary outcomes included changes in white blood cell (WBC) counts, creatine kinase (CK), haemoglobin(Hb), and albumin(Alb); the secondary outcomes included coagulation and fibrinolysis parameters.

RESULTS

Compared with single-dose TXA, patients received three dose TXA had significantly reduced WBC counts and fibrinogen/fibrin degradation product (FDP) levels, increased albumin and fibrinogen levels, and prolonged PT on post-operative day (POD) three. Though patients received three dose TXA had a tendency that increased Hb, decreased CK, reduced D-D, and prolonged APTT on POD3, it is not statistically significant. And the other measured outcomes on POD1 and POD2W shared a similar statistical result, except PT. The PT is significantly prolonged on POD2W in three dose group compared with single dose.

CONCLUSION

Three-dose TXA contribute to attenuate early post-operative systemic inflammatory response and nutritional loss, increase fibrinogen, reduce FDP levels, and prolong PT in THA patients within an ERAS pathway, which may associate with reduced early post-operative haemorrhagic tendency, thrombosis risks, and hypercoagulability.

The Association between Cytokines and 365-Day Readmission or Mortality in Adult Cardiac Surgery

Cardiac surgery results in a multifactorial systemic inflammatory response with inflammatory cytokines, such as interleukin-10 and 6 (IL-10 and IL-6), shown to have potential in the prediction of adverse outcomes including readmission or mortality. This study sought to measure the association between IL-6 and IL-10 levels and 1-year hospital readmission or mortality following cardiac surgery. Plasma biomarkers IL-6 and IL-10 were measured in 1,047 patients discharged alive after isolated coronary artery bypass graft surgery from eight medical centers participating in the Northern New England Cardiovascular Disease Study Group between 2004 and 2007. Readmission status and mortality were ascertained using Medicare, state all-payer claims, and the National Death Index. We evaluated the association between preoperative and postoperative cytokines and 1-year readmission or mortality using Kaplan-Meier estimates and Cox's proportional hazards modeling, adjusting for covariates used in the Society of Thoracic Surgeons 30-day readmission model. The median follow-up time was 1 year. After adjustment, patients in the highest tertile of postoperative IL-6 values had a significantly increased risk of readmission or death within 1 year (HR: 1.38; 95% CI: 1.03-1.85), and an increased risk of death within 1 year of discharge (HR: 4.88; 95% CI: 1.26-18.85) compared with patients in the lowest tertile. However, postoperative IL-10 levels, although increasing through tertiles, were not found to be significantly associated independently with 1-year readmission or mortality (HR: 1.25; 95% CI: .93-1.69). Pro-inflammatory cytokine IL-6 and anti-inflammatory cytokine IL-10 may be postoperative markers of cardiac injury, and IL-6, specifically, shows promise in predicting readmission and mortality following cardiac surgery.

Perioperative poor grip strength recovery is associated with 30-day complication rate after cardiac surgery discharge in middle-aged and older adults - a prospective observational study

BACKGROUND

Although perioperative care during heart surgery has improved considerably, the rate of postoperative complications has remained stable. It has not been concluded how to better apply grip strength to clinical, postoperative complications. So our study aimed at researching the best way for using grip value for predicting early postoperative complications.

METHODS

A total of 212 patients with mean age 63.8 ± 6.3 who underwent cardiac surgery participated in our study. We analyzed the ROC curve of grip strength, grip/weight and grip recovery with complications, found the best cutoff point. Logistic regression confirmed the association between grip strength grouping and complications.

RESULTS

We found that 36 patients had 30-day complications. EuroSCORE were 2.15 ± 1.52 and 2.42 ± 1.58 between normal and complication groups, respectively. The area under the receiver-operating characteristic curve (AUC) of grip recovery take the most area (0.837, p < 0.001), and the cutoff point was 83.92%. In logistic regression, lower grip recovery has higher risk impact on 30-day complications for 25.68 times than normal group, after adjusted surgery-related factors. After regrouped characteristic information by grip recovery cutoff point, we found that percentage of the estimated 6 min walk distance (41.5 vs 48.3, p = 0.028) and hospitalization time (7.2 vs 6.1, p = 0.042) had worse trends in lower recovery group.

CONCLUSIONS

Poor grip recovery may be related to higher risk of postoperative complications within 30 days after discharge in middle-aged and older people independent of surgical risk. The results of this study provide a reference for the development of rehabilitation programs in the early postoperative recovery, and may also be a prognostic indicator for postoperative high-risk groups.

TRIAL REGISTRATION

Our research was registered on Research Registry website, the registry number was ChiCTR1800018465. Date: 2018/9/20. Status: Successful.

Food and heart-the nutritional jungle: Patients' experiences of dietary habits and nutritional counselling after coronary artery bypass grafting

AIMS AND OBJECTIVES

The aim of the study was to examine patients' experience of dietary habits and nutritional counselling in the early period during hospitalisation after coronary artery bypass surgery (CABG).

BACKGROUND

Undergoing CABG, patients have two different nutritional needs, extra proteins and calories for the first period after surgery and a heart-healthy diet when the recovery period is over. These needs can be difficult to manage for the patients.

DESIGN

Qualitative study.

METHODS

Interviews were conducted and analysed within a phenomenological-hermeneutic frame inspired by the French philosopher Paul Ricoeur. Patients undergoing CABG were interviewed 4-5 days after surgery at Odense University Hospital from March to May, 2017. The study adhered to the COREQ guidelines.

RESULTS

In total, 15 patients were interviewed (mean age 65 years, 87% men). After analysing the interviews following themes emerged, "Different needs-the nutritional jungle", "Food and heart-the lacking attention," and "The force of habits-being under the influence from spouses on dietary habits".

CONCLUSION

The interviewed patients had no or only a little knowledge about how to eat after heart surgery. In general, they experienced a lack of attention to nutritional counselling by the nursing staff during hospitalisation. Furthermore, the health behaviour of men seems to be different from women's, and therefore, interventions aiming at optimising men's health might be prioritised. Finally, spouses have a great influence on eating habits, why they should be involved in nutritional counselling.

RELEVANCE TO CLINICAL PRACTICE

This study provides important and relevant knowledge about patients' lacking knowledge about nutrition. When planning nutritional measures, whether it is promoting healing after heart surgery or preventing progression of arteriosclerosis, the study contributes with suggestions as to which factors should be considered in this process-men's health behaviour and spouses' influence on dietary habits in the household.

Current Evidence about Nutrition Support in Cardiac Surgery Patients-What Do We Know?

Nutrition support is increasingly recognized as a clinically relevant aspect of the intensive care treatment of cardiac surgery patients. However, evidence from adequate large-scale studies evaluating its clinical significance for patients&rsquo; mid- to long-term outcome remains sparse. Considering nutrition support as a key component in the perioperative treatment of these critically ill patients led us to review and discuss our understanding of the metabolic response to the inflammatory burst induced by cardiac surgery. In addition, we discuss how to identify patients who may benefit from nutrition therapy, when to start nutritional interventions, present evidence about the use of enteral and parenteral nutrition and the potential role of pharmaconutrition in cardiac surgery patients. Although the clinical setting of cardiac surgery provides advantages due to its scheduled insult and predictable inflammatory response, researchers and clinicians face lack of evidence and several limitations in the clinical routine, which are critically considered and discussed in this paper.

Mini-Nutritional Assessment Short-Form as a useful method of predicting poor 1-year outcome in elderly patients undergoing orthopedic surgery

AIM

The present study aimed to determine whether the Mini-Nutritional Assessment Short-Form (MNA-SF) can predict the 1-year outcome of orthopedic fracture surgery in elderly patients.

METHODS

This 1-year prospective study assessed nutrition using the MNA-SF at baseline, and postoperatively at 6 and 12 months. Repeated measures analysis of covariance was used to examine functional change over time for two MNA-SF categories. Multivariable logistic regression analysis with forward stepwise modeling was carried out to identify risk factors of functional decline, emergency department visit, hospital readmission and mortality at follow up.

RESULTS

There were 312 participants, 11 of whom died (3.53%) during 1-year follow up. The mean age was 74.04 ± 7.65 years. A total of 88.1% and 11.9% of the participants were well nourished (MNA-SF 12-14 points) or at risk of undernutrition (0-11 points), respectively. For MNA-SF as a continuous variable, lower MNA-SF scores were associated with a significantly higher risk of emergency department visit at 6-month follow up, and mortality at 12-month follow up (emergency room visit, adjusted odds ratio 0.78, 95% CI 0.63-0.96, P < 0.05; mortality, adjusted odds ratio 0.73, 95% CI 0.57-0.94, P < 0.05). No association was found between functional decline and hospital readmission, and MNA-SF scores. For MNA-SF categories, functional decline was more profound in patients at risk of undernutrition than in well-nourished patients, especially 6-12 months postoperatively.

CONCLUSIONS

The MNA-SF could be an effective and non-invasive preoperative screening tool to predict functional decline, emergency department visit and mortality during the year after surgery. Geriatr Gerontol Int 2017; 17: 2361-2368.

Prioritizing Functional Capacity as a Principal End Point for Therapies Oriented to Older Adults With Cardiovascular Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association

Adults are living longer, and cardiovascular disease is endemic in the growing population of older adults who are surviving into old age. Functional capacity is a key metric in this population, both for the perspective it provides on aggregate health and as a vital goal of care. Whereas cardiorespiratory function has long been applied by cardiologists as a measure of function that depended primarily on cardiac physiology, multiple other factors also contribute, usually with increasing bearing as age advances. Comorbidity, inflammation, mitochondrial metabolism, cognition, balance, and sleep are among the constellation of factors that bear on cardiorespiratory function and that become intricately entwined with cardiovascular health in old age. This statement reviews the essential physiology underlying functional capacity on systemic, organ, and cellular levels, as well as critical clinical skills to measure multiple realms of function (eg, aerobic, strength, balance, and even cognition) that are particularly relevant for older patients. Clinical therapeutic perspectives and patient perspectives are enumerated to clarify challenges and opportunities across the caregiving spectrum, including patients who are hospitalized, those managed in routine office settings, and those in skilled nursing facilities. Overall, this scientific statement provides practical recommendations and vital conceptual insights.

Poor preoperative nutritional status is an important predictor of the retardation of rehabilitation after cardiac surgery in elderly cardiac patients

BACKGROUND

Preoperative nutritional status and physical function are important predictors of mortality and morbidity after cardiac surgery. However, the influence of nutritional status before cardiac surgery on physical function and the progress of postoperative rehabilitation requires clarification.

AIMS

To determine the effect of preoperative nutritional status on preoperative physical function and progress of rehabilitation after elective cardiac surgery.

METHODS

We enrolled 131 elderly patients with mean age of 73.7 ± 5.8 years undergoing cardiac surgery. We divided them into two groups by nutritional status as measured by the Geriatric Nutritional Risk Index (GNRI): high GNRI group (GNRI ≥ 92, n = 106) and low GNRI group (GNRI < 92, n = 25). Physical function was estimated by handgrip strength, knee extensor muscle strength (KEMS), the Short Physical Performance Battery (SPPB), and 6-minute walk test (6MWT). Progress of postoperative rehabilitation was evaluated by the number of days to independent walking after surgery, length of stay in the ICU, and length of hospital stay.

RESULTS

After adjusting for potential confounding factors, preoperative handgrip strength (P = 0.034), KEMS (P = 0.009), SPPB (P < 0.0001), and 6MWT (P = 0.012) were all significantly better in the high GNRI group. Multiple regression analysis revealed that a low GNRI was an independent predictor of the retardation of postoperative rehabilitation.

CONCLUSIONS

Preoperative nutritional status as assessed by the GNRI could reflect perioperative physical function. Preoperative poor nutritional status may be an independent predictor of the retardation of postoperative rehabilitation in patients undergoing elective cardiac surgery.

Perioperative strokes after coronary artery bypass grafting with staged carotid endarterectomy: A nationwide perspective

STUDY OBJECTIVE

To examine the risk of perioperative stroke on in-hospital morbidity and mortality in staged coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA) procedures.

DESIGN

The National Inpatient Sample (NIS) database was used to extract data on all patients who underwent staged CABG CEA procedures. They were identified using the ICD-9 (International Classification of Diseases, Ninth Revision-Clinical Modification) diagnosis and procedure codes.

SETTING

Multi-institutional.

PATIENTS

Patients who underwent staged CABG and CEA from 1999 to 2011.

INTERVENTIONS

Staged CABG and CEA procedures.

MEASUREMENTS

Various pre-operative, and perioperative risk factors and their association with in-hospital mortality and morbidity were studied.

MAIN RESULTS

The study cohort was grouped into 2761 patients who underwent staged CEA and CABG. The average age of the patient population was 69years. An in-hospital mortality of 4.96% (137) was observed. Staged procedures showed a morbidity rate of 69.21%. Patients with perioperative strokes had a mortality rate of 16.73% following staged procedures. Other notable risk factors for mortality and morbidity were post-operative myocardial infarction (MI) and congestive heart failure (CHF).

CONCLUSION

Analysis of 2761 patients over a period of 12years (1999-2011) indicate perioperative stroke to be a strong post-operative predicator of in-hospital mortality and morbidity for staged procedures. Other significant factors such as advancing age, female gender and comorbidities like CHF, left ventricular dysfunction (LVD) and post-operative MI should also be considered when determining patient risk. Further investigative studies on staged CABG and CEA procedures are needed for better patient selection and for implementing preventative strategies such as neuroprotective medication and neuromonitoring to minimize the risk of ischemic strokes.

Development of an Integrated Theory of Surgical Recovery in Older Adults

Experts argue the health care system is not prepared to meet the unique needs of older surgical patients, including how to provide the best care during the recovery phase. Nutrition plays a critical role in the recovery of surgical patients. Since older adults are at risk for malnutrition, examining the role of nutrition as a mediator for surgical recovery across the care continuum in older adults is critical. Presently there is a paucity of frameworks, models, and guidelines that integrate the role of nutrition on the trajectory of postoperative recovery in older surgical patients. The purpose of this article is to introduce the Integrated Theory of Surgical Recovery in Older Adults, an interdisciplinary middle-range theory, so that scholars, researchers, and clinicians can use this framework to promote recovery from surgery in older adults by considering the contribution of mediators of recovery (nutritional status, functional status, and frailty) unique to the older adults.