Preoperative muscle weakness as defined by handgrip strength and postoperative outcomes: a systematic review

Sarcopenia and Frailty in Patients Undergoing Transcatheter Aortic Valve Replacement

BACKGROUND

Skeletal muscle mass (SMM) plays a crucial role in risk assessment in transcatheter aortic valve replacement (TAVR) candidates, yet it remains underutilized. Traditional methods focus on weakness or performance but omit SMM. This study compared traditional and novel markers of sarcopenia and frailty in terms of their ability to predict adverse outcomes post-TAVR.

METHODS

Three risk models were evaluated for the composite outcome of perioperative complications, 1-year rehospitalization, or 1-year mortality: (1) sarcopenia by combining low muscle mass (LMM) and weakness/performance assessed by hand grip strength or gait speed; (2) frailty by an Adapted Green score; and (3) frailty by the Green-SMI score incorporating LMM by multi-level opportunistic pre-TAVR thoracic CT segmentation.

RESULTS

In this study we included 184 eligible patients from January to December of 2018, (96.7%) of which were balloon expandable valves. The three risk models identified 22.8% patients as sarcopenic, 63.6% as frail by the Adapted Green score, and 53.8% as frail by the Green-SMI score. There were higher rates of the composite outcome in patients with sarcopenia (54.8%) and frailty (41.9% with the Adapted Green and 50.5% with the Green-SMI score) compared to their non-sarcopenic (30.3%) and non-frail counterparts (25.4% with the Adapted Green and 18.8% with the Green-SMI score). Sarcopenia and frailty by Green-SMI, but not by the Adapted Green, were associated with higher risks of the composite outcome on multivariable adjustment (HR 2.2 [95% CI: 1.25-4.02], p=0.007 and HR 3.4 [95% CI: 1.75-6.65], p<0.001, respectively).

CONCLUSIONS

The integration of pre-operative CT-based SMM to a frailty score significantly improves the prediction of adverse outcomes in patients undergoing TAVR.

Comparison of Various Functional Assessment Tools to Identify Older Patients Undergoing Aortic Aneurysm Repair at Risk for Postoperative Complications

BACKGROUND

To estimate whether the benefits of aortic aneurysm repair will outweigh the risks, determining individual risks is essential. This single-center prospective cohort study aimed to compare the association of functional tools with postoperative complications in older patients undergoing aortic aneurysm repair.

METHODS

Ninety-eight patients (≥65 years) who underwent aortic aneurysm repair were included. Four functional tools were administered: the Montreal Cognitive Assessment (MoCA); the 4-Meter Walk Test (4-MWT); handgrip strength; and the Groningen Frailty Indicator (GFI). Primary outcome was the association between all tests and 30-day postoperative complications.

RESULTS

After adjusting for confounders, the odds ratio for MoCA was 1.39 (95% confidence interval [CI] 0.450; 3.157; P = 0.723), for 4-MWT 0.63 (95% CI 0.242; 1.650; P = 0.348), for GFI 1.82 (95% CI 0.783; 4.323, P = 0.162), and for weak handgrip strength 4.78 (95% CI 1.338; 17.096, P = 0.016).

CONCLUSIONS

Weak handgrip strength is significantly associated with the development of postoperative complications after aortic aneurysm repair. This study strengthens the idea that implementing a quick screening tool for risk assessment at the outpatient clinic, such as handgrip strength, identifies patients who may benefit from preoperative enhancement with help from, for example, Comprehensive Geriatric Assessment, eventually leading to better outcomes for this patient group.

Factors associated with postsurgical muscle weakness in patients who undergo thoracic aortic surgery: a retrospective cohort study

OBJECTIVE

Aortic surgery is often performed in elderly patients, and these patients have a high risk of postsurgical muscle weakness. To reinforce purposeful postsurgical rehabilitation, we aimed to investigate the factors associated with postsurgical muscle weakness in patients who underwent thoracic aortic surgery.

METHODS

This retrospective cohort study analyzed data of consecutive patients who underwent elective thoracic aortic surgery with cardiopulmonary bypass, and whose knee extensor isometric muscle strength (KEIS) were measured pre- and postoperatively at University Hospital between January 2012 and December 2018. The primary outcome was percent change in KEIS (% change in KEIS). Multivariate linear regression analysis was used to identify independent risk factors for % change in KEIS.

RESULTS

Overall, 218 patients were included. Multivariate linear regression analysis showed that mechanical ventilation time, days from initial sitting to 100 m walking, and the number of exercises in the rehabilitation room were associated with % change in KEIS.

CONCLUSIONS

This study may serve as a reference to stratify patients at risk of postsurgical muscle weakness. The preventive or alternative interventions in patients undergoing thoracic aortic surgery will be assessed in future studies.

Comparison of two handgrip dynamometers in older adults before elective surgery

BACKGROUND

Handgrip strength is a useful measurement of muscle strength and has been proposed as a single predictor of postoperative outcomes in older adults. The aim of this study was to assess the correlation and concordance of Camry digital hand grip dynamometer (EH101) with gold standard Jamar® hydraulic handgrip dynamometer in older adults previous to elective surgery.

METHODS

A cross-sectional study was conducted on patients ≥ 65 years old admitted to a Chilean private hospital for elective surgery between March 2018 and February 2019. Handgrip strength was assessed 2 times with each hand prior to surgery, using both the Jamar® dynamometer and the Camry digital dynamometer. The highest value of each dynamometer was used for analysis.

RESULTS

We included a total of 220 patients (mean age 73.1 years old ± 6.3). Maximal handgrip strength averaged 26.9 kg ± 9.6 with the Camry dynamometer and 26.9 kg ± 9.7 with the Jamar® dynamometer in the right hand and 25.5 kg ± 9.5 with the Camry dynamometer and 25.7 kg ± 9.2 with the Jamar® dynamometer with the left hand. The difference between both measures did not differ significantly from 0, with Pearson correlation index of 0.95 and Lin's concordance index of 0.95 (p < 0001). The Bland-Altman graphics show that 90% of the measures were inside the confidence limits, without systematic bias.

CONCLUSION

Camry digital dynamometer is an inexpensive and valid device to measure handgrip strength in older adults previous to elective surgery, compared to the gold standard Jamar® hydraulic handgrip dynamometer.

Musculoskeletal health state and physical function of intensive care unit survivors: protocol for a UK multicentre prospective cohort study (the MSK-ICU study)

INTRODUCTION

Survivors of critical illness frequently experience long-term physical impairment, decreased health-related quality of life and low rates of return to employment. There has been limited investigation of the underlying problems affecting physical function post-intensive care unit (ICU) admission. Musculoskeletal (MSK) conditions may be complex in presentation, with ICU survivors potentially at greater risk of their development due to the rapid muscle mass loss seen in ICU. The MSK health state of ICU survivors and its impact on physical function remain largely unknown. The aim of the MSK-ICU study is to determine and characterise the MSK health state of ICU survivors 6 months following admission to ICU, in order to inform development of targeted rehabilitation interventions.

METHODS AND ANALYSIS

The MSK-ICU study is a multicentre prospective longitudinal cohort study, evaluating the MSK health state of ICU survivors 6 months after admission to ICU. The study consists of a primary study and two substudies. The primary study will be a telephone follow-up of adults admitted to ICU for more than 48 hours, collecting data on MSK health state, quality of life, employment, anxiety and depression and symptoms of post-traumatic stress disorder. The planned sample size is 334 participants. Multivariable regression will be used to identify prognostic factors for a worse MSK health state, as measured by the MSK-Health Questionnaire. In substudy 1, participants who self-report any MSK problem will undergo a detailed, in-person MSK physical assessment of pain, peripheral joint range of movement and strength. In substudy 2, participants reporting a severe MSK problem will undergo a detailed physical assessment of mobility, function and muscle architecture.

ETHICS AND DISSEMINATION

Ethical approval has been obtained through the North of Scotland Research Ethics Committee 2 (21/NS/0143). We aim to disseminate the findings through international conferences, international peer-reviewed journals and social media.

TRIAL REGISTRATION NUMBER

ISRCTN24998809.

Mitochondrial function, grip strength, and activity are related to recovery of mobility after a total knee arthroplasty

Low muscle quality and a sedentary lifestyle are indicators for a slow recovery after a total knee arthroplasty (TKA). Mitochondrial function is an important part of muscle quality and a key driver of sarcopenia. However, it is not known whether it relates to recovery. In this pilot study, we monitored activity after TKA using a wrist mounted activity tracker and assessed the relation of mitochondrial function on the rate of recovery after TKA. Additionally, we compared the increase in activity as a way to measure recovery to traditional outcome measures. Patients were studied 2 weeks before TKA and up to 6 months after. Activity was monitored continuously. Baseline mitochondrial function (citrate synthase and complex [CP] 1-5 abundance of the electron transport chain) was determined on muscle tissue taken during TKA. Traditional outcome measures (Knee Injury and Osteoarthritis Outcome Score [KOOS], timed up-and-go [TUG] completion time, grip, and quadriceps strength) were performed 2 weeks before, 6 weeks after, and 6 months after TKA. Using a multivariate regression model with various clinical baseline parameters, the following were significantly related to recovery: CP5 abundance, grip strength, and activity (regression weights 0.13, 0.02, and 2.89, respectively). During recovery, activity correlated to the KOOS-activities of daily living (ADL) score (r = 0.55, p = 0.009) and TUG completion time (r = -0.61, p = 0.001). Mitochondrial function seems to be related to recovery, but so are activity and grip strength, all indicators of sarcopenia. Using activity trackers before and after TKA might give the surgeon valuable information on the expected recovery and the opportunity to intervene if recovery is low.

Prognostic value of combined preoperative phase angle and handgrip strength in cardiac surgery

OBJECTIVES

Phase angle (PA) constitutes a bioelectrical impedance measurement, indicating cell membrane health and integrity, hydration, and nutritional status. Handgrip strength (HS) has been also associated with body composition, nutritional status, inflammation, and functional ability in several chronic diseases. Although their prognostic significance as independent biomarkers has been already investigated regarding the outcomes of a cardiac surgery, our study is the first one to assess the combined predictive value of preoperative PA and HS.

DESIGN AND METHODS

HS and PA measurements were performed preoperativelyin 195 patients undergoing cardiac surgery. The association ofthe combination of HS and PAwith all-cause mortality rates was the primary study outcome, while its association with the intensive care unit (ICU) length of stay (LOS) was the secondary one.

RESULTS

PA was positively correlated with HS (r = 0.446, p < 0.005) and negatively with EuroSCORE II (r = - 0.306 p < 0.005). The combination of PA < 5.15 and HS < 25.5 was associated with higher one-year all-cause mortality (OR = 9.28; 95% CI 2.50-34.45; p = 0.001) compared to patients with PA > 5.15 and HS > 25.5, respectively. Patients with combined lower values of PA and HS (PA < 5.15 and HS < 30.7) were at higher risk of prolonged ICU LOS (OR = 4.02; 95% CI 1.53-10.56; p = 0.005) compared to those with higher PA-HS (PA > 5.15-HS > 30.7). The combination of PA-HS was also significantly linked with EuroSCORE II.

CONCLUSION

The combination of low preoperative PA and HS values was significantly associated with higher risk of all-cause mortality at 12 months and prolonged ICU LOS; thereby it might serve as a clinically useful prognostic biomarker after cardiac surgery procedures.

Preoperative frailty and chronic pain after cardiac surgery: a prospective observational study

Background

Chronic pain after cardiac surgery, whether or not related to the operation, is common and has negative impact on health related quality of life (HRQL). Frailty is a risk factor for adverse surgical outcomes, but its relationship with chronic pain after cardiac surgery is unknown. This study aimed to address the association between frailty and chronic pain following cardiac surgery.

Methods

This sub-study of the Anesthesia Geriatric Evaluation study included 518 patients ≥ 70 years undergoing elective cardiac surgery. Pain was evaluated with the Short-Form 36 questionnaire prior to and one year after surgery. Associations between chronic postoperative pain and frailty domains, including medication use, nutritional status, mobility, physical functioning, cognition, HRQL, living situation and educational level, were investigated with multivariable regression analysis.

Results

Chronic pain one year after cardiac surgery was reported in 182 patients (35%). Medication use, living situation, mobility, gait speed, Nagi’s physical functioning and preoperative HRQL were frailty domains associated with chronic pain after surgery. For patients with chronic pain physical HRQL after one year was worse compared to patients without chronic pain (β –10.37, 99% CI –12.57 – –8.17).

Conclusions

Preoperative polypharmacy, living alone, physical frailty and lower mental HRQL are associated with chronic pain following cardiac surgery. Chronic postoperative pain is related to worse physical HRQL one year after cardiac surgery. These findings may guide future preoperative interventions to reduce chronic pain and poor HRQL after cardiac surgery in older patients.

Trial Registration

This trial has been registered before initiation under number NCT02535728 at clinicaltrials.gov. 

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01746-x.

Handgrip strength predicts length of hospital stay in an abdominal surgical setting: the role of frailty beyond age

BACKGROUND

Chronological age per se cannot be considered a prognostic risk factor for outcomes after elective surgery, whereas frailty could be. A simple and easy-to-get marker for frailty, such as handgrip strength (HGS), may support the surgeon in decision for an adequate healthcare plan.

AIMS

The aims of this study were to: (1) determine the prevalence of frailty in an abdominal surgery setting independent of age; (2) evaluate the predictive validity of HGS for the length of hospital stay (LOS).

METHODS

This is a retrospective study conducted in subjects who underwent abdominal surgical procedures. Only subjects with complete cognitive, functional, nutritional assessments and available measurement of HGS at admission were included. A final cohort of 108 patients were enrolled in the study.

RESULTS

Subjects had a mean age of 67.8 ± 15.8 years (age range 19-93 years old) and were mostly men. According to Fried's criteria, 17 (15.7%, 4F/13 M) were fit, 58 (23.7%; 24F/34 M) were pre-frail and 33 (30.6%; 20F/13 M) were frail. As expected, HGS significantly differed between groups having frail lower values as compared with pre-frail and fit persons (fit: 32.99 ± 10.34 kg; pre-frail: 27.49 ± 10.35 kg; frail: 15.96 ± 9.52 kg, p < 0.0001). A final regression analysis showed that HGS was significantly and inversely associated with LOS (p = 0.020) independent of multiple covariates, including age.

DISCUSSION

Most of the population undergoing abdominal surgery is pre-frail or frail. The measurement of handgrip strength is simple and inexpensive, and provides prognostic information for surgical outcomes. Muscle strength, as measured by handgrip dynamometry, is a strong predictor of LOS in a surgical setting.

Handgrip strength predicts length of hospital stay in an abdominal surgical setting: the role of frailty beyond age

Background

Chronological age per se cannot be considered a prognostic risk factor for outcomes after elective surgery, whereas frailty could be. A simple and easy-to-get marker for frailty, such as handgrip strength (HGS), may support the surgeon in decision for an adequate healthcare plan.

Aims

The aims of this study were to: (1) determine the prevalence of frailty in an abdominal surgery setting independent of age; (2) evaluate the predictive validity of HGS for the length of hospital stay (LOS).

Methods

This is a retrospective study conducted in subjects who underwent abdominal surgical procedures. Only subjects with complete cognitive, functional, nutritional assessments and available measurement of HGS at admission were included. A final cohort of 108 patients were enrolled in the study.

Results

Subjects had a mean age of 67.8 ± 15.8 years (age range 19–93 years old) and were mostly men. According to Fried’s criteria, 17 (15.7%, 4F/13 M) were fit, 58 (23.7%; 24F/34 M) were pre-frail and 33 (30.6%; 20F/13 M) were frail. As expected, HGS significantly differed between groups having frail lower values as compared with pre-frail and fit persons (fit: 32.99 ± 10.34 kg; pre-frail: 27.49 ± 10.35 kg; frail: 15.96 ± 9.52 kg, p < 0.0001). A final regression analysis showed that HGS was significantly and inversely associated with LOS (p = 0.020) independent of multiple covariates, including age.

Discussion

Most of the population undergoing abdominal surgery is pre-frail or frail. The measurement of handgrip strength is simple and inexpensive, and provides prognostic information for surgical outcomes. Muscle strength, as measured by handgrip dynamometry, is a strong predictor of LOS in a surgical setting.

Replacing Sedentary Behavior With Physical Activity of Different Intensities: Implications for Physical Function, Muscle Function, and Disability in Octogenarians Living in Long-Term Care Facilities

BACKGROUND

We investigated the associations of replacing sedentary behavior (SB) with physical activity of different intensities on the physical function of octogenarians living in long-term care facilities.

METHODS

This pooled study recruited 427 older adults aged 80 years and older (69.1% female; body mass index: 27.53). For 345 participants who provided valid data, we assessed device-measured time spent in SB, light-intensity physical activity (LIPA), and moderate to vigorous physical activity (MVPA). We assessed lower limb physical function, strength, mobility, and disability. We used compositional data analysis to investigate the associations of replacing SB with physical activity on the outcomes.

RESULTS

Reallocation of SB to LIPA and MVPA was associated with a higher number of 30-second Chair Stand cycles (LIPA: +0.21, MVPA: +1.81; P < .001), greater peak force (LIPA: +11.96 N, MVPA: +27.68 N; P < .001), peak power (LIPA: +35.82 W, MVPA: +92.73 W; P < .001), peak velocity (LIPA: +0.03 m/s, MVPA: +0.12 m/s; P < .001), higher levels of grip strength (LIPA: +0.68 kg, MVPA: +2.49 kg; P < .001), and less time in the Time Up and Go (LIPA: -7.63 s, MVPA: -12.43 s; P < .001).

CONCLUSIONS

Replacing SB with LIPA or MVPA is associated with physical function and disability of older adults living in long-term care facilities.

The association of polypharmacy with functional decline in elderly patients undergoing cardiac surgery

AIM

Identifying preoperative risk factors in older patients becomes more important to reduce adverse functional outcome. This study investigated the association between preoperative medication use and functional decline in elderly cardiac surgery patients and compared polypharmacy as a preoperative screening tool to a clinical frailty assessment.

METHODS

This sub-study of the Anaesthesia Geriatric Evaluation study included 518 patients ≥ 70 years undergoing elective cardiac surgery. The primary outcome was functional decline, defined as a worse health related quality of life or disability one year after surgery. The association between polypharmacy (i.e. ≥5 prescriptions and <10 prescriptions) or excessive polypharmacy (i.e. ≥10 prescriptions) and functional decline was investigated using multivariable Poisson regression. Discrimination, calibration and reclassification indices were used to compare preoperative screening tools for patient selection.

RESULTS

Functional decline was reported in 284 patients (55%) and preoperative polypharmacy and excessive polypharmacy showed higher risks (aRRs 1.57, 95% CI 1.23 - 1.98 and 1.93, 95% CI 1.48 - 2.50, respectively). Besides cardiovascular medication, proton pomp inhibitors and central nervous system medication were significantly associated with functional decline. Discrimination between models with polypharmacy or frailty was similar (AUC 0.67, 95% CI 0.61 - 0.72). The net reclassification index improved when including polypharmacy to the basic model (17%, 95% CI 0.06 - 0.27).

CONCLUSIONS

Polypharmacy is associated with functional decline in elderly cardiac surgery patients. A preoperative medication review is easily performed and could be used as screening tool to identify patients at risk for adverse outcome after cardiac surgery.

Prognostic Value of Handgrip Strength in Older Adults Undergoing Cardiac Surgery

BACKGROUND

Although multidimensional frailty scales have been proven to predict mortality and morbidity in cardiac surgery, there is a need for rapid tools that could be easily administered at the point of care. Handgrip strength (HGS) is an attractive option that can be measured in acutely ill and bed-bound patients, although it has yet to be validated in a large cardiac surgery cohort.

METHODS

This is a post hoc analysis of a multicentre prospective study in older patients undergoing coronary artery bypass grafting and/or valve surgery from 2011 to 2019. HGS was measured before surgery and classified by sex-stratified cutoffs. The primary outcome was 1-year mortality and secondary outcomes were 30-day mortality, discharge disposition, and prolonged length of stay.

RESULTS

There were 1245 patients included in the analysis (mean age 74.0 ± 6.6 years; 30% female). Weak HGS was associated with advanced age, heart failure, kidney disease, malnutrition, and various frailty scales. In those with weak vs normal HGS, respectively, 1-year mortality was 17% vs 6%, 30-day mortality was 10% vs 3%, prolonged length of stay was 34% vs 19%, and discharge to a health care facility was 45% vs 26% (all P < 0.001). After adjustment, HGS was predictive of 1-year and 30-day mortalities, with odds ratios of 2.44 (95% confidence interval [CI] 1.39-4.29) and 2.83 (1.38-5.81), respectively. HGS cutoffs of < 26 kg in men and < 16 kg in women had the highest predictive performance.

CONCLUSIONS

HGS is a simple and effective tool to identify patients at higher risk of mortality and protracted recovery after cardiac surgery.

Implementing grip strength assessment in hip fracture patients: a feasibility project

Objectives:

Risk stratification scores are used in hip fracture surgery, but none incorporate objective tests for low muscle strength. Grip strength testing is simple and cheap but not routinely assessed for patients with hip fracture. This project aimed to assess the feasibility of implementing grip strength testing into admission assessment of patients with hip fracture.

Methods:

A scalable protocol and a corresponding training programme of instructional presentations and practical assessments were designed and delivered by and for physiotherapy staff. Grip strength values were collected pre-surgery on patients with hip fracture at a single centre whilst supine in bed. Implementation of the process was evaluated using narrative, quantitative and cost measures.

Results:

53 hip fracture patients with a mean age 80.6 (SD 10.4), of which 36 (67.9%) were female, were included. Testing was offered to 42/52 (81%) patients. Cognitive impairment prevented 14/42 (33%) of patients from completing testing; one patient declined testing. Of the 27 patients who completed testing, 14/27 (52%) had low grip strength as defined by EWGSOP2 criteria. The projected cost of testing for one year was £2.68-£2.82 per patient. Fidelity to the protocol was high using multiple criteria.

Conclusions:

Grip strength assessment is acceptable to physiotherapy staff and can be rapidly and cost-effectively implemented into hip fracture admission assessment.

Impaired Handgrip Strength Does Not Predict Postoperative Morbidity in Major Hepatobiliary Surgery

BACKGROUND

Assessment of preoperative handgrip strength (HGS) is an objective and inexpensive bedside tool, which has been investigated to predict morbidity risk in elective surgery. However, its use is not validated in patients undergoing major elective hepatobiliary surgery (MEHS). The aim of this study is to investigate the use of HGS to predict morbidity in patients undergoing MEHS.

METHODS

This is a single-center prospective study involving 81 patients who underwent MEHS over 21 mo from July 2014 to March 2016. MEHS was defined as any hepatobiliary surgery expected to last more than 2 h and/or with an anticipated blood loss of ≥500 mL. HGS was assessed in both dominant and nondominant hands with standardization and subsequently recorded and expressed as a percentage of a general, age- and gender-matched normative values.

RESULTS

The mean age was 65.2 ± 9.5 y with male predominance (n = 52, 64.2%). Approximately, half of the patients underwent liver resection (n = 43, 53.1%). There was no difference in the incidence of Clavien-Dindo ≥ grade IIIA in both dominant HGS (impaired HGS 8/33 [24.2%], normal HGS 6/48 [12.5%]; P = 0.170) and nondominant HGS (impaired HGS 8/33 [21.1%], normal HGS 6/43 [14%]; P = 0.399). Dominant and nondominant HGS showed poor discriminatory ability in the prediction of Clavien-Dindo ≥ grade IIIA complications (dominant HGS area under the curve [AUC] = 0.572; nondominant HGS AUC 0.545). However, the use of dominant HGS showed moderate discriminatory ability to predict the length of hospital stay ≥21 d (AUC = 0.759).

CONCLUSIONS

The use of HGS may not predict Clavien-Dindo ≥ grade IIIA complications, but predicts a prolonged length of hospital stay ≥21 d.

Association of Sarcopenia and Body Composition With Short-term Outcomes After Liver Resection for Malignant Tumors

Importance

Previous retrospective studies have shown that sarcopenia substantially alters the postoperative and oncological outcomes after liver resection for malignant tumors. However, the evidence is limited to small retrospective studies with heterogeneous results and the lack of standardized measurements of sarcopenia.

Objective

To investigate the role of sarcopenia as a risk factor associated with 90-day morbidity after liver resection for malignant tumors.

Design, Setting, and Participants

This cohort study included 234 consecutive patients undergoing liver resection for malignant tumors at San Camillo Forlanini Hospital, Rome, Italy, between June 1, 2018, and December 15, 2019. Muscle mass and strength were assessed using the skeletal muscle index (SMI) on preoperative computed tomographic scans and the handgrip strength test, respectively. Patients were then divided into the following 4 groups: group A (normal muscle mass and strength), group B (reduced muscle strength), group C (reduced muscle mass), and group D (reduced muscle mass and strength).

Main Outcomes and Measures

The primary outcome of the study was 90-day morbidity. The following secondary outcomes were investigated: 90-day mortality, hospital stay, and readmission rate.

Results

Sixty-four major and 170 minor hepatectomies were performed in 234 patients (median age, 66.50 [interquartile range, 58.00-74.25] years; 158 men [67.5%]). The median SMI of the entire population was 46.22 (interquartile range, 38.60-58.20) cm/m2. The median handgrip strength was 30.80 (interquartile range, 22.30-36.90) kg. Patients in group D had a statistically significantly higher rate of 90-day morbidity than patients in the other groups (51.5% [35 of 68] vs 38.7% [29 of 75] in group C, 23.1% [3 of 13] in group B, and 6.4% [5 of 78] in group A; P < .001). Compared with patients in the other groups, those in group D had a longer hospital stay (10 days vs 8 days in group C, 9 days in group B, and 6 days in group A; P < .001), and more patients in this group were readmitted to the hospital (8.8% [6 of 68] vs 5.3% [4 of 75] in group C, 7.7% [1 of 13] in group B, and 0% [0 of 78] in group A; P = .02). Sarcopenia, portal hypertension, liver cirrhosis, and biliary reconstruction were independent risk factors associated with 90-day morbidity.

Conclusions and Relevance

Sarcopenia appears to be associated with adverse outcomes after liver resection for malignant tumors. Both muscle mass measurements on computed tomographic scans and muscle strength assessments with the handgrip strength test should be performed at the first clinical encounter to better classify patients and to minimize the risk of morbidity.

Randomised clinical trial: combined impact and resistance training in adults with stable Crohn's disease

BACKGROUND

Crohn's disease (CD) is a predisposing factor for bone loss and muscle dysfunction, which could lead to osteoporotic fractures and physical disability, respectively.

AIM

To assess the effect of 6 months of combined impact and resistance training on bone mineral density (BMD) and muscle function in adults with CD.

METHODS

In this randomised controlled trial, 47 adults with stable CD were assigned to exercise (n = 23) or control (n = 24) groups and followed up for 6 months. The exercise group received usual care plus a 6-month combined impact and resistance training programme, involving three, 60-minute sessions per week and a gradual tapering of supervision to self-management. The control group received usual care alone. The primary outcomes were BMD (via dual energy X-ray absorptiometry) and muscle function (measures of upper and lower limb strength and endurance) at 6 months.

RESULTS

At 6 months, BMD values were superior in the exercise group with statistical significance at lumbar spine (adjusted mean difference 0.036 g/cm², 95% CI 0.024-0.048; P < 0.001), but not at femoral neck (0.018 g/cm², 0.001-0.035; P = 0.059) or greater trochanter (0.013 g/cm², -0.019 to 0.045; P = 0.415) after correcting for multiple outcomes. The exercise group also had superior values for all muscle function outcomes (P < 0.001; unadjusted mean differences ranging 22.6‒48.2%), and lower fatigue severity (P = 0.005). Three exercise-related adverse events were recorded: two instances of light-headedness and one of nausea.

CONCLUSIONS

The intervention improved BMD and muscle function in adults with CD and appears as a suitable model of exercise for reducing future risk of osteoporotic fractures and disability.

TRIAL REGISTRATION

ISRCTN11470370.

Comparison of multidimensional frailty score, grip strength, and gait speed in older surgical patients

BACKGROUND

Frail older adults are at increased risk of post-operative morbidity compared with robust counterparts. Simple methods testing frailty such as grip strength or gait speed have shown promising results for predicting post-operative outcome, but there is a debate regarding the most appropriate and precise frailty assessment method. We compared the predictive value of multidimensional frailty score (MFS) with grip strength, gait speed, or conventional risk stratification tool for predicting post-operative complications in older surgical patients.

METHODS

From January 2016 to June 2017, 648 older surgical patients (age ≥ 65 years) were included for analysis. MFS was calculated based on the preoperative comprehensive geriatric assessment. Grip strength and gait speed were measured before surgery. The primary outcome was a composite of post-operative complications (e.g. pneumonia, urinary tract infection, delirium, acute pulmonary thromboembolism, and unplanned intensive care unit admission). The secondary outcome was the 6 month all-cause mortality.

RESULTS

Among 648 patients (mean age 76.6 ± 5.4 years, 52.8% female), 66 (10.2%) patients experienced post-operative complications, and the 6 month mortality was 3.9% (n = 25). Grip strength, gait speed, MFS, and American Society of Anesthesiologists (ASA) classification could predict post-operative complication but only MFS (hazard ratio = 1.581, 95% confidence interval 1.276-1.959, P < 0.001) could predict 6 month mortality after adjustment. MFS (C-index = 0.750) had a superior prognostic utility compared with age (0.638, P = 0.008), grip strength (0.566, P < 0.001), and ASA classification (0.649, P = 0.004). MFS improved the predictive value on age [C-index of 0.638 (age) vs. 0.758 (age + MFS), P < 0.001] and ASA classification [C-index of 0.649 (ASA) vs. 0.765 (ASA + MFS), P < 0.001] for post-operative complication; however, gait speed or grip strength did not provide additional prognostic value in both age and ASA.

CONCLUSIONS

Multidimensional frailty score based on preoperative comprehensive geriatric assessment showed better utility than age, grip strength, gait speed, or ASA classification for predicting post-operative complication and 6 month mortality. MFS also showed incremental predictive ability for post-operative complications with the addition of age and ASA classification. Accordingly, MFS is superior to grip strength or gait speed for predicting complications among older surgical patients.

Sarcopenia and Postoperative Complication Risk in Gastrointestinal Surgical Oncology: A Meta-analysis

OBJECTIVE

The aim of the study was to evaluate sarcopenia as a predictor of postoperative risk of major and total complications after surgery for gastrointestinal cancer.

BACKGROUND

Sarcopenia is associated with poor survival in gastrointestinal cancer patients, but the role of sarcopenia as prognostic tool in surgical oncology has not been established, and no consensus exists regarding assessment and management of sarcopenic patients.

METHODS

We performed a systematic search for citations in EMBASE, Web of Science, and PubMed from 2004 to January 31, 2017. Random effects meta-analyses were used to estimate the pooled risk ratio for postoperative complications by Clavien-Dindo grade (total complications: grade ≥2; major complications: grade ≥3) in patients with sarcopenia versus patients without sarcopenia. Stratified analyses were performed by sarcopenia criteria, cutoff level, assessment methods, study quality, cancer diagnosis, and "Enhanced Recovery After Surgery" care.

RESULTS

Twenty-nine studies (n = 7176) were included with sarcopenia prevalence ranging between 12% and 78%. Preoperative incidence of sarcopenia was associated with increased risk of major complications (risk ratio 1.40; 95% confidence interval, 1.20-1.64; P < 0.001; I = 52%) and total complications (risk ratio 1.35; 95% confidence interval, 1.12-1.61; P = 0.001; I = 60%). Moderate heterogeneity was found for both meta-analyses. Subgroup analyses showed that sarcopenia remained a consistent risk factor across stratification by sarcopenia criteria, assessment methods, study quality, and diagnoses.

CONCLUSIONS

Sarcopenia was associated with an increased risk of complications after gastrointestinal tumor resection, but lack of methodological consensus hampers the interpretation and clinical utilization of these findings. Combining assessment of muscle mass with measures of physical function may increase the prognostic value and accuracy in preoperative risk stratification.

Handgrip Strength in Preoperative Elective Cardiac Surgery Patients and Association With Body Composition and Surgical Risk

BACKGROUND

Handgrip strength (HGS) is a potential method to approximate perioperative risk in cardiothoracic surgery patients and correlates well with European System for Cardiac Operative Risk Evaluation (EuroSCORE) values. This study aimed to characterize the functional capacity in preoperative cardiac surgery patients through HGS.

METHODS

This cross-sectional study investigated patients aged 18 years or older. The collected data included surgical risk (EuroSCORE), body mass index (BMI), body composition (electrical bioimpedance), and HGS.

RESULTS

The mean age of the 278 participants was 62.1 ± 11.2 years, of whom 61.5% were male, 43.2% were overweight, and 26.3% were obese. The main types of surgery were myocardial revascularization (50%) and valve replacement (40.6%). HGS values differed between genders in all age groups (P < 0.05) and were approximately 40% lower than reference values for healthy individuals. The values differed with respect to operative risk (P = 0.003) and had a moderate positive correlation with fat-free mass (r_s = 0.435, P < 0.001), a moderate negative correlation with fat mass (r_s = -0.447, P < 0.001), and weak negative correlations with age (r_s = -0.270, P < 0.01) and EuroSCORE (r_s = -0.316, P < 0.01).

CONCLUSIONS

The HGS values of preoperative elective cardiac surgery patients were below reference values for healthy individuals, were lower in male patients, were positively correlated with fat-free mass, and were negatively correlated with fat mass, age, and operative risk. Its preoperative use in these patients is an attractive complementary method of risk assessment in clinical practice.

Improving nutritional status assessment in patients with chronic pancreatitis

INTRODUCTION

Chronic pancreatitis (CP) is a progressive inflammatory disorder causing irreversible destruction of pancreatic tissue, leading to malnutrition. A previous study has found that currently used screening methods (periodic recording of body weight and faecal and serological markers) fall short in identifying and curbing malnutrition. Moreover, data is lacking regarding change in nutritional status over time. The aim of our study is to investigate changes in nutritional status in CP patients over time and to determine whether a more extensive set of measurements would be beneficial for nutritional screening of these patients.

METHODS

CP patients who had undergone a nutritional assessment in 2012 were recruited to undergo a second assessment. The assessment consisted of anthropometric measurements, bioelectrical impedance analysis (BIA), handgrip strength (HGS), the Mini Nutritional Assessment (MNA), determination of faecal and serological markers and the Short Form Health (SF-36) questionnaire. These two assessments were compared and correlations between the various measures were calculated.

RESULTS

Twenty-eight patients underwent a second assessment. An increase in fat mass and a decrease in both fat free mass (FFM) and HGS were observed. The number of patients scoring under the 10th percentile for FFM (43%-54%) and HGS in their dominant side (38%-46%) increased. FFM and HGS were positively correlated (R = 0.57).

CONCLUSION

Even though current guidelines for CP follow-up were adhered to, there was a general deterioration in nutritional status. HGS correlated with FFM. HGS might be useful as a screening instrument for malnutrition in CP patients.

Appetite during the recovery phase of critical illness: a cohort study

BACKGROUND/OBJECTIVES

Reduced appetite is a recognised physiological symptom in survivors of critical illness. While reduced appetite has been reported by patients after intensive care unit (ICU) discharge, quantification using visual analogue scales (VAS) has not been previously performed, and follow-up duration has been limited. We aimed to describe appetite scores in ICU survivors during the first 3 months after ICU discharge and explore association with systemic inflammation.

SUBJECTS/METHODS

Secondary analysis of data collected in a complex rehabilitation intervention trial (RECOVER). A subgroup of 193 patients provided specific consent for inclusion in the blood sampling sub-study during consent for the main study. We studied appetite using a VAS; serum C-reactive protein (CRP); interleukin-1β and interleukin-6 (IL-1β and IL-6); and hand-grip strength.

RESULTS

Median (interquartile range) score on 0-10 appetite VAS was 4.3 (2.0-6.5) 1 week after ICU discharge, improving to 7.1 (4.6-8.9) by 3 months (mean difference 1.7 (0.9-2.4), p < 0.01). Number of days spent in an acute hospital following an intensive care stay was associated with poorer appetite scores (p = 0.03). CRP concentration and appetite were significantly associated at 1 week after ICU discharge (p = 0.01), but not at 3 months after ICU discharge (p = 0.67).

CONCLUSIONS

ICU survivors experience reduced appetite during the acute recovery phase of critical illness that could impact on nutritional recovery and this was associated with CRP concentration 1 week after ICU discharge.

Combination of measures of handgrip strength and red cell distribution width can predict in-hospital complications better than the ASA grade after hip fracture surgery in the elderly

BACKGROUND

Early detection of a high-risk patient following hip fracture surgery is of paramount clinical importance. American Society of Anesthesiologists (ASA) grading is an easy and efficient index in predicting a worse outcome. The red cell distribution width (RDW) and handgrip strength, are gaining interest as a prediction tool as well. Accordingly, the objective of this study was to investigate the potential association between ASA, RDW and grip strength and detect the effects of combining RDW and grip strength for predicting early complication after hip fracture surgery in the elderly.

METHODS

Eighty-three consecutive patients operated with hip fracture surgeries were identified retrospectively. Age, gender, diagnosis, RDW, handgrip strength and ASA grade were recorded. Admission to the intensive care unit (ICU), length of ICU stay, transfer to other departments, in-hospital death, and readmission were investigated as early complications. Logistic regression analysis was applied to evaluate the estimates in predicting complications, and receiver operating characteristics curves were constructed to compare the estimates and decide which method is more accurate.

RESULTS

After the surgery, 52% of the patients were admitted to the ICU. From the analyses, RDW and grip strength had no significant relation with each other. However, the ICU stay was correlated with RDW and grip strength but not for the ASA grade. A higher ASA grade and grip strength could independently predict ICU admission. The combination of RDW with grip strength outweighed the ASA grade in predictive ability.

CONCLUSIONS

The current study indicated that combining RDW and grip strength measures can be efficient and clinically relevant in predicting early postoperative complications after fragility hip fracture in the elderly. Due to the objectivity and availability of those two approaches, patient care, and functional outcomes are expected to be improved by adopting these measures in the clinical setting.

Comparison of Macintosh, McCoy and C-MAC D-Blade video laryngoscope intubation by prehospital emergency health workers: a simulation study

The aim of the this study is to evaluate the intubation success rates of emergency medical technicians using a Macintosh laryngoscope (ML), McCoy laryngoscope (MCL), and C MAC D-Blade (CMDB) video laryngoscope on manikin models with immobilized cervical spines. This randomized crossover study included 40 EMTs with at least 2 years' active service in ambulances. All participating technicians completed intubations in three scenarios-a normal airway model, a rigid cervical collar model, and a manual in-line cervical stabilization model-with three different laryngoscopes. The scenario and laryngoscope model were determined randomly. We recorded the scenario, laryngoscope method, intubation time in seconds, tooth pressure, and intubation on a previously prepared study form. We performed Friedman tests to determine whether there is a significant change in the intubation success rate, duration of tracheal intubation, tooth pressure, and visual analog scale scores due to violations of parametric test assumptions. We performed the Wilcoxon test to determine the significance of pairwise differences for multiple comparisons. An overall 5 % type I error level was used to infer statistical significance. We considered a p value of less than 0.05 statistically significant. The CMDB and MCL success rates were significantly higher than the ML rates in all scenario models (p < 0.05). The CMDB intubation duration was significantly shorter when compared with ML and MCL in all models. CMDB and MCL may provide an easier, faster intubation by prehospital emergency health care workers in patients with immobilized cervical spines.

Nerve Stimulator versus Ultrasound-Guided Femoral Nerve Block; a Randomized Clinical Trial

INTRODUCTION

Pain control is the most important issue in emergency department management of patients with femoral bone fractures. The present study aimed to compare the procedural features of ultrasonography and nerve stimulator guided femoral nerve block in this regard.

METHOD

In this randomized clinical trial, patients with proximal femoral fractures presenting to emergency department were randomly divided into two groups of ultrasonography or nerve stimulator guided femoral block and compared regarding success rate, procedural time, block time, and need for rescue doses of morphine sulfate, using SPSS 20.

RESULTS

50 patients were randomly divided into two groups of 25 (60% male). The mean age of studied patients was 35.14 ± 12.95 years (19 - 69). The two groups were similar regarding age (p= 0.788), sex (p = 0.564), and initial pain severity (p = 0.513). In 2 cases of nerve stimulator guided block, loss of pinprick sensation did not happen within 30 minutes of injection (success rate: 92%; p = 0.490). Ultrasonography guided nerve block cases had significantly lower procedural time (8.06 ± 1.92 vs 13.60 ± 4.56 minutes; p < 0.001) and lower need for rescue doses of opioid (2.68 ± 0.74 vs 5.28 ± 1.88 minutes; p < 0.001).

CONCLUSION

Ultrasonography and nerve stimulator guided femoral block had the same success rate and block duration. However, the ultrasonography guided group had lower procedure time and lower need for rescue doses of morphine sulfate. Therefore, ultrasonography guided femoral block could be considered as an available, safe, rapid, and efficient method for pain management of femoral fracture in emergency department.

Highly Flexible Graphene Oxide Nanosuspension Liquid-Based Microfluidic Tactile Sensor

A novel graphene oxide (GO) nanosuspension liquid-based microfluidic tactile sensor is developed. It comprises a UV ozone-bonded Ecoflex-polydimethylsiloxane microfluidic assembly filled with GO nanosuspension, which serves as the working fluid of the tactile sensor. This device is highly flexible and able to withstand numerous modes of deformation as well as distinguish various user-applied mechanical forces it is subjected to, including pressing, stretching, and bending. This tactile sensor is also highly deformable and wearable, and capable of recognizing and differentiating distinct hand muscle-induced motions, such as finger flexing and fist clenching. Moreover, subtle differences in the handgrip strength derived from the first clenching gesture can be identified based on the electrical response of our device. This work highlights the potential application of the GO nanosuspension liquid-based flexible microfluidic tactile sensing platform as a wearable diagnostic and prognostic device for real-time health monitoring. Also importantly, this work can further facilitate the exploration and potential realization of a functional liquid-state device technology with superior mechanical flexibility and conformability.

Association of Grip Strength, Upper Arm Circumference, and Waist Circumference with Dementia in Older Adults of the WiSE Study: A Cross-Sectional Analysis

OBJECTIVE

We examined the associations of handgrip strength, upper arm circumference, and waist circumference with dementia among Singapore older adults.

DESIGN

Cross-sectional epidemiological study.

SETTING

Residential homes, day care centres, nursing homes and institutions.

PARTICIPANTS

2,565 men and women aged 60 years and above who participated in the Well-being of the Singapore Elderly (WiSE) study in 2013.

MEASUREMENTS

Socio-demographic correlates, dietary habits, health behaviours, grip strength, upper arm circumference, and waist circumference were collected. Grip strength was measured using a hand dynamometer with the dominant hand. Upper arm circumference was measured using a measuring tape around the thickest part of the upper arm while waist circumference measured in centimetres was measured at the narrowest part of the body between the chest and hips for women, and measured at the level of the umbilicus for men. Dementia was diagnosed using the 10/66 dementia diagnostic criteria.

RESULTS

Mean grip strength was 13.07 kg (SE=0.60) for people with dementia and 21.98 kg (SE=0.26) for people without dementia. After adjusting for all factors, grip strength remained significantly associated with dementia (p <0.0001). Upper arm circumference was associated with dementia (p <0.0001) but this association was only significant in the univariate analysis. Waist circumference was not significantly associated with dementia.

CONCLUSIONS

Lower grip strength was independently associated with dementia in the older adult population in Singapore. Further research needs to be done to ascertain whether this association exists for specific types of dementia and look into the relationship of other anthropometric measurements with dementia in Singapore.

Grip strength among community-dwelling older people predicts hospital admission during the following decade

BACKGROUND

Lower grip strength on admission to hospital is known to be associated with longer stay, but the link between customary grip and risk of future admission is less clear.

OBJECTIVE

To compare grip strength with subsequent risk of hospital admission among community-dwelling older people in a U.K. setting.

DESIGN

Cohort study with linked administrative data.

SETTING

Hertfordshire, U.K.

SUBJECTS

A total of 2,997 community-dwelling men and women aged 59-73 years at baseline.

METHODS

The Hertfordshire Cohort Study (HCS) participants completed a baseline assessment between 1998 and 2004, during which grip strength was measured. Hospital Episode Statistics and mortality data to March 2010 were linked with the HCS database. Statistical models were used to investigate the association of grip strength with subsequent elective, emergency and long-stay hospitalisation and readmission.

RESULTS

There was a statistically significant negative association between grip strength and all classes of admission in women [unadjusted hazard ratio per standard deviation (SD) decrease in grip strength for: any admission/death 1.10 (95% CI: 1.06, 1.14), elective admission/death 1.09 (95% CI: 1.05, 1.13), emergency admission/death 1.21 (95% CI: 1.13, 1.31), long-stay admission/death 1.22 (95% CI: 1.13, 1.32) and unadjusted relative risk per SD decrease in grip strength for 30-day readmission/death 1.30 (95% CI: 1.19, 1.43)]. These associations remained significant after adjustment for potential confounding factors (age, height, weight for height, smoking, alcohol, social class). In men, unadjusted rates for emergency admission/death, long-stay admission/death and readmission/death were significantly associated with grip strength; associations that similarly withstood adjustment.

CONCLUSION

This study provides the first evidence that grip strength among community-dwelling men and women in the U.K. is associated with risk of hospital admission over the following decade.

Prehabilitation to enhance perioperative care

Patients who are elderly, malnourished, anxious, and have a low physical function before surgery are likely to have suboptimal recovery from cancer surgery. A multimodal prehabilitation program is proposed, consisting of exercise training and nutritional and psychological support, which increases physiologic reserve before the stress of surgery. This interventional approach seems to improve ability to undergo the stress of surgery and faster recovery. The integration of exercise, adequate nutrition, and psychosocial components, with medical and pharmacologic optimization in the presurgical period, deserves to receive more attention by clinicians to elucidate the most effective interventions.

[Physical activity diminishes aging-related decline of physical and cognitive performance]

Aging-related decline of muscle force, walking speed, locomotor coordination, aerobic capacity and endurance exert prognostic impact on life expectancy. Proper use of training may diminish the aging process and it may improve the quality of life of elderly persons. This paper provides a brief summary on the impact of training on aging-related decline of physical and cognitive functions.

New normative values for handgrip strength: results from the UK Biobank

OBJECTIVES

To develop normative values for right and left handgrip strength after stratification for confounders like gender, age, and height.

DESIGN

Cross-sectional, descriptive.

SETTING

General population.

PARTICIPANTS

A total of 502,713 people living in the United Kingdom.

INTERVENTION

None.

MEASUREMENTS

Handgrip strength was measured using a Jamar hydraulic hand dynamometer, which is considered to be an accurate instrument to measure handgrip strength. In addition, self-reported chronic conditions and ethnic background were registered, and lung function was assessed using spirometry.

RESULTS

After exclusion of all individuals with missing data, a nonwhite ethnic background, the presence of 1 or more self-reported conditions, and/or an obstructive lung function (defined as FEV1/FVC <0.7), new normative values for right and left handgrip strength were derived from 224,830 and 224,852 individuals (54.2% women; age: 55.0 [8.0] years; height: 169.0 [9.2] cm; body mass index: 26.9 [4.4] kg/m(2)) with a nonobstructed spirometry (FEV1: 3.0 [0.8] L). Men were stronger than women. Moreover, significant associations were found between handgrip strength and height, and between handgrip strength and age. Finally, percentiles 5, 10, 25, 50, 75, 90, and 95 were calculated for right and left handgrip strength, after stratification for gender, age, and height.

CONCLUSION

The UK Biobank dataset provided the opportunity to determine new normative values for handgrip strength in men and women aged 39 to 73 years. These normative values take into consideration age, height, and measurement side. Therefore, these new normative handgrip strength values are of broad clinical interest.

Clinical and economic characteristics of hip fracture patients with and without muscle atrophy/weakness in the United States

This retrospective analysis of hip fracture patients with and without muscle atrophy/weakness (MAW) revealed that those with MAW had significantly higher healthcare utilization and costs compared with hip fracture patients without MAW.

PURPOSE

Examine the demographics, clinical characteristics, and healthcare resource utilization and costs of hip fracture patients with and without MAW.

METHODS

Using a large US claims database, individuals who were newly hospitalized for hip fracture between 1 Jan 2006 and 30 September 2009 were identified. Patients aged 50-64 years with commercial insurance (Commercial) or 65+ years with Medicare supplemental insurance (Medicare) were included. The first hospitalization for hip fracture was defined as the index stay. Patients were categorized into three cohorts: patients with medical claims associated with MAW over the 12 months before the index stay (pre-MAW), patients whose first MAW claim occurred during or over the 12 months after the index stay (post-MAW), and patients without any MAW claim (no-MAW). Multivariate regressions were performed to assess the association between MAW and healthcare costs over the 12-month post-index period, as well as the probability of re-hospitalization.

RESULTS

There were 26,122 Medicare (pre-MAW, 839; post-MAW, 2,761; no-MAW, 22,522) and 5,100 Commercial (pre-MAW, 132; post-MAW, 394; no-MAW, 4,574) hip fracture patients included in this study. Controlling for cross-cohort differences, both the pre-MAW and post-MAW cohorts had significantly higher total healthcare costs (Medicare, $7,308 and $18,753 higher; Commercial, $18,679 and $25,495 higher) than the no-MAW cohort (all p < 0.05) over the 12-month post-index period. The post-MAW cohort in both populations was also more likely to have any all-cause or fracture-related re-hospitalization during the 12-month post-index period.

CONCLUSIONS

Among US patients with hip fractures, those with MAW had higher healthcare utilization and costs than patients without MAW.