Clinical outcomes and prognostic factors in patients directly transferred to the intensive care unit from long-term care beds in institutions and hospitals: a retrospective clinical study

Factors Affecting Hospitalization and Death of Older Patients Who Need Long-Term Care—The Necessity of the Support for Dysphagia in Home Dental Care

The demand for home dental care is increasing, but how it should be involved in the continuation of life at home for elderly people who need care has not been examined. Therefore, we examined whether items examined by dentists can affect hospitalization and death. The study included 239 patients with oral intake. They were divided into regular and non-regular diet groups, and ages, nutritional statuses, activities of daily living (ADLs), Charlson Comorbidity Indexes (CCI) and swallowing functions were compared. The nutritional statuses and ADLs of the three groups at the first visit and after one year were compared. The groups included those with stable, declined and improved diet forms. Factors influencing hospitalization and death over three years were examined. Nutritional status, swallowing function, CCI and ADLs were worse in the non-regular diet group. The declined diet form group had lower ADL levels and nutritional statuses at the first visit. A proportional hazards analysis showed significant differences in the changes in diet form for the stable and declined groups related to hospitalization (hazard ratio (HR): 6.53) and death (HR: 3.76). Changes in diet form were thought to affect hospitalization and death, and it is worthwhile to assess swallowing function in home dental care.

U-Shape Relationship between Plasma Leucine Level and Mortality in the Intensive Care Unit

Patients in the intensive care unit (ICU) are at high risk of mortality which is not well predicted. Previous studies noted that leucine has prognostic value in a variety of diseases. This study investigated whether leucine concentration was a useful biomarker of metabolic and nutritional status and 6-month mortality in ICU. We recruited 454 subjects admitted to ICU (348 and 106 in the initiation and validation cohorts, respectively) with an acute physiology and chronic health evaluation (APACHE II) score ≥ 15. We measured plasma leucine concentrations, traditional biomarkers, and calculated APACHE II and sequential organ failure assessment (SOFA) scores. Leucine levels were weakly correlated with albumin, prealbumin, and transferrin levels (r = 0.30, 0.12, and 0.15, p = 0.001, 0.029, and 0.007, respectively). During follow-up, 116 (33.3%) patients died. Compared to patients with leucine levels between 109 and 174 μM, patients with leucine > 174 μM or <109 μM had a lower cumulative survival rate. Death was also associated with age, higher APACHE II and SOFA scores, C-reactive protein, and longer stays in the ICU, but with lower albumin, prealbumin, and transferrin. Patients with leucine levels > 174 μM had higher alanine aminotransferase levels, but no significant differences in other variables; patients with leucine levels < 109 μM had higher APACHE II and SOFA scores, higher incidence of using inotropic agents, longer ICU and hospital stays, but lower albumin and transferrin levels. Multivariable analysis demonstrated that leucine > 174 μM was an independent predictor of mortality, especially early mortality. However, among patients who stayed in ICU longer than two weeks, leucine < 109 μM was an independent predictor of mortality. In addition, leucine < 109 μM was associated with worse ventilator weaning profiles. These findings were similar in the validation cohort. Our study demonstrated a U-shape relationship between leucine levels and mortality rate in ICU.

Elevated plasma phenylalanine predicts mortality in critical patients with heart failure

Aims

Previous studies found a relationship between elevated phenylalanine levels and poor cardiovascular outcomes. Potential strategies are available to manipulate phenylalanine metabolism. This study investigated whether increased phenylalanine predicted mortality in critical patients with either acute heart failure (HF) or acute on chronic HF, and its correlation with inflammation and immune cytokines.

Methods and results

This study recruited 152 subjects, including 115 patients with HF admitted for critical conditions and 37 normal controls. We measured left ventricular ejection fraction (LVEF), plasma concentrations of phenylalanine, C‐reactive protein, albumin, pre‐albumin, transferrin, and pro‐inflammatory and immune cytokines. Acute Physiology and Chronic Health Evaluation (APACHE II), Sequential Organ Failure Assessment (SOFA), and maximal vasoactive–inotropic scores (VIS_max) were calculated. Patients were followed up until death or a maximum of 1 year. The primary endpoint was all‐cause death. Of the 115 patients, 37 (32.2%) were admitted owing to acute HF, and 78 (67.8%) were admitted owing to acute on chronic HF; 64 (55.7%) had ST elevation/non‐ST elevation myocardial infarction. An LVEF measured during the hospitalization of <40%, 40–50%, and ≥50% was noted in 51 (44.3%), 15 (13.1%), and 49 (42.6%) patients, respectively. During 1 year follow‐up, 51 (44.3%) patients died. Death was associated with higher APACHE II, SOFA, and VIS_max scores; higher levels of C‐reactive protein and phenylalanine; higher incidence of atrial fibrillation and use of inotropic agents; lower cholesterol, albumin, pre‐albumin, and transferrin levels; and significant changes in pro‐inflammatory and immune cytokines. Phenylalanine levels demonstrated an area under the receiver operating characteristic curve of 0.80 for mortality, with an optimal cut‐off value set at 112 μM. Phenylalanine ≥ 112 μM was associated with a higher mortality rate than was phenylalanine < 112 μM (80.5% vs. 24.3%, P < 0.001) [hazard ratio = 5.07 (2.83–9.05), P < 0.001]. The Kaplan–Meier curves revealed that phenylalanine ≥ 112 μM was associated with a lower accumulative survival rate (log rank = 36.9, P < 0.001). Higher phenylalanine levels were correlated with higher APACHE II and SOFA scores, higher C‐reactive protein levels and incidence of using inotropic agents, and changes in cytokines suggestive of immunosuppression, but lower levels of pre‐albumin and transferrin. Further multivariable analysis showed that phenylalanine ≥ 112 μM predicted death over 1 year independently of age, APACHE II and SOFA scores, atrial fibrillation, C‐reactive protein, cholesterol, pre‐albumin, transferrin, and interleukin‐8 and interleukin‐10.

Conclusions

Elevated phenylalanine levels predicted mortality in critical patients, phenotypically predominantly presenting with HF, independently of traditional prognostic factors and cytokines associated with inflammation and immunity.

Phenylalanine- and leucine-defined metabolic types identify high mortality risk in patients with severe infection

OBJECTIVE

To investigate the prognostic value of phenylalanine and leucine in patients with severe infection.

METHODS

Ninety-three patients with infection who had a quick Sequential Organ Failure Assessment (qSOFA) score ≥2 were enrolled. Plasma phenylalanine, leucine, albumin, C-reactive protein, pre-albumin, and transferrin were measured and the SOFA score at enrollment was calculated after hospitalization.

RESULTS

During the 3-month follow-up, 30 (32.3%) patients died. Death was associated with higher SOFA scores, a higher incidence of bacteremia and admission to the intensive care unit, higher C-reactive protein and phenylalanine levels, worse kidney function, and lower pre-albumin and transferrin levels. Patients were categorized into three groups: high-risk type 1 (phenylalanine ≥84μM), high-risk type 2 (phenylalanine <84μM and leucine <93μM), and low-risk (other). Compared to the low-risk type patients, high-risk type 1 and 2 patients had higher mortality rates (hazard ratio 10.1 (95% CI 2.33-43.5) and hazard ratio 5.56 (95% CI 1.22-25.4), respectively). Type 1 patients had higher SOFA scores, a higher incidence of admission to the intensive care unit, and higher C-reactive protein and leucine levels. Type 2 patients had lower albumin and hemoglobin levels. Multivariable analysis showed that both high-risk types were independent predictors of death.

CONCLUSIONS

Phenylalanine- and leucine-defined risk classifications provide metabolic information with prognostic value for patients with severe infection.