Patient-related risk factors that predict poor outcome after total hip replacement.

OBJECTIVE: To identify factors associated with poor outcome after total hip replacement (THR) surgery. DATA SOURCES: This article is the first to present results from the American Medical Group Association (AMGA) THR consortium. STUDY DESIGN: The outcomes evaluated were pain and physical function. Eight patient risk factors were evaluated. These included the age, sex, race, marital status, and education of the patient; whether the patient had polyarticular disease or other comorbid conditions; and the patient's preoperative pain and physical function score. DATA COLLECTION: Data were collected from patients using AMGA-approved, self-administered questionnaires preoperatively and at six weeks, three months, six months, one year, and two years postoperatively. PRINCIPAL FINDINGS: Of the patient risk factors studied, race, education, number of comorbid conditions, and preoperative Health Status Questionnaire (HSQ) score were found to be associated with poor outcome. These risk factors were found to have an effect on both pain and physical function at six months postoperatively. Patients with higher preoperative scores were found to have higher postoperative scores, but substantially fewer of these patients received any benefit from their surgery. For each 10-point increase in preoperative score, patients could expect at least a 6-point decrease in postoperative improvement. CONCLUSIONS: Our study indicates that preoperative status is an important predictor of outcome for THR.     

Total joint replacement surgery in a rural centre

OBJECTIVE: To demonstrate that total joint replacement surgery can be safely and effectively performed in rural hospitals with acceptable outcomes. DESIGN: Case series. SETTING: A rural district hospital. Participants: Participants were 64 patients, 30 men and 34 women, who underwent total knee replacements (TKR); and 63 patients, 41 men and 22 women, who had total hip replacements (THR). Main outcome measures: Level of patient satisfaction following total joint replacement surgery, obtained by patient interview. Incidence of postoperative joint specific complications, for example infection, THR dislocation and manipulation under anaesthetic (MUA) of a TKR. RESULTS: None of the TKR or THR patients developed a deep wound infection. In this study 8.8% TKR patients had an MUA but all during a period of limited physiotherapy services; 5.8% THR patients suffered a dislocated prosthesis. Following TKR 95.3% patients reported to be 'happy' with the outcome of their surgery. Of the THR patients 97.0% declared they were 'happy' with their surgical outcome. CONCLUSIONS: There was a high level of patient satisfaction, low infection rate, acceptable levels of MUA for TKR and dislocation for THR following total joint replacement in our rural district hospital. The surgeons performed a medium volume of total joint replacements and an appropriate multidisciplinary team was in place. In such settings joint replacement surgery can be safely and successfully performed in rural centres to the benefit of rural patients, surgeons and GPs.     

Malnutrition in critically ill children: from admission to 6 months after discharge

BACKGROUND & AIMS: Little is known about the nutritional status of critically ill children during hospitalisation in and after discharge from an intensive care unit. We set up a prospective, observational study to evaluate the nutritional status of children in an intensive care unit from admission up to 6 months after discharge. A secondary aim was identifying patient characteristics that influence the course of the various anthropometric parameters. METHODS: The nutritional status of 293 children--104 preterm neonates, 96 term neonates and 93 older children--admitted to our multidisciplinary tertiary pediatric and neonatal intensive care unit was evaluated by anthropometry upon and during admission, at discharge and 6 weeks and 6 months following discharge. RESULTS: Upon admission, 24% of all children appeared to be undernourished. Preterm and term neonates, but not older children, showed a decline in nutritional status during admission. At 6 months after discharge almost all children showed complete recovery of nutritional status. Length of stay and history of disease were the parameters that most adversely affected the nutritional status of preterm and term neonates at discharge and during follow-up. CONCLUSION: While malnutrition is a major problem in pediatric intensive care units, most children have good long-term outcome in terms of nutritional status after discharge.     

Incidence and recognition of malnutrition in hospital J. P. McWhirter and C. R. Pennington BMJ 1994; 308: 945-948

This paper describes a prospective study to determine the incidence of malnutrition among patients on admission to an acute teaching hospital, to monitor their changes in nutritional status during stay and to determine awareness of nutrition in different clinical units. Nutritional status was assessed in 500 patients admitted to hospital: 100 each from general surgery, general medicine, respiratory medicine, orthopaedic surgery and medicine for the elderly. The main outcome measures were weight, height, triceps skinfold thickness, mid arm circumference, mid arm muscle circumference and grip strength. Patients were studied on admission and discharge and case notes reviewed for information about nutritional status. On admission 200 out of 500 patients were considered undernourished (BMI < 20). Of these only 96 had any nutritional information documented in the notes. 34% of patients were overweight (BMI > 25). The 112 patients reassessed on discharge had a mean weight loss of 5.4% with the greatest weight loss in those initially most malnourished. The 10 patients who were referred for nutritional support (3 for parenteral nutrition, 7 for enteral nutrition) showed a mean weight gain of 7.9%.     

Nutritional supplements after hip fracture: poor compliance limits effectiveness

BACKGROUND: Undernutrition and weight loss are important determinants of clinical outcome in older patients after hip fracture but the effectiveness of nutritional support programs in routine clinical practice remains controversial. AIMS OF THE PROJECT: To determine if oral nutritional supplements given daily for 28 days after hip fracture surgery could prevent weight loss and/or lead to improved clinical outcomes (mortality rates, discharge destination, activities of daily living or length of hospital stay) in non-malnourished community-dwelling older women with hip fracture.METHODS: One hundred and nine women with BMI range 20-30 kg/m(2) were allocated to either nutritional supplements (352 kcal/day) or usual hospital nutrition using a quasi-randomisation technique. Body weight changes were monitored at 4 and 8 weeks and clinical outcomes were recorded at discharge and at 6 months. RESULTS: No significant differences in weight change or clinical outcomes were seen between the two groups. Compliance with consuming the nutritional supplements was quite variable and there was a significant negative correlation between the amount of supplement consumed and subsequent weight change (r=-0.36, P=0.019). CONCLUSIONS: Poor compliance with oral nutritional supplements is an important determinant of the effectiveness of oral nutritional interventions in preventing weight loss after hip fracture. Whilst this may explain the lack of clinical improvements seen, our data do not support the routine use of oral nutritional supplements in non-malnourished hip fracture patients.     

上海地区普外科住院患者营养风险筛查和营养支持应用调查

目的调查普通外科住院患者入院时的营养风险及住院期间的营养支持状况,分析营养风险、营养支持与临床结局的关系.方法采用营养风险筛查2002( NRS 2002),选取2009年9月至2010年4月在上海市第六人民医院普通外科的住院患者进行营养风险筛查,并调查患者2周内的营养支持状况,统计并发症发生率、住院时间和住院费用.结果 共有3000例住院患者入选,总营养风险发生率为18.5％,胃肿瘤患者营养风险最高,为48.3％.存在营养风险和无营养风险患者的营养支持率分别为44.1％和14.3％.肠外营养和肠内营养比值为1.2:1.有营养风险的患者并发症发生率、住院时间和总住院费用均高于无营养风险的患者[24.1％比14.2％,(11.1±4.8)d比(9.6±3.7)d,(12 891.5 ±4831.2)元比(9982.7±3996.4)元,P均=0.0000).在有营养风险的胃肿瘤、结直肠肿瘤和肝胆胰肿瘤患者中,应用营养支持患者的并发症发生率、平均住院时间和住院费用明显低于未用营养支持的患者(P均＜0.05).结论普通外科住院患者存在营养风险,其中胃肿瘤患者营养风险较高.营养风险与外科住院患者的临床结局有关.对有营养风险的胃肿瘤、结直肠肿瘤和肝胆胰肿瘤患者,给予营养支持可改善临床结局.     

Malnutrition in hospitalized elderly patients: when does it matter?

BACKGROUND: Identifying the individual effects of acute illness and malnutrition on elderly patient outcome and the timing of nutritional support is still an important challenge for modern medicine. OBJECTIVE: The aims of this study were to assess the practical significance of serum albumin concentrations following acute illness as a measure of nutritional status in ageing patients and also to review recently published studies related to this field. DESIGN: Consecutive stroke patients had their nutritional status assessed from anthropometric, haematological and biochemical data during the hospital stay. Predicted energy needs and daily in-hospital energy intake were also studied in a subgroup of 24 acute stroke patients and 24 age and sex-matched hospitalized non-stroke patients. A multivariate analysis was used to measure the amount of variance in serum albumin concentrations explained by nutritional and non-nutritional clinical variables. RESULTS: Serum albumin concentrations deteriorated steadily during the study period and there was an increase in the amount of variance in the serum albumin explained by nutritional variables between admission and week 4 of the hospital stay. Almost all patients studied were in negative energy balance during hospitalization. Evidence is provided which links low serum albumin concentrations with clinical outcomes during the hospital stay and immediately following discharge. That nutritional supplementation started one week as opposed to immediately following acute illness, and continued during the convalescent period, can improve serum albumin concentrations during the hospital stay. CONCLUSION: Poor nutritional status following acute illness in ageing patients may be of more prognostic significance and amenable to therapy later on during the course of hospitalization.     

Nutritional parameters and short term outcome in arthroplasty.

OBJECTIVE: Advances in surgical techniques and management of arthroplasty patients have contributed to a significant reduction in surgical complication rates. Preoperative nutritional status has a significant impact on surgical outcome. Studies have reported improved outcomes in burn and hip fracture patients receiving nutritional supplementation during their recoveries. Our objective was to assess the effects of preoperative nutritional status on the incidence of complications, resource consumption, and length of stay of patients undergoing hip and knee replacement surgery. METHODS: One hundred and nineteen patients were evaluated. Standard preoperative laboratory tests were performed on all patients. Medical severity of illness was assessed on all patients using the Charlson Comorbidity Index. Anesthesia and surgical time was recorded. Short term outcome was assessed utilizing hospital charges as a measure of resource consumption, length of stay (LOS), in-hospital consults and the presence and number of complications during hospitalization. Non-parametric Kruskall Wallis and chi-square statistical analyses were performed. A p value <.05 was considered significant. RESULTS: Mean age was 64.6 years +/-15.62. 52.9% had osteoarthritis (OA), 4.2% had rheumatoid arthritis (RA), 5.9% had osteonecrosis (ON), 9.2% had a hip fracture and 28% had a failed total knee arthroplasty (TKA) or total hip arthroplasty (THA). Mean albumin and total lymphocyte count (TLC) were 38.5 g/L +/-4.78 SD and 1884 cells/microL +/-762 SD, respectively. Patients with albumin levels less than 34 g/L had 32.7% higher charges ($50,108+/-8203 SE vs. $33,720+/-1128 SE, p<.006), higher medical severity of illness (p = .03) and longer LOS (8.6+/-1.7 SE vs. 5.2+/-.356 SE days, p<.001). Patients with TLC less than 1200 cells/microL had higher charges ($32,544+/-1050 SE vs. $42,098+/-3122 SE, p = .004), longer LOS (5.7+/-.531 vs. 5.4 days +/-.368, p = .004) and anesthesia (242.85+/-17.55 SE vs. 198.6 min. +/-6.06 SE, p = .02) and surgical times (177.14 min. +/-17.57 SE vs. 120.21 min. +/-6.22 SE, p = .002) when compared with patients with TLC higher than 1200 cells/microL. These findings were still significant when adjusted for medical severity of illness and age. CONCLUSIONS: Our data demonstrate that preoperative nutritional status is an excellent predictor of short term outcome. Serum albumin and TLC correlate with resource consumption, length of stay and operative time in patients undergoing joint replacement surgery. These parameters may be improved with nutritional supplementation prior to surgery.     

The problem of 'noise' in monitoring patient-based outcomes: generic, disease-specific and site-specific instruments for total hip replacement

OBJECTIVES: To compare the performance of three types of patient-based health status instrument--generic, disease-specific and site-specific--in assessing changes resulting from total hip replacement (THR). METHODS: A two-stage prospective study of patients undergoing surgery for THR involving an assessment at a pre-surgical clinic and a follow-up clinic at 6 months. 173 patients with a diagnosis of arthritis and being admitted for unilateral THR were recruited in the outpatient departments of a specialist orthopaedic hospital and peripheral clinics within Oxfordshire. Patients' health status was assessed using the 12-item Oxford Hip Score, the Arthritis Impact Measurement Scales (AIMS) and SF-36 general health questionnaire together with their surgeons' assessment using Charnley hip score obtained before and 6 months after surgery. RESULTS: Effect sizes, used to compare change scores, revealed that pain and function domains changed most following THR on both the AIMS and the SF-36. 71 patients (41%) were assessed as having symptoms or problems currently affecting lower limb joints other than the hip recently replaced. Change scores were compared between these patients and all other patients who reported no current problems with other joints. The Oxford Hip Score found no significant difference between change scores for these two groups of patients while both AIMS and SF-36 physical and pain dimensions recorded significant differences of similar magnitude (physical P < 0.01, pain P < 0.05). Likely reasons for this were apparent on closer inspection of the item content of each instrument. CONCLUSIONS: Assessment of outcomes in THR is necessarily long-term. Within studies of this kind, a hip-specific instrument (Oxford Hip Score) is likely to be more able to distinguish between symptoms and functional impairment produced by the index joint, as compared with other joints and conditions, than either a disease-specific instrument (AIMS) or a generic health status measure (SF-36). This is important given the high probability of existing and subsequent co-morbidity affecting such populations of patients. This consideration is likely to be relevant to any long-term assessment programme following treatment for a condition which threatens bilateral expression over time.     

Retrospective application of the performance indicator 'hip fracture: operate within 24 hours' in 217 patients treated at the University Medical Centre Utrecht in 2000-2003: reduction in postoperative pneumonia but not mortality

OBJECTIVE: To evaluate whether patients with hip fracture who undergo surgery within 24 hours--which has been propagated as an indicator of quality care--is associated with a reduced risk of mortality and complications, compared with later surgery. DESIGN: Retrospective status study based on a prospectively designed electronic medical record. METHOD: Data were collected on patients aged > or =60 years who were admitted to the University Medical Centre Utrecht, the Netherlands, between 1 January 2000 and 31 December 2003 for hip fracture. Outcomes were compared in patients who underwent surgery within 24 hours and those who underwent surgery after more than 24 hours. The primary outcome measure was mortality (in-hospital, after 3 months, 12 year and 3 years after discharge). Secondary outcome measures were postoperative complications, postoperative duration ofhospital stay and admission to long-term care facilities. We corrected for age, gender and pre-existing comorbidity. RESULTS: A total of 217 patients were included. In the 150 patients who underwent surgery within 24 hours, the mean age was 80.5 years, 75% were female and 28% were class III or IV according to the American Society of Anesthesiologists (ASA). In the 67 patients who underwent surgery after more than 24 hours, the mean age was 80.9 years, 82% were female, and 49% were ASA class III or IV. After correcting for published risk factors, there was no relationship between the timing of surgery and mortality. Fewer patients treated within 24 hours developed pneumonia postoperatively. In this study population, the only risk factor for mortality was the preoperative condition of the patient. CONCLUSION: Postoperative pneumonia occurred less frequently in patients with hip fracture who underwent surgery within 24 hours. Postoperative mortality was related to poor patient condition but not the timing of surgery. Early surgery should be avoided in patients with severe comorbidity who are not optimally prepared for surgery.     

Trajectories of nutritional status and cognitive impairment among older Taiwanese with hip fracture

Objective

This paper describes the trajectories of nutritional status and cognitive impairment and their correlation among older Taiwanese over 1 year after hip-fracture surgery.

Design

Secondary analysis of data from a clinical trial evaluating the effects of three types of post-discharge care for 292 older hip-fracture patients (age >60 years).

Measurements

Nutritional status was assessed by the Mini Nutritional Assessment before and 1, 3, 6, 12 months after hospital discharge. Cognitive function was measured by the Mini-Mental State Examination before surgery, at hospital discharge, 6 and 12 months after discharge. Trajectories of nutritional status and cognitive impairment were depicted by latent class growth modeling, whereas linkages between nutritional-status and cognitive-impairment trajectories were assessed by multinomial logistic regression.

Results

Nutritional status in general improved significantly, particularly during the first 3 months after discharge. We identified three trajectories of nutritional status: malnourished (15.4%), at risk for malnutrition (38.9%), and well-nourished (45.7%). In contrast, cognitive changes followed four largely linear but distinct trajectories: moderately impaired (12.2%), mildly impaired (27.8%), borderline impaired (21.8%), and cognitively intact (38.2%). Trajectories of nutritional status were significantly associated with cognitive-function trajectories. For instance, relative to malnourished patients, well-nourished patients were 95% less likely (OR=0.05, CI =0.01-0.24) to be moderately cognitively impaired.

Conclusion

A good nutritional-status trajectory after hip fracture was associated with better cognitive function. To treat and care for elderly hip-fractured patients, specific interventions need to target those who are malnourished or at risk of malnutrition to decrease their risk for cognitive impairment.

     

髋关节置换与动力髋螺钉治疗重度骨质疏松老年股骨转子间骨折临床分析

目的 分析髋关节置换与动力髋螺钉(DHS)两种不同治疗方式对重度骨质疏松老年股骨转子间骨折的治疗效果.方法 回顾性分析2003年1月至2008年3月收治的51例60岁以上、合并重度骨质疏松(Singh指数Ⅲ级以下)的股骨转子间骨折患者的手术治疗效果.骨折分型采用Tronzo-Evan分型,骨质疏松程度评价采用影像学Singh指数评估.采用机械抽样法随机抽取病例,髋关节置换组19例,采用改良Gibson切口,置入合适的髋关节或者人工股骨头假体;DHS组32例,采用髋外侧入路,置入DHS.髋关节置换组患者术后第2天开始CPM机锻炼,术后3～7 d开始逐渐下床负重;DHS组患者根据患者具体情况,2～10周后开始部分负重.结果 51例患者中47例获得随访.随访时间5.0～40.5(28.1±11.9)个月.髋关节置换组19例均获得随访,其中18例(94.7%)术后髋关节功能Harris评分为优或良,1例差.DHS组28例获得随访,其中23例(82.1%)术后髋关节功能Harris评分为优或良;5例术后髋关节功能恢复不良.两组优良率比较差异有统计学意义(P＜0.05).髋关节置换组开始负重时间为(8.3±4.2)d,DHS组为(43.6±15.3)d;两组比较差异有统计学意义(P＜0.05).结论 髋关节置换治疗重度骨质疏松老年股骨转子间骨折,术后开始负重时间短于DHS内固定,髋关节功能优良率高于DHS内固定;可早期恢复患肢功能,减少并发症.     

Rates of surgical site infection after hip replacement as a hospital performance indicator: analysis of data from the English mandatory surveillance system

OBJECTIVE: To describe rates of surgical site infection (SSI) after hip replacement and to use these data to provide a simple mechanism for identifying poorly performing hospitals that takes into account variations in sample size. DESIGN: Prospective surveillance study. SETTING: A total of 125 acute care hospitals in England that participated in mandatory SSI surveillance from April 1, 2004 through March 31, 2005. PATIENTS: Patients who underwent total hip replacement (THR) or hip hemiarthroplasty (HH). METHODS: A standard data set was collected for all eligible operations at participating hospitals for a minimum of 3 months annually. Defined methods were used to identify SSIs that occurred during the inpatient stay. Data were checked for quality and accuracy, and funnel plots were constructed by plotting the incidence of SSI against the number of operations. RESULTS: Data were collected on 16,765 THRs and 5,395 HHs. The cumulative SSI incidence rates were 1.26% for THR and 4.06% for HH; the incidence densities were 1.38 SSIs per 1,000 postoperative inpatient days for THR and 2.3 SSIs per 1,000 postoperative inpatient days for HH. The risk of infection associated with revision surgery was significantly higher than that associated with primary surgery (2.7% [95% confidence interval, 2.0%-3.5%] vs. 1.1% [95% confidence interval, 1.0%-1.2%]; P=.003). Rates varied considerably among hospitals. Nineteen hospitals had rates above the 90th percentile. However, the use of funnel plots to adjust for the precision of estimated SSI rates identified 7 hospitals that warranted further investigation, including 2 with crude rates below the 90th percentile. CONCLUSIONS: Funnel plots of rates of SSI after hip replacement provide a valuable method of presenting hospital performance data, clearly identifying hospitals with unusually high or low rates while adjusting for the precision of the estimated rate. This information can be used to target and support local interventions to reduce the risk of infection.     

Preoperative nutritional status and prognostic nutritional index in patients with benign disease undergoing abdominal operations–Part I.

The aim of the first part of this study was to detect the incidence of preoperative malnutrition of clinical importance in patients with benign disease.

The preoperative nutritional status of 52 consecutive adult patients undergoing abdominal operations for benign conditions was studied prospectively by objective and subjective nutritional criteria. The postoperative outcome was monitored until discharge or death. The preoperative nutritional status was correlated with the postoperative outcome.

Protein energy malnutrition was identified in 20 (38%) of the 52 patients. Of these 20 malnourished patients, 15 (75%) developed complications after surgery, compared with 7 (22%) of the 32 well-nourished patients (p < 0.01). The most common abnormal values were serum transferrin concentration (n = 8), subscapula skinfold (n = 11), serum urea:serum creatinine ratio (n = 17), loss of appetite for more than 5 days (n = 24), and preoperative stay in hospital of longer than 5 days (n = 19).

These results indicate that a combination of objective and subjective criteria may be important in the identification of clinical malnutrition.     

Comprehensive Care Improves Physical Recovery of Hip-Fractured Elderly Taiwanese Patients With Poor Nutritional Status

ObjectivesThe effects of nutritional management among other intervention components have not been examined for hip-fractured elderly persons with poor nutritional status. Accordingly, this study explored the intervention effects of an in-home program using a comprehensive care model that included a nutrition-management component on recovery of hip-fractured older persons with poor nutritional status at hospital discharge.DesignA secondary analysis of data from a randomized controlled trial with 24-month follow-up.SettingA 3000-bed medical center in northern Taiwan.ParticipantsSubjects were included only if they had “poor nutritional status” at hospital discharge, including those at risk for malnutrition or malnourished. The subsample included 80 subjects with poor nutritional status in the comprehensive care group, 87 in the interdisciplinary care group, and 85 in the usual care group.InterventionsThe 3 care models were usual care, interdisciplinary care, and comprehensive care. Usual care provided no in-home care, interdisciplinary care provided 4 months of in-home rehabilitation, and comprehensive care included management of depressive symptoms, falls, and nutrition as well as 1 year of in-home rehabilitation.MeasurementsData were collected on nutritional status and physical functions, including range of motion, muscle power, proprioception, balance and functional independence, and analyzed using a generalized estimating equation approach. We also compared patients' baseline characteristics: demographic characteristics, type of surgery, comorbidities, length of hospital stay, cognitive function, and depression.ResultsPatients with poor nutritional status who received comprehensive care were 1.67 times (95% confidence interval 1.06–2.61) more likely to recover their nutritional status than those who received interdisciplinary and usual care. Furthermore, the comprehensive care model improved the functional independence and balance of patients who recovered their nutritional status over the first year following discharge, but not of those who had not yet recovered.ConclusionsAn in-home program using the comprehensive care model with a nutritional component effectively improved the nutritional status of hip-fractured patients with poor nutrition. This comprehensive care intervention more effectively improved recovery of functional independence and balance for patients with recovered nutritional status.     

Combined Effects of Cognitive Impairment and Nutritional Trajectories on Functional Recovery for Older Patients after Hip-Fracture Surgery

ObjectivesMalnutrition and cognitive impairment are associated with poor functional recovery in older adults following hip-fracture surgery. This study examined the combined effects of cognitive impairment and nutritional trajectories on postoperative functional recovery for older adults following hip-fracture surgery.DesignProspective longitudinal correlational study.Setting and ParticipantsThis study recruited 350 older adults (≥60 years of age) who received hip-fracture surgery at a 3000-bed medical center in northern Taiwan from September 2012 to March 2020.MethodsParticipant data were collected over a 2-year period after surgery for nutritional and cognitive status and activities of daily living (ADLs). Participants were grouped by type of nutritional trajectory using group-based trajectory modeling. Generalized estimating equations analyzed associations between trajectory groups/cognitive status at discharge and performance of ADLs.ResultsNutritional trajectories best fit a 3-group trajectory model: malnourished (19%), at-risk of malnutrition (40%), and well-nourished (41%). Nutritional status for the malnourished group declined from 12 months to 24 months following surgery; nutritional status remained stable for at-risk of malnutrition and well-nourished groups. Interactions for cognitive impairment-by-nutritional status were significant: the malnourished + intact cognition subgroup had significantly better ADLs than the malnourished + cognitive impairment subgroup (b = 27.1, 95% confidence interval = 14.0–40.2; P < .001). For at-risk of malnutrition and well-nourished groups, there were no significant differences between cognitive impairment and intact cognition in ADLs. These findings suggest that nutritional status may buffer the negative effect of cognitive impairment on ADLs.Conclusions and ImplicationsBetter nutritional status over time for older adults following hip fracture can protect against adverse influences of cognitive impairment on ADLs during postoperative recovery. Participants with malnutrition and cognitive impairment had the poorest ADLs. These findings suggest interventions tailored to improving nutritional status may improve recovery for older adults following hip-fracture surgery.     

Depression and Geographic Status as Predictors for Coronary Artery Bypass Surgery Outcomes

Purpose: To examine the relationships between depression, geographic status, and clinical outcomes following a coronary artery bypass grafting (CABG) surgery.
Methods: Using the 2004 Nationwide Inpatient Sample database, we identified 63,061 discharge records of patients who underwent a primary CABG surgery (urban 57,247 and rural 5,814). We analyzed 7 demographic variables, 19 preoperative medical and psychiatric variables, and 2 outcome variables (ie, in-hospital mortality and length of stay). Logistic regression and multivariable regression analyses were used to assess urban-rural status and depression as independent predictors of in-hospital mortality and length of stay.
Findings: Rural patients were more likely to have a comorbid depression diagnosis compared to urban patients (urban = 19.4%, rural = 21.4%, P < .001). After adjusting for confounding factors, having a comorbid depression diagnosis ( B = 1.10, P < .001) and residing in a rural area ( B = .986, P < .05) were associated with an increased length of in-hospital stay following CABG surgery. Furthermore, having a depression diagnosis (OR = 1.63, 95% CI = 1.45-2.21) and residing in a rural area (OR = 1.43, 95% CI = .896-1.45) were associated with an increased likelihood of in-hospital mortality.
Conclusions: Rural patients were more likely than urban ones to have a depression diagnosis. Depression was a significant independent predictor of both in-hospital mortality and length of stay for patients receiving CABG surgery. Also, rural patients had increased lengths of in-hospital stay as well as in-hospital mortality rates compared to those who resided in urban areas.     

住院病人营养风险筛查及营养支持对临床结局影响的研究

目的:应用欧洲营养筛查方法(NRS 2002)分析住院病人营养风险,并探讨营养支持的效果和合理性。方法:选取694例住院病人采用NRS 2002进行营养风险调查,依据病人是否接受营养支持和营养支持的类型,分析营养支持对病人临床结局的影响。结果:在694例住院病人中,营养不良率和营养风险发生率分别为为14.0%和27.5%。有营养风险的病人并发症的发生率显著高于无营养风险的病人(P0.01)。有营养问题的病人中接受营养支持者占总支持人数的81.7%,而无营养风险的病人中接受营养支持者占总支持人数的18.3%。在营养风险病人中,给予营养支持者并发症的发生率明显减少,缩短了住院时间。在营养风险病人中,肠内营养(EN)病人并发症的发生率也明显低于接受肠外营养(PN)者。结论:采用NRS 2002对住院病人营养风险和营养支持率的调查,可有效地鉴别住院病人的营养风险,并为营养支持提供依据。     

A longitudinal study of hospital undernutrition in the elderly: Comparison of four validated methods

Background  Undernutrition/nutritional risk were evaluated longitudinally in 531 hospitalized elderly by four validated methods to appraise the most feasible for routine use. Design  Within 48hrs of admission&24hrs before discharge: the following data were collected: clinical data, nutritional status (BMI, %weight loss) & risk (MNA, MUST), energy requirements (Owen et al), diet. Results  Significant changes from admission to discharge in risk/undernutrition prevalence, were not shown by BMI (≈17% vs 22%), ≥5% weight loss (≈53% vs ≈56%) or MNA 83% vs ≈81%; at admission, 93% patients were MUST high risk declining to ≈47% (p=0.001) at discharge, alongside eating resumption. By multivariate analysis comparing all methods&differences between patient groups during hospitalization, only %weight loss clarified nutritional progression: more surgical patients had ≥10% weight loss vs medicine, p<0.01. Only admission ≥5% weight loss was predictive of longer hospitalizations (OR:1.57; 95% CI 1.02–2.40; p<0.003), though MNA&MUST undernourished/high risk had significantly longer stays. MNA and MUST were the most concordant methods, p<0.001. Eating compromising symptoms were prevalent in surgery/medicine with ≥5% weight loss, MNA risk/undernutrition, and MUST high risk, p<0.005. Overall, mean energy requirements/diet were not significantly different between admission/discharge: requirements ≈1400kcal were always lower than on offer ≈2128kcal, p=0.0001. Conclusions  Rigid diets create costly waste which do not counteract nutritional deterioration. Different nutritional risk/status prevalences were unveiled at admission&discharge: >50% patients were at risk/undernourished by significant weight loss, MNA or MUST, all associated with longer stays. Recent weight loss is unarguably essential, comprehensive MNA & MUST similarly reliable; in this study dynamic MUST seemed easier to practise. Quality nutritional care before/during/after hospitalization is mandatory in the elderly.