Low phase angle is associated with the development of hepatic encephalopathy in patients with cirrhosis

AIM Evaluate the association between phase angle and the development of hepatic encephalopathy in the longterm follow-up of cirrhotic patients.METHODS This was a prospective cohort study. Clinical, nutritional and biochemical evaluations were performed. MannWhitney's U and χ2 tests were used as appropriate. Kaplan-Meier curves and Cox proportional Hazards analysis were used to evaluate the prediction and incidence of hepatic encephalopathy.RESULTS Two hundred and twenty were included; the most frequent etiology of cirrhosis was hepatitis C infection, 52% of the patients developed hepatic encephalopathy(18.6% covert and 33.3% overt); the main precipitating factors were infections and variceal bleeding. KaplanMeier curves showed a higher proportion of HE in the group with low phase angle(39%) compared to the normal phase angle group(13%)(P = 0.012). Furthermore, creatinine and phase angle remained independently associated to hepatic encephalopathy in the Cox regression multivariate analysis [hazard ratio = 1.80(1.07-3.03)]. CONCLUSION In our cohort of patients low phase angle was associated with an increased incidence of hepatic encephalopathy. Phase angle is a useful nutritional marker that evaluates cachexia and could be used as a part of the integral assessment in patients with cirrhosis.     

Nutritional evaluation in cirrhosis: Emphasis on the phase angle

Protein-calorie malnutrition(PCM) is a common condition in cirrhotic patients, leading to a worse prognosis, complications, poor quality of life and lower survival rates. Among ways of assessing nutritional status, there are anthropometric methods such as the evaluation of the triceps skinfold, the arm circumference, the arm muscle circumference and the body mass index, and nonanthropometric methods such as the subjective global assessment, the handgrip strength of non-dominant hand, and the bioelectrical impedance analysis(BIA). PCM is frequently under-diagnosed in clinical settings in patients with cirrhosis due to the limitations of nutritional evaluation methods in this population. BIA is a useful method, but cannot be indicated in patients with abnormal body composition. In these situations, the phase angle(PA) has been used, and can become an important tool in assessing nutritional status in any situation. The PA is superior to anthropometric methods and might be considered as a nutritional indicator in cirrhosis. The early characterization of the nutritional status in patients with cirrhosis means an early nutritional intervention, with a positive impact on patients' overall prognosis. Among the usually accepted methods for nutritional diagnosis, the PA provides information in a quick and objective manner.     

Mortality rate of chronically ill geriatric patients with subnormal serum thyrotropin concentration: a 2-yr follow-up study

We investigated the natural course of subclinical thyroid dysfunctions in geriatric patients, especially regarding their association with mortality rate. Ninety-three randomly selected chronically ill geriatric patients 64–87 (median: 77) yr of age participated in the screening study with a 2-yr follow-up. Serum thyrotropin (thyroid-stimulating hormone [TSH]), free thyroxine, triiodothyronine, and antibodies against thyroid peroxidase were measured. During the follow-up, patients with suppressed TSH levels who were otherwise euthyroid (untreated) had a higher mortality rate than patients with normal TSH (5/8 vs 18/64; p<0.05). The initial clinical state of these two subgroups did not differ significantly. Two-thirds of patients with treated hyperthyroidism died. The mortality rate of patients with initially subnormal but not suppressed TSH level was average and did not differ statistically from either the euthyroid or the hyperthyroid groups. Only 1 of 13 euthyroid patients with positive thyroid antibody titers developed a subsequent subclinical hypothyroidism. Subclinical hyperthyroidism was found to be associated with a higher mortality rate in chronically ill geriatric patients, which justifies screening for thyroid dysfunction and treatment of subclinical hyperthyroidism. In addition, a subnormal but measurable TSH was not indicative regarding the future development of hyperthyroidism. Finally, during the 2-yr follow-up, antibody positivity in the euthyroid cases did not prove to be predictive for the subsequent development of hypothyroidism.     

Rehabilitation outcomes of older Chinese patients with different cognitive function in a geriatric day hospital

The relationship between cognitive function and geriatric day hospital (GDH) rehabilitation has not been explored. This study investigated this association in 547 older Chinese patients attended GDH. Cognitive status was assessed by Cantonese version of mini-mental state examination (C-MMSE). Functional independence measure (FIM) upon GDH admission and discharge were measured, with FIM gain = FIM discharge − FIM admission while FIM efficiency = FIM gain/by number of GDH visits. FIM discharge ≥90 was defined as satisfactory outcome of rehabilitation. Positive correlation was observed between C-MMSE admission and FIM discharge (p < 0.001). There were significant differences in the FIM admission and FIM discharge among the three C-MMSE groups, with lower discharge scores in low C-MMSE groups (p < 0.001). The FIM gain and FIM efficiency during GDH rehabilitation were not different among different C-MMSE groups. C-MMSE admission (p = 0.03) and FIM admission (p < 0.001) were both positive independent predictors for a satisfactory rehabilitation outcomes (FIM discharge ≥90). Cognitive function was not associated with FIM gain and efficiency. This suggested that selected patients with impaired cognition could still benefit from GDH rehabilitation.     

Low testosterone is associated with decreased function and increased mortality risk: a preliminary study of men in a geriatric rehabilitation unit

OBJECTIVES: To evaluate whether low testosterone levels are associated with greater depression or poorer function in a geriatric rehabilitation unit. DESIGN: Retrospective review. SETTING: Geriatric rehabilitation unit. MEASUREMENTS: Low testosterone levels were defined as total testosterone of 3.0 ng/mL or less or free testosterone of 9.0 pg/mL or less. Age, ethnicity, weight, depression, ambulation, length of rehabilitation, and 6-month rehospitalization and mortality rates were obtained. Overall illness severity was determined using the Cumulative Illness Rating Scale for Geriatrics. RESULTS: Low testosterone levels were present in 29 of 44 (65.9%) men. There were no significant differences between men with low and normal testosterone levels in ethnicity, age, weight, depression, and overall illness severity. Lower testosterone levels were correlated with decreased ability to ambulate and transfer (Spearman P>.34; P<.05). There were no significant differences between men with low and normal testosterone in length of stay on the rehabilitation unit (mean+/-standard deviation= 19.6+/-11.6 vs 17.7+/-17.5 days, P=.68) or rehospitalization rates (41.4% vs 26.7%; P=.34). Men with low testosterone had a trend toward increased 6-month mortality (31.0% vs 6.7%; chi(2)=3.3, P=.07) and shorter survival time (log rank=3.2; df 1, P=.07). After entering testosterone and variables with potential prognostic significance for mortality in a stepwise manner in a Cox regression analysis, there was a significant mortality risk associated with low testosterone (hazard ratio=27.9, 95% confidence interval=2.0-384.0; P=.01). CONCLUSION: Low testosterone levels were correlated with decreased physical function and increased risk for 6-month mortality. Prospective studies with larger sample sizes and better standardized testosterone measures are needed to confirm these findings.     

Influence of orthostatic hypotension on mortality among patients discharged from an acute geriatric ward

BACKGROUND: Orthostatic hypotension (OH) is a common finding among older patients. The impact of OH on mortality is unknown. OBJECTIVE: To study the long-term effect of OH on total and cardiovascular mortality. PATIENTS AND METHODS: A total of 471 inpatients (227 males and 244 females), with a mean age of 81.5 years who were hospitalized in an acute geriatric ward between the years 1999 and 2000 were included in the study. Orthostatic tests were performed 3 times during the day on all patients near the time of discharge. Orthostatic hypotension was defined as a fall of at least 20 mmHg in systolic blood pressure (BP) and/or 10 mmHg in diastolic BP upon assuming an upright posture at least twice during the day. Patients were followed until August 31, 2004. Mortality data were taken from death certificates. RESULTS: One hundred and sixty-one patients (34.2%) experienced OH at least twice. Orthostatic hypotension had no effect on all cause and cause specific mortality. Over a follow-up of 3.47+/-1.87 years 249 patients (52.8%) had died 83 of whom (33.3%) had OH. Age-adjusted mortality rates in those with and without OH were 13.4 and 15.7 per 100 person-years, respectively. Cox proportional hazards model analysis demonstrated that male gender, age, diabetes mellitus, and congestive heart failure increased and high body mass index decreased total mortality. CONCLUSIONS: Orthostatic hypotension is relatively common in elderly patients discharged from acute geriatric wards, but has no impact on vascular and nonvascular mortality.     

Increased hospital mortality in patients with bedside hippus

Background

Hippus is a prominent, repetitive oscillation of the pupils. Although regarded by some as a normal variant of pupillary unrest, the clinical importance of hippus has not been investigated systematically in hospitalized patients.

Methods

We conducted a retrospective cohort study of 117 hospitalized patients demonstrating hippus. To mitigate observer bias, 486 control patients were selected using 2 adjacent admissions by the same attending physician before and after each index case. The primary outcomes were mortality during the admission and within 30 days of discharge.

Results

Patients with bedside hippus were more likely to die within 30 days of observation (P <.00005). Independent risk factors for death by 30 days were altered mental status (odds ratio [OR] 4.11; 95% confidence interval [CI], 2.05-8.25, P <.001), hippus (OR 2.99; 95% CI, 1.46-6.11, P = .003), cirrhosis (P = .029), and renal disease (P = .054); angiotensin-system inhibitors were protective (P = .012). Patients with hippus were more likely to have altered mental status (OR 11.23; 95% CI, 6.27-20.09, P <.001), a history of trauma (OR 3.76; 95% CI, 1.65-8.59, P = .002), cirrhosis (P = .038), renal disease (P = .051), and a history of using iron supplements (P = .016).

Conclusion

The recognition of hippus in hospitalized patients is a clinically important predictor of early mortality.     

Day care service use is associated with lower mortality in community-dwelling frail older people

OBJECTIVES: To clarify the association between day care service use and 21-month mortality in community-dwelling frail older people. DESIGN: Prospective cohort study (the Nagoya Longitudinal Study for Frail Elderly). SETTING: Community-based. PARTICIPANTS: One thousand six hundred seventy-three community-dwelling older people (540 men, 1,133 women). MEASUREMENTS: Data included the clients' demographic characteristics; depression as assessed using the short version of the Geriatric Depression Scale; a rating for basic activities of daily living (ADLs); comorbidity; number of prescribed medications and physician-diagnosed chronic diseases; use of home-care services, including day care, visiting nurse, and home-help services; and number of regular medical checkups. Survival analysis of 21-month mortality was conducted using Kaplan-Meier curves and multivariate Cox proportional hazards models. RESULTS: Of the 1,673 participants, 726 were day care service users at baseline, and 268 (94 day care service users, 174 nonusers) died during the 21-month follow-up. Multivariate Cox regression models adjusting for potential confounders showed that day care service use was associated with reduction in mortality. Subgroup analysis demonstrated that day care service use was associated with less risk of mortality in subjects who were female; were in the youngest age group (65-74); had higher ADL scores, lower comorbidity, depression, no dementia; and used a visiting nurse service. Participants using day care service two and three times or more a week had 63% or 44% lower relative hazard ratios, respectively, than participants not using the service. CONCLUSION: Among community-dwelling frail older people, day care service use two or more times per week was associated with 44% to 63% lower 21-month mortality.     

Hypoalbuminemia is also a marker of fluid excess determined by bioelectrical impedance parameters in dialysis patients

Hypoalbuminemia may be secondary to volume expansion conditions and an independent risk factor for cardiovascular disease. Bioelectrical impedance analysis (BIA) is an accurate, non-invasive method to measure body composition, especially the water compartments in humans. The aim of this cross-sectional study is to evaluate the relationship between serum albumin concentration (SA) and hydration state measured by whole BIA. The study investigated 108 non-selected patients (73 on hemodialysis, 35 on peritoneal dialysis) with a mean age of 61.4 +/- 15.6 years, 42.7% of whom were female. The patients were allotted to groups according to their SA: Group 1, < or = 3.5 g/dL; Group 2, 3.6-4.0 g/dL; and Group 3, >4.0 g/dL. The BIA parameters used included: total body water, intracellular water (ICW), extracellular water (ECW), phase angle (PA), body cell mass (BCM), ICW/ECW ratio and ICW/ECW ratio patients/controls (fluid index). Seventy-five healthy volunteers formed the control group. A strong positive correlation was found between the PA and fluid index (r (2) = 0.993, P < 0.001), as well as between the PA and SA (r = 0.386, P < 0.001), and the ICW/ECW ratio and SA (r = 0.227, P < 0.001). The ECW was negatively correlated with SA (r = -0.330, P < 0.001). Every 0.1 g/dL decrease in SA was associated with a 0.33 L increase in ECW. Group 1 patients had lower reactance (P = 0.006), PA (P < 0.001), BCM (P = 0.012), fluid index (P < 0.001) and ICW/ECW ratio (P = 0.015), and an increased ECW (NS) than groups 2 and 3. We conclude that hypoalbuminemia is also a marker of fluid excess. The SA is associated to the fluid index and the PA allows assessment of the dry weight and its variations in an individualized manner in dialysis patients.     

Malnutrition is independently associated with an increased risk of major cardiovascular events in adult patients with congenital heart disease

Background and aimsMalnutrition is found frequently during chronic diseases, and its prevalence and relation to disease outcome in adult patients with congenital heart disease (CHD) remains unknown.Methods and resultsA cohort of 393 consecutive stable congenital heart disease (CHD) patients was followed up in a single dedicated clinical unit. Demographic, clinical and laboratory parameters, along with a nutritional risk index (NRI), were studied, as well as major acute cardiovascular events (MACE), defined as arterial thrombotic events, heart failure requiring hospitalization or cardiovascular and non-cardiovascular mortality. The median age of the patients was 23 years (17–35) and 225 (57%) were males. Median plasma albumin concentration was 4.5 (4.2–4.7) g/dL, the body mass index was 23 (21–27) kg/m², the NRI was 112 (106–118), and 33 (8%) patients showed malnutrition (NIR<100). A worse NYHA functional class (II and III), total cholesterol and serum glucose levels were significant risk factors associated with malnutrition (NRI<100) in CHD patients. During a median follow-up of 8 (5–10) years, 39 (10%) CHD patients suffered a MACE. Multivariable Cox regression analysis showed that older patients (years) [HR 1.06 (1.04–1.09), p < 0.001], CHD patients with great anatomical complexity [HR 4.24 (2.17–8.27), p < 0.001] and those with a lower NRI [HR 0.95 (0.93–0.98), p = 0.001] had a significant worse MACE-free survival, being the NRI a better predictor of MACE than albumin concentration.ConclusionsA low NRI is independently associated with a significant increased risk of MACE in CHD patients.     

Low total cholesterol is associated with high total mortality in patients with coronary heart disease

The present non-intervention screening study was undertakento explore the relationships between pre-existing low totalcholesterol and all-cause mortality. Eleven thousand, five hundredand sixty-three patients with coronary heart disease who attendeda screening visit but were not included in the Bezafibrate InfarctionPrevention study were followed-up for a mean of 3·3 yearsafter determination of baseline total cholesterol. Five hundredand ninety-five (5%) of this largely unselected population whohad total cholesterol levels 160 mg. dl^–1 formed thestudy population. The remaining 10 968 patients acted as controls.The relative risk of all-cause mortality among patients withlow cholesterol compared to others was 1·49 (95% CI:1·16–1·91). The relative risk of non-cardiacdeath was 2·27 times higher in the low cholesterol groupthan in the controls (95· CI: 1·49–3·45),whereas the risk of cardiac death was the same in both groups(relative risk 1·09; 95% CI: 0·76–1·56).The most frequent cause of non-cardiac death associated withlow total cholesterol was cancer. These results in patientswith coronary heart disease add weight to previous studies associatinglow total cholesterol with an increased risk of non-cardiacdeath. However, a longer follow-up of this cohort of patientsis necessary in order to clarify this association.     

Phase angle as a predictor of functional outcomes in patients undergoing in-hospital rehabilitation after hip fracture surgery

ObjectivesTo evaluate the association between the phase angle and functional outcomes in patients after in-hospital postoperative rehabilitation for fragility hip fracture.MethodsA prospective observational study was conducted in 68 patients over 65 years of age who had undergone a two-week postoperative rehabilitation for hip fracture. Phase angle of the non-fractured limb was used to reduce the error caused by postoperative edema. Participants were divided into groups according to phase angle terciles. Multivariable linear regression models adjusted for relevant factors known to affect functional outcomes after hip fracture were performed to identify the association between phase angle of the non-fractured limb and functional outcomes at discharge as evaluated the Functional Ambulation Category and Berg Balance Scale.ResultsThe mean age of this study population was 81.9 ± 6.2 years and the average phase angle of the non-fractured limb was 3.6 ± 1.3°. The lowest tercile of phase angle (<3.0°) was independently associated with worse functional outcomes as measured by the Functional Ambulation Category and Berg Balance Scale at discharge (adjusted coefficient [β] = -0.287, P = 0.004; β = -0.172, P = 0.049, respectively) after adjusting for relevant covariates.ConclusionsLow phase angle of the non-fractured limb was independently associated with worse functional outcomes at rehabilitation discharge in patients who undergoing hip fracture surgery. Phase angle may reflect both the pre-fracture body composition and functional status. It is a useful indicator for functional outcomes after postoperative rehabilitation for fragility hip fracture.