Prevalence of osteosarcopenia and its association with mortality and fractures among patients undergoing hemodialysis.

INTRODUCTION: Osteosarcopenia is an age-related syndrome characterized by the coexistence of osteoporosis and sarcopenia. Little is known about the clinical implications of osteosarcopenia among patients undergoing hemodialysis. This study investigated the prevalence of osteosarcopenia and its association with all-cause mortality and fractures in this population. MATERIALS AND METHODS: This retrospective cohort study included outpatients undergoing hemodialysis in Japan. Sarcopenia was defined according to the recommendations of the Asian Working Group for Sarcopenia 2019. Osteoporosis was defined as a T-score of the calcaneus bone < - 2.5. We divided patients into three groups: robust (no osteoporosis or sarcopenia), osteoporosis or sarcopenia alone (osteoporosis without sarcopenia or sarcopenia without osteoporosis), and osteosarcopenia (osteoporosis and sarcopenia). Cox proportional-hazard and negative binomial regression models were used to estimate the associations between osteosarcopenia and all-cause mortality and fractures. RESULTS: Among the 328 patients (mean age, 65.5 ± 11.3 years; men, 59.1%), the prevalence of osteosarcopenia was 22.9%. During the follow-up period (1972 person-years), 131 deaths and 113 fractures occurred. Patients with osteoporosis or sarcopenia alone (hazard ratio 1.36; 95% confidence interval 0.85-2.18) and osteosarcopenia (hazard ratio 2.13; 95% confidence interval, 1.23-3.68) showed a higher risk of all-cause mortality than the robust group. Similar results were observed for the risk of fractures in patients with osteosarcopenia. CONCLUSIONS: Patients undergoing hemodialysis showed a high prevalence of osteosarcopenia, and osteosarcopenia was associated with a poor prognosis in this patient population. Assessing osteosarcopenia may be useful for accurate prognostic stratification of patients undergoing hemodialysis.

Cancer history and physical function in patients with cardiovascular disease.

Both cancer and cardiovascular disease (CVD) cause skeletal muscle mass loss, thereby increasing the likelihood of a poor prognosis. We investigated the association between cancer history and physical function and their combined association with prognosis in patients with CVD. We retrospectively reviewed 3,796 patients with CVD (median age: 70 years; interquartile range [IQR]: 61-77 years) who had undergone physical function tests (gait speed and 6-minute walk distance [6MWD]) at discharge. We performed multiple linear regression analyses to assess potential associations between cancer history and physical function. Moreover, Kaplan-Meier curves and Cox regression analyses were used to evaluate prognostic associations in four groups of patients categorized by the absence or presence of cancer history and of high or low physical function. Multiple regression analyses showed that cancer history was significantly and independently associated with a lower gait speed and 6MWD performance. A total of 610 deaths occurred during the follow-up period (median: 3.1 years; IQR: 1.4-5.4 years). The coexistence of low physical function and cancer history in patients with CVD was associated with a significantly higher mortality risk, even after adjusting for covariates (cancer history/low gait speed, hazard ratio [HR]: 1.93, P < 0.001; and cancer history/low 6MWD, HR: 1.61, P = 0.002). Cancer history is associated with low physical function in patients with CVD, and the combination of both factors is associated with a poor prognosis.

Reserved gait capacity and mortality among patients undergoing hemodialysis.

BACKGROUND: Patients undergoing hemodialysis (HD) have difficulty increasing their gait speed in daily life. The extent of the increase from the usual gait speed (UGS) to the maximum gait speed (MGS) is considered the reserved gait capacity (RGC). Little is known regarding the implications of RGC. This study aimed to investigate the association between RGC and all-cause mortality in patients undergoing HD. METHODS: In this retrospective study, we assessed the usual and maximum 10-m walking speed of outpatients who underwent HD between October 2002 and August 2021. RGC was defined as the ratio of MGS to UGS. Patients were divided into three groups according to the tertiles of RGC (low, moderate and high). A Cox proportional hazards regression model was used to examine the association between RGC and all-cause mortality. RESULTS: Of the 496 (median age 66.0 years; men 59%) participants, 186 patients died during the follow-up (incident ratio of 62.0 per 1000 person-years). The patients with moderate [hazard ratio (HR) 0.66, 95% confidence interval (CI) 0.46-0.94] and high (HR 0.44, 95% CI 0.30-0.65) RGC had a lower risk of mortality than the low RGC group. Furthermore, even when restricted to a population with only UGS <1.0 m/s, the group with high RGC still had a lower risk of mortality than those with low RGC (HR 0.55, 95% CI 0.33-0.94). CONCLUSIONS: Lower RGC was independently associated with an increased risk of all-cause mortality among patients on HD; high RGC had a survival advantage even with a slow UGS.

Comparison of the association between six different frailty scales and clinical events in patients on hemodialysis.

BACKGROUND: Frailty is associated with adverse outcomes in patients undergoing hemodialysis (HD). However, no study has used various frailty assessments in patients on HD to examine their association with clinical events. In this study, we investigated the association between clinical events and six frailty scales. METHODS: Outpatients who underwent HD between 2018 and 2020 were retrospectively enrolled. Frailty was defined using the Fried Frailty Phenotype, Study of Osteoporotic Fractures (SOF) Index, Short Physical Performance Battery (SPPB), Frail Screening Index, FRAIL scale and Clinical Frailty Scale. Outcomes were clinical events, including a composite of multiple (i.e. recurrent) all-cause hospitalizations, fractures and/or all-cause mortality. The association of clinical events and the frailty scales were investigated using negative binomial regression analysis. RESULTS: Fried Frailty Phenotype [incident rate ratio (IRR), 1.62; 95% confidence interval (CI), 1.49-1.76], SOF Index (IRR, 1.42; 95% CI, 1.10-1.83), SPPB (IRR, 1.79; 95% CI, 1.11-2.88) and Clinical Frailty Scale (IRR, 1.65; 95% CI, 1.04-2.61) were significantly associated with clinical events. However, Frail Screening Index (IRR, 1.38; 95% CI, 0.60-3.18) and FRAIL scale (IRR, 1.30; 95% CI, 0.88-1.92) showed no significant association with clinical events. CONCLUSIONS: Objective frailty assessments (SPPB) and medical staff impression-based frailty (Clinical Frailty Scale) may be useful prognostic predictors for patients on HD. Questionnaire-based frailty assessment should be carefully considered when used as a measurement of frailty.

Relationship between the spread of COVID-19, social frailty, and depressive symptoms in patients with heart failure.

In community-dwelling older people, coronavirus disease 2019 (COVID-19) has been reported to be associated with the development of frailty and depressive symptoms. We aimed to investigate whether the spread of COVID-19 is associated with the development of frailty in patients with heart failure (HF). The presence of the multi-domain of frailty in 257 patients with HF was assessed at hospital discharge. The spread of COVID-19 was significantly associated with the development of social frailty and depressive symptoms. Evaluation of these symptoms during hospitalization would support disease management and understanding of their social and psychological conditions.

The Association of Short Physical Performance Battery With Mortality and Hospitalization in Patients Receiving Hemodialysis.

OBJECTIVE: The Short Physical Performance Battery (SPPB) is recommended for evaluating physical performance in patients on hemodialysis (HD). However, the association between SPPB score and long-term health outcomes in these patients remains unclear. We examined the association of SPPB score with all-cause mortality, all-cause hospitalization, and cardiovascular hospitalization in patients on HD. DESIGN AND METHODS: This retrospective cohort study included 326 patients (median age, 68 years; 62% men) who received outpatient HD therapy. These patients were divided into 2 SPPB groups: low (SPPB ≤9) and high (SPPB >9). We investigated the association of SPPB score and their change over time with health outcomes using Cox regression analysis. RESULTS: Low SPPB score was associated with a higher risk for all-cause mortality (hazard ratio [HR]: 3.19, 95% confidence interval [95% CI]: 1.89-5.38), all-cause hospitalization (HR: 2.01, 95% CI: 1.44-2.82), and cardiovascular hospitalization (HR: 2.20, 95% CI: 1.45-3.35). Additionally, change in SPPB score over 1 year was associated with health outcomes. CONCLUSIONS: Lower SPPB score was significantly associated with a higher risk for all-cause mortality, all-cause hospitalization, and cardiovascular hospitalization. The SPPB may be a valuable indicator for risk stratification in patients on HD. Additionally, preventive treatments may be an effective management strategy in limiting the high mortality and hospitalization rates in patients with decreased SPPB score.

Trajectory of Serum Albumin Prior to Death in Patients Receiving Hemodialysis.

OBJECTIVE: Although some clinical expert guidelines recommend regular monitoring of serum albumin levels in patients undergoing maintenance hemodialysis, little is known about the serum albumin trajectory patterns over time, and it is unclear how the trajectory change before death. METHODS: We performed this retrospective study using data from 421 patients receiving hemodialysis in a dialysis facility. We divided patients into died and survived groups according to whether they died during the observation period. To compare the albumin trajectories during the observation period between the died and survived groups, linear mixed-effect models and a backward timescale from the year of death or study end were used. RESULTS: During the observation period (median, 5.1 years; maximum, 8.4 years), 115 patients receiving dialysis died. The serum albumin level showed steeper decline 3 years before death in the died group than in the survived group. The difference in albumin between the died and survived groups became apparent 3 years before death (difference, 0.08 g/dL; 95% confidence interval, 0.00-0.15 g/dL; P = .04), and the difference widened over time (difference at 1 year before death, 0.24 g/dL; 95% confidence interval, 0.14-0.33 g/dL; P < .001). Furthermore, in an analysis of albumin trajectories according to cause of death, the albumin level showed a downward trend regardless of the cause of death. CONCLUSION: The serum albumin trajectory differed between patients undergoing hemodialysis who died and who survived, supporting the importance of monitoring the albumin trajectory in clinical practice.

Trends and Outcomes of Early Rehabilitation in the Intensive Care Unit for Patients With Cardiovascular Disease: A Cohort Study With Propensity Score-Matched Analysis.

BACKGROUND: The effectiveness of acute-phase cardiovascular rehabilitation (CR) in intensive care settings remains unclear in patients with cardiovascular disease (CVD). This study aimed to investigate the trends and outcomes of acute-phase CR in the intensive care unit (ICU) for patients with CVD, including in-hospital and long-term clinical outcomes. METHOD: This retrospective cohort study reviewed a total of 1,948 consecutive patients who were admitted to a tertiary academic ICU for CVD treatment and underwent CR during hospitalisation. The endpoints of this study were the following: in-hospital outcomes: probabilities of walking independence and returning home; and long-term outcomes: clinical events 5 years following hospital discharge, including all-cause readmission or cardiovascular events. It evaluated the associations of CR implementation during ICU treatment (ICU-CR) with in-hospital and long-term outcomes using propensity score-matched analysis. RESULTS: Among the participants, 1,092 received ICU-CR, the rate of which tended to increase with year trend (p for trend <0.001). After propensity score matching, 758 patients were included for analysis (pairs of n=379 ICU-CR and non-ICU-CR). ICU-CR was significantly associated with higher probabilities of walking independence (rate ratio, 2.04; 95% CI 1.77-2.36) and returning home (rate ratio, 1.22; 95% CI 1.05-1.41). These associations were consistently observed in subgroups aged >65 years, after surgery, emergency, and prolonged ICU stay. ICU-CR showed significantly lower incidences of all-cause (HR 0.71; 95% CI 0.56-0.89) and cardiovascular events (HR 0.69; 95% CI 0.50-0.95) than non-ICU-CR. CONCLUSIONS: The implementation of acute-phase CR in ICU increased with year trend, and is considered beneficial to improving in-hospital and long-term outcomes in patients with CVD and various subgroups.

Glycemic status and the association of change in blood pressure with incident cardiovascular disease.

BACKGROUND: The clinical benefit of blood pressure (BP) reduction in individuals with diabetes has not been fully elucidated. We sought to identify the clinical impact of BP reduction on incident cardiovascular disease in people having diabetes and hypertension. METHODS: We conducted a retrospective cohort study including 754,677 individuals (median age 47 years, 75.8 % men) with stage 1/stage 2 hypertension. Participants were categorized using fasting plasma glucose (FPG) at baseline as normal FPG (FPG < 100 mg/dL) (n = 517,372), prediabetes (FPG:100-125 mg/dL) (n = 197,836), or diabetes mellitus (FPG ≥126 mg/dL) (n = 39,469). The primary outcome was heart failure (HF), and the secondary outcomes included ischemic heart disease (IHD) including myocardial infarction and angina pectoris, and stroke. RESULTS: Over a mean follow-up of 1111 ± 909 days, 18,429 HFs, 17,058 IHDs, and 8,795 strokes were recorded. Reduction in BP of< 120/80 mmHg at 1year was associated with a lower risk of developing HF (HR:0.77, 95% CI:0.72-0.82), IHD (HR:0.84, 95% CI:0.79-0.89), and stroke (HR:0.75, 95% CI:0.69-0.82) in individuals with normal FPG, whereas it was not associated with a risk of developing HF (HR:0.98, 95% CI:0.81-1.17) and stroke (HR:0.82, 95% CI:0.62-1.09) in those with DM. Interaction analyses showed that the influence of BP reduction on incident HF was attenuated with people with prediabetes or DM. A multitude of sensitivity analyses confirmed our results. CONCLUSIONS: The association of BP reduction with the risk of developing HF was attenuated with deteriorating glucose tolerance. The optimal management strategy for hypertensive people with prediabetes or DM for the prevention of developing cardiovascular disease (particularly HF) is needed to be established.

Comparison of cardiovascular outcomes between SGLT2 inhibitors in diabetes mellitus.

BACKGROUND: There have been scarce data comparing cardiovascular outcomes between individual sodium-glucose cotransporter-2 (SGLT2) inhibitors. We aimed to compare the subsequent cardiovascular risk between individual SGLT2 inhibitors. METHODS: We analyzed 25,315 patients with diabetes mellitus (DM) newly taking SGLT2 inhibitors (empagliflozin: 5302, dapagliflozin: 4681, canagliflozin: 4411, other SGLT2 inhibitors: 10,921). We compared the risks of developing heart failure (HF), myocardial infarction (MI), angina pectoris (AP), stroke, and atrial fibrillation (AF) between individual SGLT2 inhibitors. RESULTS: Median age was 52 years, and 82.5% were men. The median fasting plasma glucose and HbA1c levels were 149 (Q1-Q3:127-182) mg/dL and 7.5 (Q1-Q3:6.9-8.6) %. During a mean follow-up of 814 ± 591 days, 855 HF, 143 MI, 815 AP, 340 stroke, and 139 AF events were recorded. Compared with empagliflozin, the risk of developing HF, MI, AP, stroke, and AF was not significantly different in dapagliflozin, canagliflozin, and other SGLT inhibitors. For developing HF, compared with empagliflozin, hazard ratios of dapagliflozin, canagliflozin, and other SGLT2 inhibitors were 1.02 (95% confidence interval [CI] 0.81-1.27), 1.08 (95% CI 0.87-1.35), and 0.88 (95% CI 0.73-1.07), respectively. Wald tests showed that there was no significant difference in the risk of developing HF, MI, AP, stroke, and AF among individual SGLT2 inhibitors. We confirmed the robustness of these results through a multitude of sensitivity analyses. CONCLUSION: The risks for subsequent development of HF, MI, AP, stroke, and AF were comparable between individual SGLT2 inhibitors. This is the first study comparing the wide-range cardiovascular outcomes of patients with DM treated with individual SGLT2 inhibitors using large-scale real-world data.

Threshold of BMI for the Development of Hypertension among Japanese Adults.

BACKGROUND: The optimal value of BMI for the development of hypertension and the influence of BMI on the development of stage 1 or stage 2 hypertension remain unclear. OBJECTIVES: We sought to identify the BMI threshold for the prevention of hypertension and how changes in BMI would influence the risk of developing hypertension. METHODS: We analyzed 1,262,356 participants (median age: 43 y; 50.9% men) with normal blood pressure [BP; systolic BP (SBP) <120 mmHg and diastolic BP (DBP) <80 mmHg] or elevated BP (SBP: 120-129 mmHg and DBP <80 mmHg). The primary outcome was stage 1 (SBP 130-139 mmHg or DBP 80-89 mmHg) or stage 2 hypertension (SBP ≥140 mmHg or DBP ≥90 mmHg). We analyzed the relation between baseline BMI, change in BMI, and the risk of developing hypertension using generalized additive models with a smoothing spline. RESULTS: During the median follow-up of 851 d, 341,212 cases of stage 1 hypertension and 70,968 cases of stage 2 hypertension were detected. The risk of developing stage 1 or stage 2 hypertension increased steeply after BMI (kg/m2) exceeded 20. The annual change in BMI was positively correlated with the risk of developing stage 1 or 2 hypertension. Contour mapping using generalized additive models demonstrated an additive increase in the risk of developing hypertension with higher baseline BMI and increases in BMI over 1 y. Body-weight gain increases the risk of developing hypertension even in underweight or normal-weight individuals based on the WHO classification. CONCLUSIONS: In Japanese adults with normal or elevated BP, the risk of developing hypertension increased with BMI when baseline BMI was >20. Body-weight gain additively interacted with baseline BMI during hypertension development. Our results underscore the importance of maintaining body weight in preventing the development of hypertension.

Proteinuria and Risk for Heart Failure in 55,191 Patients Having History of Cancer.

INTRODUCTION: We examined the association of proteinuria with the risk for heart failure (HF) and other cardiovascular disease (CVD) events in patients with prior history of breast, colorectal, or stomach cancer using a nationwide population-based database. METHODS: We conducted this retrospective observation study using the JMDC Claims Database and analyzed 55,191 patients with prior history of breast, colorectal, or stomach cancer. The median age was 54 (48-60) years, and 20,665 participants (37.4%) were men. Using urine dipstick data at baseline, 3,945 and 1,521 participants were categorized as having trace and positive proteinuria, respectively. Using Cox proportional hazards models, we examined the relationship of proteinuria with the incidence of HF and other CVD events. RESULTS: Over a mean follow-up of 2.8 ± 2.2 years, 1,597 HF, 124 myocardial infarction, 1,342 angina pectoris, 719 stroke, and 361 atrial fibrillation events were recorded. Kaplan-Meier curves showed that the cumulative incidence for HF increased with proteinuria category (log-rank p < 0.001). After multivariable adjustment, hazard ratios of trace and positive proteinuria for HF were 1.24 (95% CI, 1.04-1.47) and 1.62 (95% CI, 1.30-2.02), respectively. The presence of proteinuria was also associated with a higher risk for angina pectoris and atrial fibrillation. DISCUSSION: Proteinuria was associated with a greater risk of developing HF and other CVD events in patients with prior history of cancer. The optimal management strategy for patients with proteinuria and cancer needs to be established for the prevention of HF in cancer patients.

Impact of Glucose Tolerance and Its Change on Incident Proteinuria: Analysis of a Nationwide Population-Based Dataset.

INTRODUCTION: Although diabetes mellitus (DM) increases the risk of proteinuria, the relationship between prediabetes and proteinuria remains not fully understood. Further, whether the change in glucose is associated with the risk for proteinuria is unknown. METHODS: This was a retrospective cohort study that included 1,849,074 participants (median age, 45 years; 59.3% men). No participants were taking glucose-lowering medications, and none had positive proteinuria at the initial health check-up. Each participant was categorized into three groups: normal (hemoglobin A1c [HbA1c] of <5.7%, n = 1,563,121), prediabetes (HbA1c of 5.7-6.4%, n = 253,490), and DM (HbA1c of ≥6.5%, n = 32,463) groups. We investigated the association between each HbA1c category and incident proteinuria using Cox proportional hazards models. We analyzed the association between the annual change in HbA1c and the risk for proteinuria. RESULTS: A total of 65,954 participants developed proteinuria during the observation period. Not only DM (hazard ratio [HR]: 2.15, 95% confidence interval [CI]: 2.07-2.24) but also prediabetes (HR: 1.14, 95% CI: 1.12-1.17) was associated with a greater risk for proteinuria. The relative risk reduction for proteinuria that was associated with prediabetes and DM was 12.3% and 53.5%, respectively. An annual increase in HbA1c was associated with a greater risk for proteinuria. This association was more pronounced in participants having prediabetes. CONCLUSION: Not only DM but also prediabetes increased the risk for proteinuria. The influence of change in HbA1c on incident proteinuria was pronounced in people with prediabetes. Optimizing glucose would provide more benefit to individuals having prediabetes for proteinuria prevention.

Change in Cardiovascular Health Metrics and Risk for Proteinuria Development: Analysis of a Nationwide Population-Based Database.

INTRODUCTION: Evidence is lacking regarding the association between cardiovascular health (CVH) metrics and the risk for proteinuria. METHODS: We performed this observational cohort study including 865,087 participants (median age, 46 years, 60.7% men) with negative proteinuria at the initial health check-up, who underwent repeated health check-ups within 4 years. Ideal CVH metrics included nonsmoking, body mass index <25 kg/m2, physical activity at goal, eating breakfast, blood pressure <120/80 mm Hg, fasting plasma glucose <100 mg/dL, and total cholesterol <200 mg/dL. The primary outcome was incident proteinuria, defined as ≥1 + on the urine dipstick test. RESULTS: Participants were categorized as having low CVH metrics defined as having 0-2 ideal CVH metrics (n = 84,439), middle CVH metrics defined as having 3-4 ideal CVH metrics (n = 335,773), and high CVH metrics defined as having 5-7 ideal CVH metrics (n = 444,875). Compared with low CVH metrics, middle CVH metrics (odds ratio (OR): 0.61, 95% CI: 0.59-0.63) and high CVH metrics (OR: 0.45, 95% CI: 0.43-0.46) were associated with a lower risk of proteinuria. The OR of a one-point increase in the ideal number of CVH metrics was 0.83 (95% CI: 0.82-0.83). All CVH metrics components except for ideal total cholesterol were associated with a decreased risk of proteinuria. A one-point improvement in the number of ideal CVH metrics at 1 year after the initial health check-up was associated with a decreased incidence of proteinuria (OR: 0.90, 95% CI: 0.89-0.92). CONCLUSION: Not only maintaining better CVH metrics but also improving CVH metrics would prevent developing proteinuria in a general population.

Comparative Analysis of Simplified, Objective Nutrition-Associated Markers in Patients Undergoing Hemodialysis.

OBJECTIVE: Protein-energy wasting is prevalent among patients undergoing dialysis. Hence, identifying an optimal index is necessary for the comprehensive measurement of nutritional status. This study evaluated and compared the prognostic significance of the modified creatinine index (mCI) and geriatric nutritional risk index (GNRI), with the principal aim to identify markers that are more closely associated with clinical events in patients undergoing hemodialysis. METHODS: We performed a retrospective cohort study of 472 patients undergoing maintenance hemodialysis (mean age, 66.4 years; 62.9% males). We evaluated the mCI, GNRI, and their respective rates of change over a 1-year period. The outcome analysis included all-cause death, number and duration of all-cause hospitalizations, and number and duration of hospitalizations due to cardiovascular disease. In addition, we analyzed the associations of the mCI, GNRI, and their trajectories with clinical outcomes using Cox proportional hazard regression and negative binomial regression. RESULTS: Over a median 3.6-year follow-up, both the lower mCI (hazard ratio 3.00; 95% confidence interval 2.19, 4.09) and lower GNRI (hazard ratio 1.76; 95% confidence interval 1.45, 2.13) per 1 standard deviation decrease were associated with a higher risk of all-cause death. However, a lower mCI was consistently associated with a higher risk of hospitalization, whereas the GNRI was poorly associated with the risk of hospitalization after adjusting for covariates. Furthermore, although a decline in the mCI over time was associated with a higher risk of each adverse event, a significant association between the change in GNRI and clinical events was not detected. CONCLUSION: The mCI at one timepoint and its trajectory had consistently stronger associations with clinical events than the GNRI in patients undergoing hemodialysis. This study further emphasizes the importance of risk screening using a marker of nutritional status in patients undergoing hemodialysis.

Factors related to daily step counts of stroke patients during hospitalization in a convalescent rehabilitation ward.

OBJECTIVES: Clarifying the factors related to decreased physical activity in post-stroke patients is essential for effective disease management. This study aimed to examine the factors influencing the amount of daily steps taken by post-stroke patients in a convalescent rehabilitation ward during activities other than rehabilitation (non-rehabilitation steps). MATERIALS AND METHODS: Eighty-nine post-stroke patients (60.8±14.4 years; 55 men) were enrolled. The inclusion criteria were walking independently within the ward and having a walking speed of ≥24 m/min. Data on patient clinical characteristics including age, sex, body mass index, stroke type, hemiparetic side, and time from stroke onset were collected. Stroke impairment and motor and cognitive functional disabilities were assessed using the Stroke Impairment Assessment Set and the Functional Independence Measure, respectively. The non-rehabilitation steps were calculated by subtracting the steps during the rehabilitation activities from the total steps using Fitbit Flex2. RESULTS: The average number of non-rehabilitation steps was 4,523±2,339 steps/day. The hierarchical multiple regression analysis revealed that sex, motor disability, and the interaction term of stroke impairment with cognitive disability were significantly related to non-rehabilitation steps. Simple slope analysis demonstrated that the stroke impairment slope was steeper at lower levels than at higher levels of cognitive disability for non-rehabilitation steps. CONCLUSIONS: In addition to independent effects of sex and motor disability, this study found that stroke impairment and cognitive disability were interactively related to non-rehabilitation steps in post-stroke patients in a convalescent rehabilitation ward. These findings may provide useful information for managing physical activity in post-stroke patients after hospital discharge.

Low skeletal muscle density combined with muscle dysfunction predicts adverse events after adult cardiovascular surgery.

BACKGROUND AND AIMS: Although muscle dysfunctions are widely known as a poor prognostic factor in patients with cardiovascular disease, no study has examined whether the addition of low skeletal muscle density (SMD) assessed by computed tomography (CT) to muscle dysfunctions is useful. This study examined whether SMDs can strengthen the predictive ability of muscle dysfunctions for adverse events in patients who underwent cardiovascular surgery. METHODS AND RESULTS: We retrospectively reviewed 853 patients aged ≥40 years who had preoperative CT for risk management purposes and who measured muscle dysfunctions (weakness: low grip strength and slowness: slow gait speed). Low SMD based on transverse abdominal CT images was defined as a mean Hounsfield unit of the psoas muscle <45. All definitions of muscle dysfunction (weakness only, slowness only, weakness or slowness, weakness and slowness), the addition of SMDs was shown to significantly improve the continuous net reclassification improvement and integrated discrimination improvement for adverse events in all analyses (p < 0.05). Low SMDs combined with each definition of muscle dysfunction had the highest risk of all-cause death (hazard ratio: lowest 3.666 to highest 6.002), and patients with neither low SMDs nor muscle dysfunction had the lowest risk of all-cause and cardiovascular-related events. CONCLUSION: The addition of SMDs consistently increased the predictive ability of muscle dysfunctions for adverse events. Our results suggest that when CT is performed for any clinical investigation, the addition of the organic assessment of skeletal muscle can strengthen the diagnostic accuracy of muscle wasting.

Association between instrumental activities of daily living with the change in left ventricular function in older patients with cardiovascular disease.

Left ventricular dysfunction is a pathophysiologic characteristic of heart failure. Impaired instrumental activities of daily living are associated with an elevated risk of mortality and heart failure in older adults. Nevertheless, the relationship between these activities and left ventricular function changes remains unclear. We determined whether instrumental activities of daily living are associated with subsequent left ventricular function changes in older cardiovascular disease patients. This retrospective cohort study included 383 outpatients with cardiovascular disease (74.5 ± 5.3 years, 273 males). Patients were divided according to the Frenchay activities index tertile and followed for six months after cardiovascular disease diagnosis. The left ventricular ejection fraction and annular early diastolic velocity (e') were measured for left ventricular systolic and diastolic function, respectively, at baseline and after one year. After adjusting for confounders, changes in the left ventricular ejection fraction were not significantly different. However, changes in the e' in the highest tertile group were significantly greater than in other groups. In the general linear model with multiple regression analysis, Frenchay activities index independently predicted the absolute change in the e'. In older cardiovascular disease patients, higher instrumental activities of daily living were associated with preserved left ventricular relaxation.

Determinants of Health-Related Quality of Life and Physical Performance-Based Components of Frailty in Patients Undergoing Hemodialysis.

OBJECTIVES: Health-related quality of life (HRQoL) measures capture the patient's experience of the burden of chronic disease and are strongly associated with adverse health-related outcomes across multiple populations. The SF-36 score is the most widely used HRQoL measure among patients with end-stage renal disease. Current understanding of determinants of the physical component summary (PCS) and the mental component summary (MCS) and their association with objectively measured physical performance and activity is limited. METHODS: As an index of HRQoL, we prospectively examined the association of SF-36 and its component scores with physical function among 155 incident dialysis patients from the Hemodialysis Center. We investigated associations of HRQoL with the physical performance-based components of the frailty using multivariate linear and logistic regression after adjustment for confounders. Impaired physical performance was defined as having either slow usual gait speed or weak handgrip strength based on standardized and validated criteria derived from a large cohort study of older adults. RESULTS: The patients had a mean age of 65 ± 11 years, and 52.3% were male. After adjusting confounders, lower PCS was independently associated with decreased physical performance and reduced physical activity, but MCS was not associated. Among the PCS subscales, only physical functioning 10 (PF-10) was consistently associated with outcomes, and every 1 point increase in PF-10 score was associated with 4% lower odds of impaired physical performance (95% confidence interval 2-7, P = .01) after adjustment. CONCLUSIONS: SF-36, especially PF-10, is a valid surrogate that discriminates low physical performance and physical inactivity in the absence of formal physical function testing in patients on hemodialysis. The routine implementation of the PF-10 in clinical care has important clinical implications for medical management and therapeutic decision-making in patients undergoing hemodialysis.

Modified Creatinine Index and Clinical Outcomes of Hemodialysis Patients: An Indicator of Sarcopenia?

OBJECTIVE: Sarcopenia (especially muscle mass assessed using gold standard techniques) has been suggested as a poorer predictor of mortality than muscle function in patients undergoing hemodialysis. Appropriate methods to estimate muscle mass for use as a good predictor of clinical outcomes remain to be established. We investigated whether the modified creatinine index (mCI), which is a surrogate marker of muscle mass, could predict mortality and cardiovascular (CV) hospitalizations independent of muscle function and other confounders in patients on hemodialysis. DESIGN AND METHODS: In this retrospective study, outpatients (n = 542; mean age, 65.3 years; 60% men; median dialysis vintage, 29 months; mean BMI, 22.0 kg/m2) undergoing hemodialysis were investigated. The mCI, handgrip strength, and gait speed were assessed and related to all-cause mortality and a composite of CV hospitalizations and all-cause mortality. Cox proportional and mixed-effects negative binomial models were fit for mortality and the composite outcomes. RESULTS: Patients were followed up for a median 3 years (interquartile range: 1.5-5.7). Each per SD increase of mCI (HR:0.63, 95% CI:0.62-0.65), handgrip strength (HR:0.51, 95% CI:0.48-0.54), and gait speed (HR:0.60, 95% CI:0.56-0.64) were significantly associated with lower all-cause mortality rates after adjusting for covariates. The mCI was consistently found to be an independent predictor of mortality after additional adjustment for handgrip strength or gait speed. Furthermore, sarcopenic conditions [i.e., lower mCI, and lower handgrip strength (HR:3.79, 95% CI:2.09-6.87) or slower gait speed (HR:4.20, 95% CI:2.38-7.41)] were significantly associated with a higher risk of mortality after adjusting for covariates. Associations of mCI with multiple CV hospitalizations and mortality were similar to those between mCI and mortality. CONCLUSION: The mCI was a good predictor of clinical outcomes and was comparable to muscle function, including handgrip strength and gait speed. The mCI is likely to provide additional diagnostic and prognostic values for sarcopenia in patients on hemodialysis.