Home return following invasive mechanical ventilation for the oldest-old patients in medical intensive care units from two US hospitals.

BACKGROUND: The aging of the US population has been associated with an increase in intensive care unit (ICU) utilization and correspondingly, invasive mechanical ventilation (IMV) among the oldest-old (age ≥80 years). While previous studies have examined ICU and IMV outcomes in the elderly, very few have focused on patient-centered outcomes, specifically home return, in the oldest-old. We investigated the rate of immediate home return following IMV in the medical ICU in previously home-dwelling oldest-old patients relative to that of a comparison group of 50-70-year olds. METHODS: Data were extracted retrospectively from patient records at Elmhurst Hospital Center in Elmhurst, NY, USA, encompassing the period from January 2009 to May 2014 and Jacobi Medical Center in the Bronx, NY, USA, from January 2010 to March 2014. Medical ICU admissions within those date ranges were screened for possible inclusion into one of two study groups based on age: ≥80 years old and 50-70 years old. The primary end point was hospital discharge: home return versus no home return (death or nonhome discharge). Cox proportional hazards' regression models were used to estimate crude and multivariable-adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for failure to return home. RESULTS: A total of 375 patients were included in the analysis: 279 (74%) patients aged 50-70 years and 96 (26%) patients aged ≥80 years. Compared to 50-70-year olds, being ≥80 years old was associated with a nearly two-fold greater risk of no home return: adjusted HR: 1.96; 95% CI 1.43-2.67. The oldest-old was at significantly increased risk of both being discharged to a skilled nursing facility or subacute rehabilitation (adjusted HR: 2.19; 95% CI 1.33-3.59) as well as of dying in the hospital (adjusted HR: 1.81; 95% CI 1.21-2.71). CONCLUSION: Previously home-dwelling oldest-old are at significantly increased risk of failing to return home immediately following medical ICU admission with IMV as compared to patients aged 50-70 years. These results can help medical ICU staff establish appropriate expectations when addressing the families of their oldest patients. Further studies are needed to evaluate the potential for delayed home return among the oldest old and to assess the ability of frailty indices to predict home return within this ICU population.

Immunonutrition Is Associated With a Decreased Incidence of Graft-Versus-Host Disease in Bone Marrow Transplant Recipients: A Meta-Analysis.

INTRODUCTION: Graft-versus-host disease (GVHD) is a serious complication of bone marrow transplantation (BMT), requiring higher doses of glucocorticoids or immunosuppressive therapies and further straining transplant recipients. Immunonutrition, such as vitamins and amino acid supplements, increase immunity and decrease inflammation and oxidative stress. This meta-analysis examines the impact of immunonutrition on the incidence of GVHD and postoperative infections among BMT recipients. METHODS: A comprehensive literature search for all published randomized controlled trials was conducted with PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2016). Keywords in the search included variations of terms related to immunonutrition, such as "vitamin," "glutamine," and "transplant." Outcomes included incidence of GVHD and infection. RESULTS: Ten randomized controlled trials involving 681 BMT recipients were analyzed: 332 receiving immunonutrition and 349 receiving standard nutrition. Immunonutrition is correlated with a decreased incidence of GVHD by 19% (relative risk [RR] = 0.810, 95% CI: 0.695-0.945, P = .007). There was no significant difference in the incidence of infections with immunonutrition (RR = 1.016, 95% CI: 0.819-1.261, P = .885). Subgroup analysis of glutamine compared with N-acetylcysteine, selenium, and eicosapentaenoic acid showed no significant difference in the incidence of GVHD or infections (RR = 0.913, 95% CI: 0.732-1.139, P = .419; RR = 0.951, 95% CI: 0.732-1.235; P = .708, respectively). CONCLUSION: The use of immunonutrition is associated with a reduced risk of GVHD in BMT recipients, potentially as a result of improved immune support and free radical scavenging. Providing immunonutrient supplements is a valuable adjunct in the routine care of BMT recipients, helping to alleviate a common and deadly complication.