Predictive factors and clinical impact of ICU-acquired weakness on functional disability in mechanically ventilated patients with COVID-19.

BACKGROUND: Patients with critical COVID-19 often require invasive mechanical ventilation (IMV) and admission to the intensive care unit (ICU), resulting in a higher incidence of ICU-acquired weakness (ICU-AW) and functional decline. OBJECTIVE: This study aimed to examine the causes of ICU-AW and functional outcomes in critically ill patients with COVID-19 who required IMV. METHODS: This prospective, single-center, observational study included COVID-19 patients who required IMV for ≥48 h in the ICU between July 2020 and July 2021. ICU-AW was defined as a Medical Research Council sum score <48 points. The primary outcome was functional independence during hospitalization, defined as an ICU mobility score ≥9 points. RESULTS: A total of 157 patients (age: 68 [59-73] years, men: 72.6%) were divided into two groups (ICU-AW group; n = 80 versus non-ICU-AW; n = 77). Older age (adjusted odds ratio [95% confidence interval]: 1.05 [1.01-1.11], p = 0.036), administration of neuromuscular blocking agents (7.79 [2.87-23.3], p < 0.001), pulse steroid therapy (3.78 [1.49-10.1], p = 0.006), and sepsis (7.79 [2.87-24.0], p < 0.001) were significantly associated with ICU-AW development. In addition, patients with ICU-AW had significantly longer time to functional independence than those without ICU-AW (41 [30-54] vs 19 [17-23] days, p < 0.001). The development of ICU-AW was associated with delayed time to functional independence (adjusted hazard ratio: 6.08; 95% CI: 3.05-12.1; p < 0.001). CONCLUSIONS: Approximately half of the patients with COVID-19 requiring IMV developed ICU-AW, which was associated with delayed functional independence during hospitalization.

Metabolic and ventilatory changes during postural change from the supine position to the reclining position in bedridden older patients.

The prevention of pneumonia in bedridden older patients is important, and its recurrence in these patients is a relevant issue. Patients who are bedridden and inactive, and have dysphagia are considered to be at risk for pneumonia. Efforts to reduce the bedridden state and low activity may be necessary to reduce the risk of developing pneumonia in bedridden older patients. This study aimed to clarify the effects of postural change from the supine position to the reclining position on metabolic and ventilatory parameters and on safety in bedridden older patients. Using a breath gas analyzer and other tools, we assessed the following 3 positions: lying on the back (supine), resting in the Fowler position (Fowler), and resting in an 80° recline wheelchair (80°). Measurements were oxygen uptake, carbon dioxide output, gas exchange ratio, tidal volume (VT), minute volume, respiratory rate, inspiratory time, expiratory time, total respiratory time, mean inspiratory flow, metabolic equivalents, end-expiratory oxygen, and end-expiratory carbon dioxide as well as various vital signs. The study analysis included 19 bedridden participants. The change in oxygen uptake driven by changing the posture from the supine position to the Fowler position was as small as 10.8 mL/minute. VT significantly increased from the supine position (398.4 ±â€…111.2 mL) to the Fowler position (426.9 ±â€…106.8 mL) (P  = .037) and then showed a decreasing trend in the 80° position (416.8 ±â€…92.5 mL). For bedridden older patients, sitting in a wheelchair is a very low-impact physical activity, similar to that in normal people. The VT of bedridden older patients was maximal in the Fowler position, and the ventilatory volume did not increase with an increasing reclining angle, unlike that in normal people. These findings suggest that appropriate reclining postures in clinical situations can promote an increase in the ventilatory rate in bedridden older patients.

Impact of physical frailty on the clinical outcomes of older patients hospitalized for pneumonia.

AIM: This study aimed to assess the association between physical frailty and clinical outcomes among older patients hospitalized for pneumonia. METHODS: This study examined 852 consecutive patients hospitalized for pneumonia between October 2018 and September 2020. Patients who were <65 years old, scheduled for admission, did not receive inpatient rehabilitation, or died during admission were excluded. A short physical performance battery (SPPB) test was performed by physical therapists upon discharge. The primary outcome measure was a composite endpoint of readmission or mortality due to any cause within 6 months of discharge. RESULTS: In total, 521 patients (median age, 80 years; interquartile range, 74-86 years) were included in the analyses, and were divided into the following two groups: robust group with SPPB scores >9 (n = 150), and physical frailty group with SPPB scores ≤9 (n = 371). Of these, 346 (66.4%) patients were men; and the median SPPB score was 6 (interquartile range, 1-10). During the median follow-up period of 53 days (interquartile range, 4-180 days), 92 (17.6%) patients were readmitted and 25 (4.8%) patients died. Patients with physical frailty were at an increased risk for the primary endpoint (hazard ratio, 2.21; 95% confidence interval, 1.44-3.41; P < 0.001); the risk remained significant after adjusting for multiple variables (adjusted hazard ratio, 1.70; 95% confidence interval, 1.05-2.74; P = 0.028). CONCLUSIONS: Among older patients with pneumonia, physical frailty status at discharge was an independent risk factor for readmission and mortality within 6 months after initial discharge. Geriatr Gerontol Int 2021; 21: 926-931.

Clinical impact of functional independent measure (FIM) on 180-day readmission and mortality in elderly patients hospitalized with acute decompensated heart failure.

Activities of daily living (ADL) are important prognostic factors for heart failure. The functional independent measure (FIM) has emerged as a comprehensive valid measure of ADL from both physical and cognitive perspectives. This study aimed to investigate the prognostic impact of the FIM score on clinical outcomes in hospitalized patients with acute decompensated heart failure (ADHF). We retrospectively analyzed 473 ADHF patients, with available pre-discharge FIM scores, admitted to our institution between May 2018 and May 2020. Primary outcome measures, defined as a composite of 180-day all-cause deaths and readmissions, were compared among three tertiles. The median FIM score was 102 (interquartile range: 85-115). Tertile 1 corresponded to an FIM score > 111 (n = 154), Tertile 2 to that of 90-111 (n = 167), and Tertile 3 to that of < 90 (n = 152). During follow-up, 28 deaths and 114 readmissions occurred. Patients with lower FIM scores were associated with a graded increase in the risk of primary outcome measure (p = 0.001). Even after multivariable adjustment, the results remained significant [Tertile 1 vs 3; adjusted hazard ratio: 3.28 (95% confidence interval: 1.72-6.56), p < 0.001; Tertile 2 vs 3; 2.32 (1.27-4.47), p = 0.006]. FIM scores were significantly associated with readmission or death within 180 days of discharge in hospitalized ADHF patients.

Low Muscle Mass is Associated with Walking Function in Patients with Acute Ischemic Stroke.

BACKGROUND: Muscle mass might be a possible predictor for walking function in patients with stroke; however, evidence is limited. OBJECTIVE: To investigate whether skeletal muscle mass is associated with walking function at discharge during the acute phase. METHODS: In this observational cohort study, we assessed skeletal muscle mass in patients with acute ischemic stroke using the noninvasive and portable multifrequency bio-impedance device. This device can easily be used in bedridden patients. Appendicular skeletal muscle mass was converted to skeletal muscle index (SMI) standardizing by height squared (kg/m2). The primary outcome was walking function assessed by the modified Rankin Scale score at acute phase hospital discharge. Logistic regression analysis was used to determine the association between skeletal muscle mass and walking function. RESULTS: Of the 107 patients enrolled, low SMI (SMI: male <7.0 kg/m2, female <5.7 kg/m2) was identified in 29.9% (19.7% in men, 48.6% in women). Logistic regression analysis showed that low SMI [OR: 4.02, 95% confidence interval (CI): 1.38-11.7, p = 0.001] independently associated with walking function at discharge. Further, patients with mild and moderate severity had significant difficulty in walking when they had low SMI (p = 0.039). CONCLUSIONS: Low skeletal muscle mass at the onset of ischemic stroke is an independent predictor of walking function at discharge during the acute phase. Our findings highlight the importance of detecting skeletal muscle mass in patients with acute ischemic stroke.

Impact of Weekly Teriparatide on the Bone and Mineral Metabolism in Hemodialysis Patients With Relatively Low Serum Parathyroid Hormone: A Pilot Study.

Adynamic bone disease in HD patients is characterized by skeletal resistance to parathyroid hormone (PTH) or suppression of PTH release, leading to a downregulated bone turnover and bone fracture. Hence, we examined the efficacy of weekly teriparatide for HD patients with low PTH indicating adynamic bone disease without a history of parathyroidectomy. Fifteen HD patients with low PTH were recruited in this prospective observational study. Of them, 10 received teriparatide for 12 months and five nontreated patients were enrolled as control. Primary outcomes were defined as the changes in bone mineral density and bone turnover markers. Bone mineral density at the lumbar spine increased by 3.7% and 2.5% at 6 and 12 months, respectively, and bone formation markers increased, while bone resorption markers did not change in the teriparatide group. At 12 months after teriparatide administration, endogenous PTH was secreted followed by the recovery of low bone turnover. 40% of patients in the teriparatide group dropped out due to adverse events and the most common adverse event was transient hypotension. This study suggests that weekly teriparatide for HD patients with low PTH in the absence of parathyroidectomy accelerates bone formation and bone turnover, leading to increased trabecular bone mass and secretion of endogenous PTH.

Relationship between the Functional Independence Measure and Mann Assessment of Swallowing Ability in hospitalized patients with pneumonia.

AIM: Pneumonia ranks high among the causes of death worldwide. However, the predictive values of activities of daily living, the nutrition index and the aspiration index measured objectively remain unclear. The present study aimed to examine the associations of activity, nutrition and dysphagia with pneumonia. METHODS: We assessed 992 hospitalized patients. Logistic regression analysis was used to examine the predictors of pneumonia. Receiver operating characteristic curve analysis was used to determine the cut-off values of variables. Kaplan-Meier and Cox hazards regression analyses were used to examine the incidence of pneumonia and the factors associated with pneumonia. RESULTS: We finally enrolled 393 inpatients. Of the 393 patients, 102 (26.0%) had pneumonia. On logistic regression analysis, age, Functional Independence Measure (FIM)-motor score and Mann Assessment of Swallowing Ability (MASA) score were independent predictors of pneumonia. The FIM-motor and MASA cut-off values were 19.5 (area under the curve 0.83, P < 0.01) and 170.5 (area under the curve 0.82, P < 0.01), respectively. Kaplan-Meier analysis showed that the no pneumonia rate was significantly lower among patients with FIM-motor scores <20 than among those with FIM-motor scores ≥20 (log-rank test, P < 0.01), and was significantly lower among patients with MASA scores <171 than among those with MASA scores ≥171 (log-rank test, P < 0.01). Cox regression analysis showed that FIM-motor (hazard ratio 0.97, P = 0.009) and MASA scores (hazard ratio 0.99, P < 0.01) were significantly associated with pneumonia. CONCLUSIONS: In addition to the infectious risk, the FIM-motor and MASA scales are useful tools to predict the development of pneumonia in older adults. Geriatr Gerontol Int 2018; 18: 1620-1624.

Relationship between functional independence measure and geriatric nutritional risk index in pneumonia patients in long-term nursing care facilities.

AIM: The prevention of pneumonia is an urgent issue among Japanese older adults. However, little has been reported on the relationship between a Functional Independence Measure (FIM) and the Geriatric Nutrition Risk Index (GNRI) for the prevention of pneumonia in patients in long-term care facilities in Japan. We aimed to clarify the relevance of FIM and GNRI for inpatients with and without pneumonia. METHODS: We identified 233 patients who were hospitalized in our long-term nursing hospital from April 2012 to September 2013. We compared differences in FIM among GNRI classes for four groups: (i) pneumonia/high GNRI; (ii) pneumonia/low GNRI; (iii) no pneumonia/high GNRI; and (iv) no pneumonia/low GNRI. To assess the pneumonia predictors, we used a logistic regression for long-term nursing patients. Receiver operating characteristic analysis showed cut-off values and the area under the curve. RESULTS: A total of 88 (37.8%) of 233 inpatients had pneumonia. FIM of the pneumonia/low GNRI groups was significantly lower than that of the no pneumonia/high and low GNRI groups. Logistic regression showed that FIM (P < 0.001; OR -1.035, 95% CI -1.019-1.051) and GNRI (P = 0.017; OR -1.038, 95% CI -1.007-1.070) were predictors of pneumonia. The cut-off values for FIM and GNRI were 26.6 (P < 0.001, the area under the curve 0.70) and 80.5 (P < 0.001, the area under the curve 0.65), respectively. CONCLUSION: Low activity and malnutrition might lead to the development of pneumonia. FIM and GNRI are useful predictor tools that could help to prevent pneumonia in Japanese patients in long-term care facilities. Geriatr Gerontol Int 2017; 17: 1617-1622.

Abnormal autoregulation and tubuloglomerular feedback in prediabetic and diabetic OLETF rats.

The mechanisms underlying the development and prevention of diabetic nephropathy are still not fully understood. In the present study in the Otsuka Long-Evans Tokushima Fatty (OLETF) model of type 2 diabetic rats, we investigated whether renal hemodynamic abnormalities exist and whether they precede the onset of diabetes. Using OLETF rats in both prediabetic and diabetic stages, we assessed autoregulatory responses of total renal blood flow (RBF) and of superficial (SBF) and deep renal cortical (DBF) blood flow to stepwise reductions of renal perfusion pressure (RPP) induced by a manual clamp on the abdominal aorta. During clamp-induced reductions of RPP by 10 or 20 mmHg, RBF fell significantly more in OLETF rats than in lean control [Long-Evans Tokushima Otsuka (LETO)] rats. Whereas SBF showed no significant changes in either OLETF rats or LETO rats during mild clamping, DBF decreased significantly more in OLETF rats than LETO rats. Reduced autoregulatory efficiency in OLETF rats was observed in both prediabetic and diabetic stages. Micropuncture studies showed that tubuloglomerular feedback (TGF) responses of stop flow pressure are reduced in prediabetic (-7.3 vs. -25.7%) as well as in diabetic OLETF rats compared with LETO control rats (-4.4 vs. -18.8%). Renal corticotomy was performed to measure glomerular capillary pressure (Pgc) directly. Pgc of deep cortical glomeruli was higher than superficial glomerular Pgc in both strains of rats, but the difference was especially pronounced in OLETF rats (deep 78 +/- 2 vs. superficial 57 +/- 4 mmHg). This study demonstrates reduced autoregulatory adjustments and impaired TGF efficiency in prediabetic OLETF rats. Thus abnormal RBF regulation precedes the onset of diabetes and is especially pronounced in the deep cortical region.