Hiroshi Shamoto

Early Commencement of Oral Intake and Physical Function are Associated with Early Hospital Discharge with Oral Intake in Hospitalized Elderly Individuals with Pneumonia

job: A qualitative study of medical student reflections on safe hospital discharge. J Am Geriatr Soc 2014;62:1147–1154. 12. Kripalani S, LaFevre F, Philips CO et al. Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care. JAMA 2007;297:831–841. 13. Careyva B, Snyderman D, Diemer G. Medical student perceptions of hospital discharge transitions in care. Med Teach 2013;36:967. 14. Daugherty SR, DeWitt BC, Rowley BD. Learning, satisfaction, and mistreatment during medical internship: A national survey of working conditions. JAMA 1998;279:1194–1199. 15. De SK, Henke PK, Ailawadi G et al. Attending, house officer, and medical student perceptions about teaching in the third-year medical school general surgery clerkship. J Am Coll Surg 2004;199:932–942.

Sarcopenia Is Highly Prevalent in Older Medical Patients With Mobility Limitation: Comparisons According to Ambulatory Status.

BACKGROUND The association of sarcopenia with disability with ambulatory status is uncertain because most studies have targeted people who could walk independently. This study explored the prevalence of sarcopenia regardless of ambulatory status and the impact of ambulatory status on sarcopenia. MATERIALS AND METHODS In total, 778 consecutive patients, aged ≥65 years and admitted to a hospital, were enrolled. Ambulatory status was divided into 4 grades according to mobility as described in the Barthel index. Sarcopenia was defined as a loss of appendicular muscle mass index (AMI) with bioelectrical impedance and decreased muscle strength with handgrip strength (HGS); cutoff values were adopted from the Asian Working Group for Sarcopenia. RESULTS The mean patient age was 83.2 ± 8.3 years; 37.8% were male patients. Mobility limitation was associated with higher age, underweight body mass index, malnourishment, and comorbidities (all P < .001). AMI and HGS gradually decreased with declining ambulatory status (P < .001). The prevalence of sarcopenia in the independent walk, walk with help, wheelchair, and immobile groups was 57.9%, 76.1%, 89.4%, and 91.7%, respectively. AMI prevalence declined and sarcopenia drastically increased in patients who were unable to walk independently compared with those who could walk independently (P < .001). Multivariate regression analyses showed that mobility limitation was an independent indicator of decreasing AMI and sarcopenia after adjustment for confounders. CONCLUSION Patients with dependent ambulatory status experienced a higher prevalence of sarcopenia compared with those with ambulation; in addition, decline in ambulatory status was an independent indicator for the presence of sarcopenia after adjustment for potential confounders.Background: The association of sarcopenia with disability with ambulatory status is uncertain because most studies have targeted people who could walk independently. This study explored the prevalence of sarcopenia regardless of ambulatory status and the impact of ambulatory status on sarcopenia. Materials and Methods: In total, 778 consecutive patients, aged ≥65 years and admitted to a hospital, were enrolled. Ambulatory status was divided into 4 grades according to mobility as described in the Barthel index. Sarcopenia was defined as a loss of appendicular muscle mass index (AMI) with bioelectrical impedance and decreased muscle strength with handgrip strength (HGS); cutoff values were adopted from the Asian Working Group for Sarcopenia. Results: The mean patient age was 83.2 ± 8.3 years; 37.8% were male patients. Mobility limitation was associated with higher age, underweight body mass index, malnourishment, and comorbidities (all P < .001). AMI and HGS gradually decreased with declining ambulatory status (P < .001). The prevalence of sarcopenia in the independent walk, walk with help, wheelchair, and immobile groups was 57.9%, 76.1%, 89.4%, and 91.7%, respectively. AMI prevalence declined and sarcopenia drastically increased in patients who were unable to walk independently compared with those who could walk independently (P < .001). Multivariate regression analyses showed that mobility limitation was an independent indicator of decreasing AMI and sarcopenia after adjustment for confounders. Conclusion: Patients with dependent ambulatory status experienced a higher prevalence of sarcopenia compared with those with ambulation; in addition, decline in ambulatory status was an independent indicator for the presence of sarcopenia after adjustment for potential confounders.

Reliability and Validity of a Simplified Comprehensive Assessment Tool for Feeding Support: Kuchi‐Kara Taberu Index

To verify the reliability and validity and develop an English version of an instrument (Kuchi‐Kara Taberu Index (KT Index)) to comprehensively assess and intervene in problems with eating and swallowing.

Feeding Support Team for Frail, Disabled, or Elderly People during the Early Phase of a Disaster

Japan was struck by two catastrophic disasters on March 11, 2011 and on April 16, 2016. The former was the Great East Japan Earthquake (M9.0) and the latter was the Kumamoto Earthquake (M7.0). Most inhabitants in the affected areas of both disasters were forced to live in evacuation centers right after the earthquake. Poor oral hygiene, inactivity, malnourishment, appetite loss, eating problems, and swallowing problems due to lack of support for frail, disabled, or elderly evacuees occur during the early phases after a disaster. Disaster-related sequelae, such as pneumonia and disuse syndrome, may also occur as a result of inappropriate nutritional and physical support. Adequate oral intake and physical activity are important to the quality of life for evacuees. We learned lessons from our experiences of evacuee support after the two disasters, focused on feeding support, which consisted of nutritional and physical care. Our experiences revealed that more rapid intervention is necessary, particularly for frail, disabled, or elderly people. In this study, based on our experiences from the two dreadful disasters in Japan, we propose a new concept of medical assistance after a disaster, the Disaster Feeding Support Team (D-FST). The D-FST is composed of multidisciplinary professionals and provides comprehensive nutritional, physical, and health support. The D-FST also performs interventions for swallowing exercises, activity, health condition, and cognition that are related to eating circumstances. We suggest that D-FSTs are organized nationwide and initiate support activities immediately after the onset of a disaster.

Effects of aging and sarcopenia on strength of swallowing muscles in older adults: Effects of sarcopenia on swallowing functions

research field and how they were correlated. However, a limitation we noted is that we cannot analyze the h-index of highly-cited journals, as the Journal Citation Report had a limitaiton on that. However, we noted that “Geriatrics and Gerontology” is a field that is new, because there are no journals that have published more than 10000 articles yet. In conclusion, we analyzed the bibliometric trends of journals in the geriatrics and gerontology field. Practitioners and researchers can use the above findings to aid them to find the right journal to read and publish in, respectively. Administrators can consider the impact of various publicationmetrices on assessing research output.

Correlation between nutritional status and frailty regarding saliva secretion and occlusal force in community-dwelling older people: Chewing, saliva secretion and occlusal force

2014-2015. Japan Diabetes Society 2015, Bunkodo, Tokyo. 6 Chen LK, Liu LK, Woo J et al. Sarcopenia in Asia: consensus report of the Asian Working Group for sarcopenia. J AmMed Dir Assoc 2014; 15: 95–101. 7 Manini TM, Clark BC. Dynapenia and aging: An update. J Gerontol A Biol Sci Med Sci 2012; 67A: 28–40. 8 Charlson MF, Pompei P, Ales KI et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40: 373–383. 9 Park SW, Goodpater BH, Strotmeyer ES et al. Decreased muscle strength and quality in older adults with type 2 diabetes. The health, aging, and body composition study. Diabetes 2006; 55: 1813–1818. 10 Mitchell WK, Williams J, Atherton P et al. Sarcopenia, dynapenia, and the impact of advancing age on human skeletal muscle size and strength; a quantitative review. Front Physiol 2012; 3: 1–18.

Angiotensin-Converting Enzyme Inhibitor in Tube-Fed Patients With Stroke History

To the Editor: In a recent article published in the Journal of the American Medical Directors Association, Lee et al1 stated that angiotensinconverting enzyme (ACE) inhibitors, reported to prevent pneumonia in poststroke and elderly Asian patients,2 did not reduce the incidence of pneumonia in tube-fed patients with stroke history. Because pneumonia in poststroke patients has a high incidence and is associated with mortality, this study of patients with severe dysphagia and stroke history was of great interest; the results could have a significant impact in clinical settings. Unfortunately, their randomized controlled study was terminated early with much less than the planned sample size because unexpectedly high mortality was observed in the ACE inhibitor intervention group. During that time, the ACE inhibitor intervention did not have a statistically significant effect on the incidence of pneumonia. The reasons for the unanticipated mortality and failure of the ACE inhibitor to prevent pneumoniawere not fully discussed.Wewould like to address some relevant concerns with the analysis and interpretation. First, differences potentially existed between the groups in the following aspects. There may have been differences in the duration of dysphagia (tube-fed period) from the initial cerebrovascular accident to the beginning of the study. The inclusion criteria were dysphagic inpatients with past stroke history who were tube-fed. Pneumonia (57.6% and 68.4% in the intervention group and placebo group, respectively) was the main reason for admission to the hospital, whereas stroke onset as the reason for admission was relatively low (6.1%and21.1%, respectively). Furthermore, theremayhavebeen fewer patientswith new stroke on admission in the intervention group than in the placebo group (phi 1⁄4 0.21, our estimate). The subacute or convalescent phase in stroke is the period during which a patient is more likely to recover from dysphagia.3 In addition, information on nutritional statuswas not reported among the baseline characteristics (eg, body mass index, nutritional status, or daily nutritional intake). Becausemid-armcircumference is known todiffer bygender,wewere unable to determinewhether a significant difference existed between the groups because of reporting amixed gender value. Information on the route of feedingwas also lacking. Thenumberof patientswho took food orally despite tube feeding (the dysphagia assessment scale indicated inclusion of patients with oral intake) and who received feeding by gastrostomy and nasogastric tubes should be reported because both nil per oral status and the tube site are associated with pneumonia.4 The authors should analyzewhether therewere baseline differences in any of these factors, allowing adjustment of factors that may have contributed to the outcome. Second, we considered the statistical methods used. The authors reported the odds ratio (OR) to outcome as unadjusted OR, age-adjusted OR, and fully adjusted OR in Table 2. Because therewere 29 patients who died (21 of whom died from pneumonia) out of 71 patients, the total number of participants was relatively few. In such a case, for statistical validity, the logistic regression analyses should only be performed with 2e3 independent variables. However, 11 independent variables including agroupingvariable and10 covariates were included in the fully adjusted models, which would tend to increase the prediction error of themodels. In addition, the statistical hypothesis test selected for evaluating improvement in swallowing function isnot sufficient todrawaconclusion. The results indicate that the data consisted of 2 sets of scores derived from the same participants. Accordingly, we suggest that theWilcoxon signed-rank test be used first to determine improvement in swallowing function in each group. Therefore, we cannot yet conclude whether low-dose ACE inhibitors improved swallowing function in this study. Finally, the integrity of the data appears problematic as we found severalapparenterrors in thearticle. There is lackof consistency in the numberofmortalities reported.Theauthors stated that thenumberof patients who died in the placebo group was 10. However, the unadjusted OR and the 95% confidence interval reported in Table 2 would be consistentwith 12 cases ofmortality in the placebo group. There is also a lack of consistency in the number of fatal pneumonias. The authors stated in the Results section that occurrence of fatal pneumonia in the placebo group was 26.3%, which was not significantly different fromthat in the intervention group.However, thenumberof fatalpneumonias reported inTable4 (7cases)differs fromthenumber calculated based on 26.3% of the placebo group (10 cases) and may refer to totalmortalities rather than those attributable to pneumonia. If the 7 cases depicted in Table 4 were correct, there would be a statistically significant difference between the groups. There was also a lack of consistency in the number of patients who were assessed for swallowing function at baseline. The authors reported dysphagia scale scores for 29 and 35 patients in the intervention and placebo groups, respectively, at baseline in Table 3, although they reported that all participants were assessed by the Royal Brisbane Hospital Outcome Measure for Swallowing. Thus, we were unable to dispel our doubts about the credibility of the data. For the reasons described above, we were not able to fully interpret the study. We request that the authors address these concerns to clarify their findings.

Impact of Body Mass Index on Activities of Daily Living in Inpatients with Acute Heart Failure

ObjectivesTo investigate the impact of body mass index on activities of daily living in inpatients with acute heart failure.DesignA retrospective cohort study.SettingA hospital-based database contains Diagnosis Procedure Combination survey data from 100 participating acute-care hospitals.Participants11,301 inpatients aged 20 year or older who were admitted to the participating hospitals with a diagnosis of acute heart failure.MeasurementsThe Barthel Index score at discharge and hospital death.ResultsThe number of patients with a body mass index of <18.5 kg/m2 (underweight), 18.5–22.9 kg/m2 (low–normal weight), 23.0–24.9 kg/m2 (high–normal weight), 25.0–29.9 kg/m2 (overweight), and ≥30.0 kg/m2 (obesity) were 1689 (15%), 4715 (42%), 1809 (16%), 2306 (20%), and 782 (7%), respectively. Median Barthel Index scores at admission and discharge were 65 and 100, respectively. Hospital death occurred in 101 (0.9%) patients. Lower body mass index was associated with lower Barthel Index score at discharge and higher mortality. Multivariable analysis adjusted for body mass index, age, sex, New York Heart Association classification, Barthel Index score at admission, the updated Charlson Comorbidity Index, length of hospital stay, number of drugs administered, and rehabilitation during hospitalization revealed that body mass index was independently associated with Barthel Index score at discharge (beta: 0.354; 95% confidence interval: 0.248–0.461) and hospital death (odds ratio: 0.926, 95% confidence interval: 0.877–0.978).ConclusionOverweight and obese inpatients showed greater independence in activities of daily living at discharge and lower rates of mortality, indicating the obesity paradox. A combination of rehabilitation and improved nutrition seems to be important in underweight patients with acute heart failure.

Cognitive impairment has no impact on hospital‐associated dysphagia in aspiration pneumonia patients

Hospital‐associated dysphagia, characterized by deconditioning of swallowing as a result of hospitalization, is sometimes observed in patients with aspiration pneumonia (AP). Cognitive impairment is known as a negative factor in dysphagia rehabilitation. The present study aimed to examine the association between cognitive impairment and hospital‐associated dysphagia in patients with AP receiving dysphagia rehabilitation.

Relationship between body mass index and functional recovery in stroke rehabilitation setting

Sir, Recently, Kalichman et al. reported in Disability and Rehabilitation that the body mass index (BMI) measured at admission to a rehabilitation center was negatively correlated with changes in the Functional Independence Measure (FIM) score (delta-FIM) among patients with stroke.[1] These findings intrigued us because weight management for obese patients with stroke remains an important issue in stroke rehabilitation settings, and because our previous research,[2] which had focused on BMI and delta-FIM, led to a conclusion different from that reported by Kalichman et al. Whether a high BMI is beneficial or harmful for the functional recovery during the rehabilitation of patients with stroke has not been proven yet.[2–6] In this letter, we would like to discuss some concerns regarding the study. First, the length of hospital stay and pre-stroke functional ability were not included in the linear regression analysis of FIM at discharge. The length of stay may be a confounder for FIM at discharge because a significant correlation between the length of stay and FIM at discharge was shown in this study [1] and in a previous article.[2] Even if the authors of the current study recruited patients with a first-ever stroke, pre-stroke functional ability, which is affected by various diseases (e.g. cardiovascular diseases, cognitive impairment and others), it is also a strong predictor of functional recovery.[2,3] Therefore, these variables should have been included in the multiple regression analysis. Second, the relationship between BMI and delta-FIM may be disputable if patients with BMI >40 kg/m were excluded. BMI (as continuous variable) and delta-FIM showed a weak relationship (rho1⁄4 0.20, p1⁄4 0.045). Moreover, considering the mean BMI of 28.45 6 5.54 kg/m that was reported in the study, the values of BMI >39.53 kg/m (five plots) would be considered as outliers, if an outlier was defined as the one which is outside the two standard deviations. The relationship between BMI and delta-FIM appeared to be questionable in the scatter diagram if patients with BMI >40 kg/m were excluded. Third, the demographic data for the different BMI categories were insufficient. Previous reports have indicated many differences in the characteristics between BMI categories, such as age, sex and comorbidities.[2–6] This information may be useful for the interpretation of the results that there were no delta-FIM differences among the BMI categories. Fourth, this study did not include underweight subjects. Although the authors concluded that BMI negatively correlated with improvement in functional parameters,[1] careful interpretation might be required. Because being underweight is an independent predictive factor for death or functional dependency,[7] the findings of this study must be confined only to normal weight, overweight or obese participants. Finally, the number of participants in the multiple regression analysis was not described. Because relatively small number of participants were analyzed (n1⁄4 102) in this study, the effect of missing National Institute of Health Stroke Scale (NIHSS) scores on the statistical power cannot be ignored. The authors should have either excluded the participants without NIHSS scores or excluded the NIHSS score as a confounding factor in the multiple regression analysis. To date, there have been various controversial reports suggesting a beneficial effect of obesity in the functional recovery of patients with stroke.[1–6,8,9] The reasons for these inconsistencies may arise due to differences in race, methods of categorizing BMI, follow-up periods, functional indicators and other factors. We have previously reported that obese Japanese patients with stroke (BMI 27.5 kg/m) had greater FIM gain than those who were normal weight (18.5 to <23.0 kg/m) or overweight (23.0 to <27.5 kg/m).[2] Although our results were consistent with several other reports which investigated Asian populations,[3,6] the relationship between BMI and function disappeared after adjusting for stroke severity.[9] Additionally, a disturbed body composition, such as sarcopenic obesity, inhibits physical function.[10] Based on the aforementioned reasons, we believe that body composition and weight change (increasing muscle mass and decreasing fat mass) during the rehabilitation period are important factors in functional recovery of obese patients. We would like to discuss the inconsistent correlation between the obesity and functional outcome.