Tanja Miličević Milardović

Ime i prezime: dr. sc. TANJA MILIČEVIĆ MILARDOVIĆ, dr. med.
 
Naslov disertacije: „STANJE UHRANJENOSTI I POKAZATELJI SMRTNOSTI I PONOVNE HOSPITALIZACIJE U INTERNISTIČKIH BOLESNIKA“
 
Mentorica: izv. prof. dr. sc. JOSIPA RADIĆ
 
Datum obrane: 3. svibnja 2022.
 
Poveznnica:
https://repozitorij.mefst.unist.hr/islandora/object/mefst%3A1412/datastream/PDF/view
 
Kvalifikacijski znanstveni radovi za doktorsku disertaciju:


Miličević T, Kolčić I, Đogaš T, Živković PM, Radman M, Radić J. Nutritional Status and Indicators of 2-Year Mortality and Re-Hospitalizations: Experience from the Internal Clinic Departments in Tertiary Hospital in Croatia. Nutrients. 2020;13(1):68.
doi: 10.3390/nu13010068
SAŽETAK:
Cilj istraživanja bio je analizirati rizik za nastanak pothranjenosti internističkih bolesnika i njegov utjecaj na smrtnost, ponovne hospitalizacije i novootkrivene bolesti tijekom dvogodišnjeg praćenja. Također, cilj je bio analizirati i razlike u stanju uhranjenosti, antropometrijskim, biokemijskim i drugim kliničkim obilježjima bolesnika, ovisno o odjelu hospitalizacije.
U istraživanje je uključeno 346 ispitanika, dok je u dvogodišnjem praćenju ostalo 218 ispitanika. Prilikom inicijalne hospitalizacije učinjena su antropometrijska mjerenja (tjelesna težina i visina, ITM, OS, WHtR, opseg nadlaktice, debljina kožnog nabora), procijenjen je nutritivni rizik (NRS-2002 upitnik), analizirani su biokemijski (glukoza, CRP, kreatinin,
eGFR) i drugi klinički parametri (dob, spol, pušenje, pridružene kronične bolesti, upotreba nutritivne potpore, duljina trajanja hospitalizacije). Nakon dvije godine zabilježeni su podaci o smrtnosti, ponovnim hosptalizacijama, novootkrivenim bolestima (šećerna bolest, maligna
bolest, arterijska hipertenzija) i upotrebi nutritivne potpore.
Rezultati su pokazali kako su internistički bolesnici uglavnom starije životne dobi i polimorbidni. Čak ih je 38,4% pod povećanim rizikom za nastanak pothranjenosti (NRS2002≥3) prilikom inicijalne hospitalizacije, iako su im antropometrijski parametri povećani.
Unatoč povećanom nutritivnom riziku, u samo 15,3% ispitanika uveden je ONS tijekom hospitalizacije. Praćeni, nutritivno ugroženi ispitanici, češće su bili ženskog spola, stariji od 65 godina, bolovali su češće od maligne bolesti (54,9% naspram 20,6%; P<0,001) i rjeđe su imali urednu bubrežnu funkciju (eGFR≥90 ml/min). Antropometrijske mjere nisu se pokazale korisnima u procjeni pothranjenosti jer je 46,3% nutritivno ugroženih bolesnika bilo preuhranjeno i pretilo (ITM≥25 kg/m2). Kod njih 25,6% uveden je ONS tijekom hospitalizacije, a 36,6% ih je koristilo ONS tijekom razdoblja praćenja. Nutritivno ugroženi bolesnici značajno su češće umirali u razdoblju praćenja (42,7% naspram 23,5%; P<0,003).
Po pitanju antropometrijskih mjera, nije bilo statistički značajne razlike među ispitanicima na različitim internističkim odjelima, osim za opseg nadlaktice (P<0,001). Kod bolesnika hospitaliziranih na Nefrologiji (54,5%), Hematologiji (45,7%), Postintenzivnoj jedinici (42,9%) te Endokrinologiji i dijabetologiji (42,9%), unatoč povišenom WHtR, bilježio se veći udio bolesnika s nižim i urednim ITM-om (<18,5-24,9 kg/m2), što se može tumačiti sarkopenijom. Također, statistički značajna razlika bilježila se za vrijednost serumskog kreatinina i eGFR (P<0,001), ovisno o odjelu hospitalizacije. Na Hematologiji (23,9%) i Postintenzivnoj jedinici (42,9%), gdje je bio hospitaliziran značajan udio nutritivno ugroženih
bolesnika, postojali su bolesnici s naizgled urednim eGFR-om (≥90 ml/min), što se može objasniti sniženom vrijednošću serumskog kreatinina, tj. smanjenom mišićnom masom i povećanim nutritivnim rizikom. Postoji statistički značajna razlika u učestalosti ponovnih hospitalizacija ovisno o inicijalnom odjelu hospitalizacije (P=0,004). Inicijalni NRS-2002 zbroj pozitivno korelira s dobi (r=0,471, P<0,001), zbrojem kroničnih bolesti (r=0,344, P<0,001), duljinom inicijalne hospitalizacije (r=0,249, P<0,001) i brojem ponovnih hospitalizacija (r=0,198, P=0,004), dok se negativna korelacija bilježi s ITM-om (r = -0,308, P <0,001), OS (r=-0,188, P=0,005), i opsegom nadlaktice (r= -0,374, P <0,001). Inicijalni NRS-2002≥3 nije se pokazao čimbenikom rizika za ponovnu hospitalizaciju i smrtnost, ali je čimbenik rizika za novootkrivene bolesti u razdoblju dvogodišnjeg praćenja (OR=5,21, 95% CI 1,38-19,75, P=0,015). Čimbenik rizika za novootkrivene bolesti jest i upotreba ONS-a
tijekom praćenja (OR=0,16, 95% CI 0,05-0,49, P=0,002). Čimbenici rizika za ponovu hospitalizaciju su vrijednost CRP-a (OR=1,01, 95% CI 1,00-1,02, P=0,032), eGFR<15 ml/min (OR=12,49, 95% CI 1,22-127,61, P=0,033) i primjena ONS-a tijekom dvogodišnjeg praćenja (OR=2,70, 95% CI 1,11-6,54, P=0,028). Čimbenici rizika za smrtnost tijekom
dvogodišnjeg praćenja su opseg nadlaktice (OR=0,87, 95% CI 0,78-0,96, P=0,008) i primjena ONS-a (OR=4,24, 95% CI 1,80-9,97, P=0,001).
Ovo istraživanje je pokazalo kako je značajan udio internističkih bolesnika pod povećanim rizikom za nastanak pothranjenosti te kako nisu primjereno nutritivno zbrinuti.
Postoji razlika u udjelu nutritivno ugroženih bolesnika, upotrebi ONS-a, pojedinim antropometrijskim mjerama i biokemijskim parametrima te učestalosti ponovnih hospitalizacija ovisno o odjelu hospitalizacije. NRS-2002≥3 se nije pokazao čimbenikom rizika za smrtnost i ponovne hospitalizacije, ali jest za novootkrivene bolesti tijekom praćenja.
Važnijim čimbenicima rizika za smrtnost i ponovne hospitalizacije tijekom dvogodišnjeg praćenja pokazala su se druge antropometrijske mjere (opseg nadlaktice) i klinička obilježja (vrijednost CRP-a, upotreba ONS-a).
 
SUMMARY:
The aim of the study was to analyze the malnutrition risk in internal medicine patients and its impact on mortality, rehospitalization, and newly diagnosed diseases rate during twoyear follow-up. We also aimed to analyze differences in nutritional status, anthropometric, biochemical, and other clinical patient characteristics, depending on the initial hospitalization department.
Total of 346 participants were included in the study, while 218 participants were followed up two years later. During the initial hospitalization, anthropometric measurements were performed (body height and weight, body-mass index, waist circumference, WHtR, upper arm circumference, skin fold thickness), nutritional risk was assessed (NRS-2002 questionnaire), biochemical parameters (glucose, CRP, creatinine, eGFR), and other clinical parameters of interest (age, sex, smoking status, chronic diseases, use of nutritional support, length of hospital stay) were analyzed. Two years later, data on mortality, re-hospitalizations, newly diagnosed diseases (diabetes, malignant disease, arterial hypertension), and the use of nutritional support were recorded.
The results showed that internal medicine patients are generally old and polymorbid.
As many as 38.4% of them are at-risk for malnutrition (NRS-2002≥3) during hospitalization, although their anthropometric parameters are increased. Despite the increased malnutrition risk, only 15.3% subjects were prescribed ONS during hospitalization. Followed-up, at-risk
participants were more likely to be female, over 65 years of age, more likely suffered from cancer (54.9% vs. 20.6%; P<0.001), and less likely had normal renal function (eGFR≥90 ml).
Anthropometric measures did not prove useful in the malnutrition assessment as 46.3% of nutritionally endangered patients proved to be overweight and obese (BMI≥25 kg/m2). In 25.6% of them, ONS was introduced during hospitalization, and 36.6% used ONS during the
follow-up period. At-risk patients died significantly more often during the follow-up period (42.7% vs. 23.5%; P<0.003). Regarding anthropometric parameters, there was no statistically significant difference between participants hospitalized in different internal medicine wards,
except for the upper-arm circumference (P<0.001). In patients hospitalized in Nephrology (54.5%), Hematology (45.7%), Post-Intensive Care Unit (42.9%) and Endocrinology and Diabetology (42.9%), despite the increased WHtR, a higher proportion of patients with lower
and regular BMI (<18.5-24.9 kg/m2) was recorded, which can be explained as the result of sarcopenia. Also, a statistically significant differences were recorded for the value of serum creatinine level and eGFR (P<0.001), depending on the hospitalization department. At the
Hematology (23.9%) and Post-Intensive Unit (42.9%), where a significant proportion of atrisk patients were hospitalized, there were patients with seemingly normal eGFR (≥90 ml/min) which may be explained by decreased serum creatinine level, i.e., decreased muscle mass and increased nutritional risk. There is a statistically significant difference in the frequency of rehospitalizations depending on the initial hospitalization ward (P=0.004).
The initial NRS-2002 sum was correlated positively with age (r=0.471, P<0.001), sum of chronic diseases (r=0.344, P<0.001), length of initial hospitalization (r=0.249, P<0.001), and number of re-hospitalizations (r=0.198, P=0.004), while a negative correlation was recorded with BMI (r= -0.308, P<0.001), waist circumference (r= -0.188, P=0.005), and
upper-arm circumference (r= -0.374, P<0.001). The initial NRS-2002≥3 was not a risk factor for rehospitalization and mortality, but it was a risk factor for newly diagnosed diseases during the two-year follow-up period (OR=5.21, 95% CI 1.38-19.75, P=0.015). The risk factor for newly diagnosed diseases was also the use of ONS during follow-up (OR=0.16,
95% CI 0.05-0.49, P=0.002). Risk factors for rehospitalization were CRP level (OR=1.01, 95% CI 1.00-1.02, P=0.032), eGFR<15 ml/min (OR=12.49, 95% CI 1.22-127.61, P=0.033) and ONS administration during the two-year follow-up period (OR=2.70, 95% CI 1.11-6.54,
P=0.028). Risk factors for mortality during the two-year follow-up period were upper-arm circumference (OR=0.87, 95% CI 0.78-0.96, P=0.008) and ONS administration (OR=4.24, 95% CI 1.80-9.97, P=0.001).
This study showed that a significant proportion of internal medicine patients are at an increased malnutrition risk and are not adequately nutritionally cared for. There is a difference in the proportion of nutritionally endangered patients, the use of ONS, individual anthropometric and biochemical parameters, and the frequency of rehospitalizations, depending on the initial hospitalization department. NRS-2002≥3 was not shown to be a risk factor for mortality and rehospitalization, but it was a risk factor for newly diagnosed diseases
during follow-up period. Other anthropometric (upper-arm circumference) and clinical features (CRP value, ONS use) proved to be important risk factors for mortality and rehospitalization rate during the two-year follow-up period. Ispiši stranicu