基线营养-炎症状态而非院内生化恶化与肺炎患者吞咽恢复相关：一项回顾性队列研究

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中文摘要

背景与目的： 吞咽困难在因肺炎住院的患者中很常见，并与营养状态密切相关。尽管入院时营养状态不佳与不良结局相关，但院内短期生化营养-炎症指标变化与吞咽恢复之间的关系仍不清楚，且难以评估，因为此类变化是用出院时测量值来定义的，而恢复往往发生得更早。我们将基线营养-炎症状态作为主要暴露，并根据最终是否发生院内生化恶化来评估纵向吞咽轨迹。
方法： 这项回顾性、单中心队列研究纳入199例因肺炎住院的成年患者。入院时、此后每周以及出院时评估功能性经口摄食量表（FOIS；范围1-7）。入院和出院时计算改良控制营养状态（mCONUT；范围0-12）评分。主要暴露为基线mCONUT，主要结局为首次达到FOIS ≥ 4的时间。Cox分析仅限于基线存在吞咽困难的患者（FOIS < 4；n = 113，61个事件），并针对基线协变量进行调整。使用线性混合效应模型，基于五个时间点的重复FOIS测量（n = 199例患者，762次观察），检验FOIS变化速率是否因最终mCONUT恶化状态而不同。
结果： 较高的基线mCONUT与延迟达到FOIS ≥ 4呈方向一致的关联，但该关联未达到常规统计学显著性（校正风险比0.88/每增加1分，95%置信区间0.77-1.01，p = 0.068）。FOIS随时间显著改善（β = +0.060/天，p < 0.001）。较高的基线mCONUT（β = -0.142，p = 0.036）和更严重的院前衰弱（β = -0.379，p < 0.001）与较低的纵向FOIS水平相关。未观察到显著的时间 × mCONUT恶化交互作用（β = +0.009，p = 0.537），没有证据表明FOIS变化速率因最终院内mCONUT恶化状态而不同。
结论： 较高的基线mCONUT与吞咽恢复延迟呈方向一致的关联，并与较低的纵向FOIS水平相关，而更严重的院前衰弱也与随时间推移较低的FOIS水平相关。根据最终院内mCONUT恶化状态，未观察到FOIS变化速率存在统计学显著差异。由于院内mCONUT变化是用出院时测量值定义的，鉴于时间顺序方面的局限性，与早期吞咽恢复的关联应谨慎解读。

英文摘要

BACKGROUND & AIMS: Dysphagia is common in patients hospitalized for pneumonia and is closely associated with nutritional status. Although poor nutritional status at admission is associated with adverse outcomes, the relationship between short-term in-hospital changes in biochemical nutritional-inflammatory indices and swallowing recovery remains unclear and is difficult to evaluate because such changes are defined using discharge measurements, whereas recovery often occurs earlier. We examined baseline nutritional-inflammatory status as the primary exposure and evaluated longitudinal swallowing trajectories according to eventual in-hospital biochemical deterioration.
METHODS: This retrospective, single-center cohort study included 199 adult patients hospitalized for pneumonia. The Functional Oral Intake Scale (FOIS; range 1-7) was assessed at admission, weekly thereafter, and at discharge. Modified Controlling Nutritional Status (mCONUT; range 0-12) scores were calculated at admission and discharge. The primary exposure was baseline mCONUT, and the primary outcome was time to first achievement of FOIS ≥ 4. The Cox analysis was restricted to patients with baseline dysphagia (FOIS < 4; n = 113, 61 events) and adjusted for baseline covariates. A linear mixed-effects model using repeated FOIS measurements across five timepoints (n = 199 patients, 762 observations) examined whether the rate of FOIS change differed according to eventual mCONUT-worsening status.
RESULTS: Higher baseline mCONUT showed a directionally consistent association with delayed achievement of FOIS ≥ 4, although the association did not reach conventional statistical significance (adjusted hazard ratio 0.88 per 1-point increase, 95% confidence interval 0.77-1.01, p = 0.068). FOIS improved significantly over time (β = +0.060/day, p < 0.001). Higher baseline mCONUT (β = -0.142, p = 0.036) and greater pre-hospital frailty (β = -0.379, p < 0.001) were associated with lower longitudinal FOIS levels. No significant time × mCONUT-worsening interaction was observed (β = +0.009, p = 0.537), providing no evidence that the rate of FOIS change differed according to eventual in-hospital mCONUT-worsening status.
CONCLUSION: Higher baseline mCONUT showed a directionally consistent association with delayed swallowing recovery and was associated with lower longitudinal FOIS levels, while greater pre-hospital frailty was also associated with lower FOIS levels over time. No statistically significant difference in the rate of FOIS change was observed according to eventual in-hospital mCONUT-worsening status. Because in-hospital mCONUT change was defined using discharge measurements, associations with early swallowing recovery should be interpreted cautiously owing to temporal-ordering limitations.