Bioelectric impedance and individual characteristics as prognostic factors for post-operative complications

Standardized phase angle: relationship with functionality, muscle mass and postoperative outcomes in surgical cancer patients

To evaluate the association of standardized phase angle (SPA) with nutritional status, functional parameters, and postoperative outcomes in surgical cancer patients. This prospective study includes 59 cancer patients from Pelotas (Brazil) admitted for elective cancer surgery. We obtained the phase angle through Bioelectrical Impedance Analysis (BIA) and standardized it according to the population's reference values. We estimated the muscle mass using BIA for later calculation of the Skeletal Muscle Index (SMI) and performed handgrip strength (HGS) and gait speed (GS) tests. We used the Patient-Generated Subjective Global Assessment (PG-SGA) to assess the nutritional status. Postoperative complications and duration of hospital stay were evaluated as the outcomes. The prevalence of malnutrition in the sample was 28.8%, according to ASG-PPP. SPA was statistically lower in patients with malnutrition, with lower HGS and reduced GS. For postoperative outcomes, patients with severe complications and those with prolonged hospitalization also had lower SPA values. The greater the number of functional alterations in patients, the lower the SPA value, mainly when associated with reduced muscle mass assessed by BIA, suggesting that muscle mass reduction plays an important role in the association between functional alterations and phase angle in patients with cancer. According to the parameters used in this study, low SPA value was associated with impaired nutritional and functional status and negative outcomes in the analyzed sample.

Capillary leak and endothelial permeability in critically ill patients: a current overview

Capillary leak syndrome (CLS) represents a phenotype of increased fluid extravasation, resulting in intravascular hypovolemia, extravascular edema formation and ultimately hypoperfusion. While endothelial permeability is an evolutionary preserved physiological process needed to sustain life, excessive fluid leak-often caused by systemic inflammation-can have detrimental effects on patients' outcomes. This article delves into the current understanding of CLS pathophysiology, diagnosis and potential treatments. Systemic inflammation leading to a compromise of endothelial cell interactions through various signaling cues (e.g., the angiopoietin-Tie2 pathway), and shedding of the glycocalyx collectively contribute to the manifestation of CLS. Capillary permeability subsequently leads to the seepage of protein-rich fluid into the interstitial space. Recent insights into the importance of the sub-glycocalyx space and preserving lymphatic flow are highlighted for an in-depth understanding. While no established diagnostic criteria exist and CLS is frequently diagnosed by clinical characteristics only, we highlight more objective serological and (non)-invasive measurements that hint towards a CLS phenotype. While currently available treatment options are limited, we further review understanding of fluid resuscitation and experimental approaches to target endothelial permeability. Despite the improved understanding of CLS pathophysiology, efforts are needed to develop uniform diagnostic criteria, associate clinical consequences to these criteria, and delineate treatment options.

Phase angle as a prognostic indicator of surgical outcomes in patients with gastrointestinal cancer

BACKGROUND

In patients with gastrointestinal cancer with planned elective surgery, malnutrition increases the risk of adverse outcomes in the postoperative period. The phase angle, measured by the bioelectrical impedance analysis is an indicator of the metabolic and functional status of the patient. It may be an important prognostic indicator for the clinical outcome of post-surgical treatment in patients with gastrointestinal cancer.

PATIENTS AND METHODS

In this prospective study, 70 patients with gastrointestinal cancer had their phase angles measured by the bioelectrical impedance analysis before the surgery. During the first month after the surgery, we documented the postoperative complications from the patient's records and classified them according to the Clavien Dindo classification of surgical complications. The time of hospitalization was also recorded. The data was statistically analysed in SPSS.

RESULTS

We found a statistically significant difference (p = 0.036) in the average value of phase angles between the group of patients who had postoperative complications (phase angle 5.09°) and the group without postoperative complications (5.64°). We noted a correlating trend of decreasing phase angle values and increasing hospitalization time (Pe R = -0,40, p = 0,001). The phase angle cut-off value (5.5°) was calculated using the ROC curve method, predicting a higher risk of the postoperative complications (p = 0,037) in patients with lower phase angle.

CONCLUSIONS

Lower phase angle values before surgery were associated with more complications during the first month after surgery and longer hospitalization time. We found that a phase angle below than 5.5° could serve as a marker that predicts a greater risk of postoperative complications.

Association of a Bioimpedance Profile with Optical Coherence Tomography Features in Diabetic Macular Edema

We examined the association between bioimpedance profiles and optical coherence tomography (OCT) features in patients with diabetic macular edema (DME). This cross-sectional study included 100 eyes of 100 patients with type 2 diabetes mellitus. The systemic fluid status was assessed using extracellular water-to-total body water ratio (ECW/TBW) and phase angle (PhA), which was measured using bioimpedance equipment. ECW/TBW was higher in the DR (diabetic retinopathy) with DME group than in the no DR and DR without DME groups (p = 0.007 and p = 0.047, respectively); however, no significant difference was observed between the no DR and DR without DME groups. The PhA values were significantly lower in the DR with DME group (5.45 ± 0.84) than in the no DR (6.69 ± 0.69) and DR without DME groups (6.05 ± 1.15) (p < 0.001, p = 0.032, respectively). The presence of multiple HRF (hyper-reflective foci) was associated with a significantly higher ECW/TBW (p = 0.001). In the group with the most significant HRF, PhA was lower than in those with none or moderate amounts of HRF (p < 0.05). Bioimpedance fluid profiles of patients with OCT features of DME suggest a connection between the overall systemic state, including fluid status and DME development. Further research is required to fully understand and utilize this information for effective clinical assessment and treatment planning.

Relationship between Bioelectrical Impedance Phase Angle and Upper and Lower Limb Muscle Strength in Athletes from Several Sports: A Systematic Review with Meta-Analysis

The phase angle (PhA) of bioelectrical impedance is determined by primary factors such as age, body mass index and sex. The researchers' interest in applying PhA to better understand the skeletal muscle property and ability has grown, but the results are still heterogeneous. This systematic review with a meta-analysis aimed to examine the existence of the relationship between PhA and muscle strength in athletes. The data sources used were PubMed, Scielo, Scopus, SPORTDiscus, and Web of Science and the study eligibility criteria were based on the PECOS. The searches identified 846 titles. From those, thirteen articles were eligible. Results showed a positive correlation between PhA and lower limb strength (r = 0.691 [95% CI 0.249 to 0.895]; p = 0.005), while no meta-analysis was possible for the relationships between PhA and lower limb strength. Furthermore, GRADE shows very low certainty of evidence. In conclusion, it was found that most studies showed a positive correlation between PhA and vertical jump or handgrip strength. The meta-analysis showed the relationship between PhA and vertical jump, however, little is known for the upper limbs as was not possible to perform a meta-analysis, and for the lower limbs we performed it with four studies and only with vertical jump.

Handgrip strength is correlated with activities of daily living, balance, and body composition in patients with thoracolumbar compression fracture

This study assessed the relationship between handgrip strength (HGS) and activities of daily living, balance, walking speed, calf circumference, body muscle, and body composition in elderly patients with thoracolumbar vertebral compression fracture (VCF). A cross-sectional study in a single hospital was performed with elderly patients diagnosed with VCF. After admission, we evaluated HGS, 10-meter walk test (speed), Barthel Index, Berg Balance Scale (BBS), numerical rating scale of body pain, and calf circumference. We examined skeletal muscle mass, skeletal muscle mass index, total body water (TBW), intracellular water, extracellular water (ECW), and phase angle (PhA) in patients with VCF using multi-frequency direct segmental bioelectrical impedance analysis after admission. A total of 112 patients admitted for VCF were enrolled (26 males, 86 females; mean age 83.3 years). The prevalence of sarcopenia according to the 2019 Asian Working Group for Sarcopenia guideline was 61.6%. HGS was significantly correlated with walking speed (P < .001, R = 0.485), Barthel Index (P < .001, R = 0.430), BBS (P < .001, R = 0.511), calf circumference (P < .001, R = 0.491), skeletal muscle mass index (P < .001, R = 0.629), ECW/TBW (P < .001, r = -0.498), and PhA (P < .001, R = 0.550). HGS was more strongly correlated with walking speed, Barthel Index, BBS, ECW/TBW ratio, and PhA in men than women. In patients with thoracolumbar VCF, HGS is associated with walking speed, muscle mass, activities of daily living measured using the Barthel Index, and balance measured using BBS. The findings suggest that HGS is an important indicator of activities of daily living, balance, and whole-body muscle strength. Furthermore, HGS is related to PhA and ECW/TBW.

Nascent to novel methods to evaluate malnutrition and frailty in the surgical patient

Preoperative nutrition status is an important determinant of surgical outcomes, yet malnutrition assessment is not integrated into all surgical pathways. Given its importance and the high prevalence of malnutrition in patients undergoing surgical procedures, preoperative nutrition screening, assessment, and intervention are needed to improve postoperative outcomes. This narrative review discusses novel methods to assess malnutrition and frailty in the surgical patient. The Global Leadership Initiative for Malnutrition (GLIM) criteria are increasingly used in surgical settings although further spread and implementation are strongly encouraged to help standardize the diagnosis of malnutrition. The use of body composition (ie, reduced muscle mass) as a phenotypic criterion in GLIM may lead to a greater number of patients identified as having malnutrition, which may otherwise be undetected if screened by other diagnostic tools. Skeletal muscle loss is a defining criterion of malnutrition and frailty. Novel direct and indirect approaches to assess muscle mass in clinical settings may facilitate the identification of patients with or at risk for malnutrition. Selected imaging techniques have the additional advantage of identifying myosteatosis (an independent predictor of morbidity and mortality for surgical patients). Feasible pathways for screening and assessing frailty exist and may determine the cost/benefit of surgery, long-term independence and productivity, and the value of undertaking targeted interventions. Finally, the evaluation of nutrition risk and status is essential to predict and mitigate surgical outcomes. Nascent to novel approaches are the future of objectively identifying patients at perioperative nutrition risk and guiding therapy toward optimal perioperative standards of care.

Usefulness of phase angle on bioelectrical impedance analysis as a surveillance tool for postoperative infection in critically ill patients

Purpose

Bioelectrical impedance analysis (BIA) has advantages of obtaining results quickly, safely, reproducibly, and non-invasively. Phase angle (PhA) is one of the parameter of BIA, its values represent the permeability or integrity of cell membrane. With the exception of C-reactive protein (CRP), few studies have estimated an association between PhA and these conventional biomarkers. Herein, we aimed to investigate the association between the PhA value and the conventional inflammatory markers in postoperative patients in intensive care unit (ICU). Also, the correlation between the change in PhA and the occurrence of infectious complication were determined.

Methods

From July 2020 to February 2022, retrospective observation study conducted in 221 patients who admitted to ICU after abdominal surgery. BIA measurements and blood sampling were routinely performed the next morning. The relationship between PhA and the inflammatory markers were assessed after adjusting for age and body mass index. Univariate and multivariate logistic regression analysis was performed to examine the predisposing factors for postoperative infections.

Results

Among 221 patients admitted to ICU after abdominal surgery, infectious complications occurred in 62 cases. CRP, procalcitonin, or presepsin levels were negatively correlated with PhA in both gender. (-0.295, -0.198 or -0.212 of partial correlation coefficients, respectively in males, and 0.313, -0.245 or -0.36 of partial correlation coefficients, respectively in females) But, white blood cell did not show significant association with PhA in both genders. For males, increased level of CRP on postoperative day 1 (POD1) was revealed as the significant predicting factor for postoperative infectious complication [odds ratio (OR): 1.184, 95% confidence interval (CI): 1.090-1.285, p < 0.001]. For females, increased Acute Physiology and Chronic Health Evaluation II score at admission (OR: 1.457, 95% CI: 1.068-1.987, p = 0.018), increased level of presepsin on (OR: 1.003, 95% CI: 1.001-1.006, p = 0.016) and decreased value of PhA on POD1 (OR: 0.980, 95% CI: 0.967-0.993, p = 0.003) were revealed as the significant predicting factors.

Conclusion

Phase angle obtained through BIA can be used as a predictor of infection as it shows a significant association with inflammatory markers. Phase angle measurements through BIA could improve patient prognosis after abdominal surgery through the careful observation of infections and early, appropriate treatment.

Bioelectrical Impedance Analysis (BIA)- Derived Phase Angle in Children and Adolescents: A Systematic Review

Phase angle (PhA), a directly-measured bioelectrical impedance analysis variable, is suggested to be a proxy of body cell mass as well as extracellular/intracellular water ratio, and is related to cellular integrity and functions. The aim of this systematic review was to evaluate PhA in healthy youths in relation to sex, age, weight status, physical fitness, and sports activities. A systematic literature search (preferred reporting items for systematic reviews and meta-analyses criteria) until January 2022 was performed using PubMed, Embase, Scopus, and Web of Science regarding studies on PhA in healthy children and adolescents 4-18 years of age. Quality was assessed according to the National Institute of Health. After removing duplicates and studies not fulfilling the inclusion criteria, 22 cross-sectional and 1 longitudinal were considered appropriate. As for quality, 14 articles were rated fair and 9 good. Ten studies found that PhA increases with age: the increase was more marked after puberty, whereas changes in younger subjects are by far less defined. A clear sex difference was found in adolescents, likely due to pubertal development. Limited evidence suggests that PhA increases in participants with very high BMI. Limited data were reported on physically active youths without convincing findings. Positive associations of PhA with physical fitness and fat-free mass were found in few studies. In conclusion, partial and limited evidence suggests that changes in PhA over the first 2 decades of life reflect modification in body composition and fat-free mass composition. Further studies are needed for confirming PhA as a relevant marker of nutritional status in youths.

Tailoring prehabilitation to address the multifactorial nature of functional capacity for surgery

Mounting evidence suggests that recovery begins before the surgical incision. The pre-surgery phase of recovery - the preparation for optimal surgical recovery - can be reinforced with prehabilitation. Prehabilitation is the approach of enhancing the functional capacity of the individual to enable them to withstand a stressful event. With this narrative review, we apply the Wilson & Cleary conceptual model of patient outcomes to specify the complex and integrative relationship of health factors that limit functional capacity before surgery. To have the greatest impact on patient outcomes, prehabilitation programs require individualized and coordinated care from medical, nutritional, psychosocial, and exercise services. This article is protected by copyright. All rights reserved.

The Extracellular Mass to Body Cell Mass Ratio as a Predictor of Mortality Risk in Hemodialysis Patients

The extracellular mass/body cell mass ratio (ECM/BCM ratio) is a novel indicator of nutritional and hydration status in hemodialysis (HD) patients. This study aimed to explore the ECM/BCM ratio as a predictor of mortality risk with nutritional-inflammatory markers in HD patients. A prospective observational study was conducted in 90 HD patients (male: 52.2%; DM: 25.60%). Clinical and biochemical parameters [serum albumin, serum C-reactive protein (s-CRP), interleukine-6 (IL-6)] were analysed and bioelectrical impedance analysis (BIA) was performed. Protein-energy wasting syndrome (PEW) was diagnosed using malnutrition-inflammation score (MIS). Based on BIA-derived measurements, the ECM/BCM ratio with a cut-off point of 1.20 was used as a PEW-fluid overload indicator. Comorbidity by Charlson index and hospital admissions were measured. Out of 90 HD patients followed up for 36 months, 20 patients (22.22%) died. PEW was observed in 24 survivors (34.28%) and all non-survivors. The ECM/BCM ratio was directly correlated with MIS, s-CRP, Charlson index and hospital admissions but was negatively correlated with phase angle and s-albumin (all, p < 0.001). Values of the ECM/BCM ratio ≥ 1.20 were associated with higher probability of all-cause mortality (p = 0.002). The ECM/BCM ratio ≥ 1.20, IL-6 ≥ 3.1 pg/mL, s-CRP and s-albumin ≥ 3.8 g/dL and Charlson index were significantly associated with all-cause mortality risk in multivariate adjusted analysis. This study demonstrates that the ECM/BCM ratio ≥ 1.20 as a nutritional marker and/or fluid overload indicator had a significant prognostic value of death risk in HD patients.

Hypertension Predisposition and Thermoregulation Delays in Adolescents with Polycystic Ovary Syndrome: A Pilot Study

Background: Polycystic ovary syndrome (PCOS) is a heterogeneous disorder in which clinical, sonographic, and endophenotypic features have been underinvestigated or inconclusive, especially in the early stages of the disease (adolescence/young adulthood). Objective: This prospective pilot study focused on the differences of multiple physiological functions between Greek adolescent/young adult females suffering from PCOS and age- and body mass index (BMI)- matched healthy controls. Study design: Nineteen PCOS patients and eighteen healthy controls (aged 13 to 23 years) were studied for: (i) biochemical and hormonal dysfunction by measuring circulating glucose, insulin, and androgen levels; (ii) arterial stiffness with pulse wave analysis (PWA) by Sphygmocord; (iii) intima-media thickness (IMT) by ultrasound; (iv) heart rate variability (HRV) by Task Force Monitor; and (v) QT, QRS, QT, P, QRSD by electrocardiogram (ECG). Statistical analysis included Hedge’s g correction for small samples bias, and the results are shown using the Hedge’s g effect size and 95% CI, in line with precision medicine prerequisites. Results: Significant differences in pulse wave velocity (PWV) (g = 0.964 [0.296, 1.632]), subendocardial viability ratio (SEVR) carotid (g = −0.679 [−1.329, −0.030]), pulse pressure (PP) carotid (g = 0.942 [0.275, 1.608]), systolic pressure (SP) carotid (g = 0.785 [0.129, 1.440]), free-testosterone (g = 0.677 [0.042, 0.312]), and Delta4-androstenedione (g = 0.735 [0.097, 0.373]) were observed between PCOS patients and controls. No differences were detected in the remaining endocrine and PWA or ECG biomarkers. Conclusions: Our multidisciplinary approach showed early onset of vascular dysfunction, predisposition to hypertension, thermoregulation delays, and metabolic syndrome changes in adolescent/young adult PCOS.

Standardized Phase Angle for Predicting Nutritional Status of Hemodialysis Patients in the Early Period After Deceased Donor Kidney Transplantation

Background

This study was designed to verify whether early posttransplant standardized phase angle (SPhA) determines nutrition status of hemodialysis patients in regard to different nutritional markers and predicts handgrip strength (HGS) 6 months after kidney transplantation.

Methods

A total of 82 kidney transplant recipients on maintenance hemodialysis treatment entered the study. Nutritional status was evaluated before kidney transplantation, at the hospital discharge date, and 6 months after. We used bioelectrical impedance analysis (BIA), three different malnutrition screening tools, HGS, and anthropometric measurements. Demographic profiles and biochemical nutritional markers were collected. SPhA values, adjusted for age and BMI, were used in our study.

Results

In the early posttransplant period, kidney transplant recipients lost muscle mass, gained fat mass, and developed mostly negative SPhA, accompanied by significantly lower albumin levels. The subjects with lower than median (<-1.46) SPhA_dis [the SPhA (at discharge) adjusted for hospitalization time and the baseline SPhA] displayed lower values of albumin concentration (43.4 vs. 45.1 g/l, p = 0.010), hemoglobin (124 vs. 133 g/l, p = 0.016), GNRI (113 vs. 118, p = 0.041), and HGS (30 vs. 33 kg, p = 0.043). These patients had higher ferritin concentrations (420 vs. 258 mkmol/l, p = 0.026), longer inpatient stays (32 vs. 21 days, p < 0.001), and higher MIS scores (3 vs. 1, p = 0.001).

Conclusion

At the moment of hospital discharge, lower than the median SPhA is related to protein-energy wasting, represented as lower concentrations of nutrition biomarkers and an active inflammatory response. Higher SPhA before kidney transplantation predicts HGS 6 months after kidney transplantation, especially in women.

The importance of body composition assessment in the rehabilitation process

Introduction. This personal study provides several aspects of the importance of body composition assessment in rehabilitation process in order to manage fat mass (FM), fat-free mas imbalances (FFM), pre-sarcopenia status, sarcopenia and risks association and to improve global functionality. Health outcomes and risk estimations regarding fat mass and skeletal muscle mass (SMM) plays a major role and should be integrated into the rehabilitation process routine in order to avoid functional impairment and physical disability by applying specific kinetic programs. Material and method. A number of 14 subjects classified as outpatients who have received physical therapy at home- kinesiotherapy for post-fracture / dislocation status of the lower limbs in accordance with the medical recommendations and legislation in force. At the end of the rehabilitation phase, the body composition was measured using bio impedance in order to adjust the next step of the active rehabilitation. The measurements were obtained with a completely bioelectrical impedance analyzer (BIA). Single frequency BIA (SF-BIA) was used. For each subject major body compartments determined as FFM (including bone mineral tissue, total body water-TBW and visceral protein), SMM and FM were measured as a tissue-system by means of linear empirical equations stored in the system memory together with personal physical data. IBM SPSS software version 25 was used for statistical analysis. Results and discussions. Four age groups determined as follows: 21.43% for 18-39 years, 50-69 years, >70 years each and 35.71% for 40-49 years, based on the rate of muscle loss, because its integrity is essential for rehabilitation program. From the 14 subjects there are 57.14 % men and 42.86% women, from urban environment 78.57% and rural 21.43%. Mean Age is 48.79 years ± 18.792 Std. Deviation. Fat mass from BIA recorded 21.43% cases low and normal each, and high/very high 57.14% of total cases. Consequently, of BMI (body mass index) association, 57.14% are at normal weight, 35.71% overweight and with obesity and 7.14% underweight. One Sample Chi-Square test applied to BMI Type Associate with FM reveals the statistical significance, < .05(.014). Fat-free mass index (FFMI), fat mass index (FMI), skeletal mass index (SMI) were computed by adjusted with height square. FMI somatotype components results are 64.3% adipose cases, 21.4% intermediate and 14.3% lean. One Sample Chi-Square test applied to FMI Types reveals the statistical significance < .05(.046). Regression equation of standard BMI and FMI with scatter plots for 77.8% of cases was computed in the present study. FFMI somatotype components recorded 57.1% intermediate cases, 21.4% slender and solid each. Regression equation of standard BMI and FFMI with scatter plots for 57.4% of cases was computed. Three patients exceeded 15 seconds at the chair stand test so probable sarcopenia was identified. From BIA were extracted the value for the skeletal mass and SMI was calculated by height adjusted: 13 (92.86%) cases have normal values and one (7.14%) case have optimal value. Regression equation of standard BMI and SMI with scatter plots for 66.4% of cases was computed. Pearson correlation (CI =99%) denotes strong statistical relationship between BMI and FMI (r=0.882), FFMI (r=0.815), Age (r=0.659), Water (r=-0.693). FMI also correlates strongly with Age (r= 0.707), Water (r=-0.925) and Proteins values (r=-0.819). FFMI also correlates strongly with SMI (r=0.984). Water correlates with Protein (r=0.848, CI = 99%). Beta regression analysis strongly correlates SMI prediction with FFMI (ß=0.731), Water (ß=0.138) and Protein (ß=-0.370) for p<0.05. Anova significance of .000 (CI=99%) with applicability of 99.8% of the cases (R2 =0.998) proved that constant predictors: Water (%), FFMI, Proteins (%), FMI, BMI interact to influence SMM variability. 64.25% of subjects recorded an insufficient water level and 71.43% of subjects recorded an insufficient proteins level. Body composition evaluation should be integrated into routine clinical practice for the initial assessment and sequential follow-up and the strongest point of BIA is the possibility to replace invasive laboratory analysis with a quick, noninvasive test that can be carried out in a medical office. Body composition evaluation should be performed at the different stages of the disease, during the course of treatments and the rehabilitation phase. Conclusions. For each patient specific kinetic program will be developed. FMI increase (64.3% adipose cases) denotes the risk of metabolic syndrome and insulin resistance. Consequently, resistive and concentric exercises will be applied. For FFMI loss (57.1% intermediate cases, 21.4% slender) and SMI increasing (92.86% cases have normal values but not optimal ones, 21.43% pre-sarcopenia detected by positive chair test) resistance, eccentric/concentric exercises should be applied. All kinetic programs will be preceded by warm-up and followed by stretching taking into account cardiac reserve for each patient. Maximal/sub-maximal force exercises will be used age-related. Additional water (64.25% of subjects recorded an insufficient water level) and proteins levels (71.43% of subjects recorded an insufficient proteins level) must be balanced by nutritional support in accordance with rehabilitation consult and current physician approval in the interdisciplinary team. BIA may be an important supporting tool for health professionals in order to customize the rehabilitation programs for each patient. Keywords: body composition, rehabilitation, bioelectrical impedance, fat-free mass index, fat mass index, skeletal muscle index,

Phase angle and metabolic parameters in severely obese patients

Introduction

Introduction: obese patients present an inflammatory and metabolic profile that leads to oxidative stress and cellular damage. Phase angle is an indicator of cellular integrity and has been proposed as a prognostic parameter for changes in the metabolic profile. Objective: to investigate the possible association between phase angle and metabolic parameters in obese patients. Material and method: this was a cross-sectional study of adult obese patients who attended a specialized clinic between 2014 and 2016. All patients were ≥ 18 years of age, with a body mass index ≥ 35 kg/m2. All data were obtained from medical records and made part of the clinical protocol. Patients were divided into two groups using a cutoff point for phase angle, and the groups were compared using the Kruskal-Wallis or Chi-squared test for quantitative and categorical variables, respectively. Correlations were identified by Spearman's and Pearson's correlation analyses. All between-group differences were considered statistically significant at p ≤ 0.05. Results: a low phase angle was present in 30.5 % of the 141 patients enrolled in the study. We found an association between low phase angle and presence of hyperuricemia (p = 0.018) when adjusted for waist circumference, dysglycemia, arterial hypertension, and hyperuricemia. There was no correlation between phase angle and the components of body composition. Conclusions: there is an association of phase angle with uric acid levels, but not with other metabolic parameters.

[Development and Implementation of a Nutrition Medicine Strategy to optimize Medical Service for Malnourished Patients at a Tertiary Referral Centre]

BACKGROUND

Malnutrition in hospitalised patients is an important and underestimated problem, with a negative impact on outcome and survival - not only in surgical patients. There is a discrepancy between optimal treatment as defined in relevant guidelines on clinical nutrition and the clinical reality. The Main reason for this discrepancy is the lack of established structures for nutrition medicine as an integral part of clinical routines. The necessary structural development is impaired mainly by the lack of resources, but in isolated cases also by the lack of appreciation of the problem. Therefore, practicability and feasibility with regard to local conditions are pivotal for sustainable improvement in a nutrition strategy in hospitalised patients.

METHODS

We describe the institutional and procedural measures taken at a tertiary referral centre to implement a nutrition medicine strategy. The underlying nutrition medicine methodology and definitions are introduced and practical implementation at our centre is illustrated by four examples of ongoing projects.

RESULTS

Using the described systematics, structural changes were implemented at our centre within one year that allowed malnutrition screening, the treatment of patients with complex nutritional care and improvements in the nutritive status of hospitalised patients by ongoing and future project initiatives.

SUMMARY

The successfully implemented structural change at the University Hospital of Bonn described here may serve as a modular example for other hospitals striving to improve clinical nutrition and outcome in hospitalised patients.

Usefulness of bioelectrical impedance analysis and ECW ratio as a guidance for fluid management in critically ill patients after operation

We determined the relationship between changes in bioelectrical impedance analysis (BIA) parameters and response of critically ill patients to fluid therapy during early postoperative period. Associations between BIA values indicating volume status of postoperative patient and clinical outcomes were also evaluated. From May 2019 to April 2020, patients who were admitted to the surgical intensive care unit (SICU) of our institution at more than 48 h after surgery were enrolled. Volume status was measured with a portable BIA device every morning for five days from SICU admission. Overhydration was defined as the case where extracellular water (ECW) ratio > 0.390 measured by BIA. Participants were daily classified into an overhydration or a normohydration group. The relationship between daily hydration status and postoperative outcome was evaluated. Most of the 190 participants showed the overhydration status in the first 48 h after surgery. The overhydration status on day 3 was significant predictor of postoperative morbidities (OR 1.182) and in-hospital mortality (OR 2.040). SOFA score was significant factor of postoperative morbidities (OR 1.163) and in-hospital mortality (OR 3.151) except for the overhydration status on day 3. Cut-off values of overhydration status by ECW ratio at day 3 for predicting postoperative morbidities and in-hospital mortality were > 0.3985 and > 0.4145, respectively. BIA would be a useful and convenient tool to assess the volume status of patients requiring intensive fluid resuscitation in early postoperative period. Overhydration status by ECW ratio on postoperative day 3 needs careful monitoring and appropriate interventions to improve clinical outcomes.

Effects of sarcopenia and malnutrition on morbidity and mortality in gynecologic cancer surgery: results of a prospective study

BACKGROUND

Malnutrition and sarcopenia often occur simultaneously in cancer patients and are thought to have harmful effects on both surgical and oncological outcomes. Therefore, we want to evaluate the effects of sarcopenia and malnutrition on severe postoperative complications and overall survival in gynecologic cancer patients.

METHODS

We assessed nutritional parameters and run a bioelectrical impedance analysis in 226 women. Extracellular mass to body cell mass index, phase angle alpha, muscle mass, and fat mass were evaluated. To determine if patients suffer from sarcopenia, we ran the Timed 'Up and Go' test, performed hand grip strength, and calculated a skeletal muscle index. Postoperative complications were categorized using Clavien-Dindo Classification. Utilizing ROC analysis and logistic regression, we determined predictive clinical factors for severe postoperative complications. Kaplan-Meier method and log-rank test were used for overall survival analysis.

RESULTS

Of the 226 female patients, 120 (53%) had a BMI ≥ 25 kg/m2 , 56 (26%) had a phase angle < 4.75°, and 68 (32%) were sarcopenic according to skeletal muscle index < 27%. Within 30 days after surgery, 40 (18%) patients developed severe postoperative complications, and 4% had died. According to multivariable regression analysis, ECOG status > 1 (OR 4.56, 95% CI: 1.46-14.28, P = 0.009), BMI ≥ 25 kg/m2 (OR 8.22, 95% CI: 3.01-22.48, P < 0.001), phase angle < 4.75° (OR 3.95, 95% CI: 1.71-9.10, P = 0.001), and tumour stage ≥ III A (OR 3.65, 95% CI: 1.36-9.76, P = 0.01) were predictors of severe postoperative complications. During 59 months of follow-up, 108 (48%) patients had died. According to multivariable Cox regression ECOG status > 1 (HR 2.51, 95% CI: 1.25-5.03, P = 0.01), hypoalbuminemia (HR 2.15, 95% CI: 1.28-3.59, P = 0.004), phase angle < 4.5° (HR 1.76, 95% CI 1.07-2.90, P = 0.03), tumour stage ≥ III A (HR 2.61, 95% CI: 1.53-4.45, P < 0.001), and severe postoperative complications (HR 2.82, 95% CI: 1.80-4.41, P < 0.001) were predictors of overall mortality.

CONCLUSIONS

We observed that preoperatively assessed ECOG status > 1, BMI > 25 kg, as well as phase angle alpha < 4.75° and FIGO stage ≥ III A are significantly associated with severe postoperative complications within the first month. Whereas ECOG status > 1, hypoalbuminemia, phase angle < 4.5° as well as FIGO stage ≥ III A and severe postoperative complications within 30 days correlate significantly with poor overall survival.

Body composition, muscle function and biochemical values in patients after pancreatic surgery: An observational study

BACKGROUND & AIMS

The complex nature of pancreatic operation makes it a high-risk and technically demanding major abdominal procedure, resulting in early pathophysiological alterations. This study aims to observe changes in body composition, muscle function and biochemical values in patients during the early postoperative days (PODs) following pancreaticoduodenectomy or total pancreatectomy.

METHODS

Assessment of body composition by bioimpedance spectroscopy, muscle function by peak expiratory flow rate (PEFR) and maximum handgrip strength (HGS), and biochemical values were measured in patients the day before surgery and on PODs 3, 6 and 9.

RESULTS

Significant changes occurred among 34 patients on POD 3 in body weight +2.3 (0.8-3.6) kg, total body water +2.8 (1.1-5.9) L, extracellular water +2.5 (1.2-3.7) L, intracellular water +1.1 (-0.4-1.9) L, phase angle -1.0 (-1.2 to -0.7)°, PEFR -250.0 (-407.5 to -125.0) L/m and HGS -4.8 (-7.3 to -3.0) kg, C-reactive protein +78.0 (41.0-102.8) mg/L, haemoglobin -34.5 (-45.8 to -26.0) g/L, albumin -12 (-16.5 to -10.0) g/L.

CONCLUSIONS

Changes in water distribution, phase angle, initial reduced muscle function and altered biochemical values were observed during the first 9 PODs.

Repurposing Individualized Nutritional Intervention as a Therapeutic Component to Prevent the Adverse Effects of Radiotherapy in Patients With Cervical Cancer

Worldwide, cervical cancer was the fourth leading cause of cancer death among women, while in Mexico was the second cause (5.28%). Cancer patients receiving chemotherapy and radiotherapy have a high risk of malnutrition secondary to the disease and treatment, affects the patient's overall, with adverse effects on gastrointestinal symptoms. These use affects the medical therapy. The aim of the present study was to evaluate the benefits on individualized nutritional therapy on decrease weight loss and gastrointestinal adverse effects and to consider these outcomes in pharmacology research, especially in repurposing drugs. We conducted a longitudinal design with two comparation groups with medical diagnosis of cervical cancer and received radiotherapy weekly, 1) the intervention group (nutritional intervention and counseling -INC-) with 20 participants and 2) control group (retrospective cohort -CG-) with 9 participants. Weekly body composition, dietary intake, adverse effects (gastrointestinal symptoms), glucose, hemoglobin, and blood pressure were analyzed during 4 to 5 weeks. Both groups had weight loss weekly (p = 0.013 and p = 0.043 respectively) but the CG vs INC presented loss fat-free mass ≥500g in 67 and of 37% respectively. By the end of the intervention a 25% of the INC group had <10 g/dL of hemoglobin vs 60% for the CG. To compare the dietary intake of vitamins (A and folic acid), fiber (p = 0.006), iron (p = 0.03) and energy (mainly carbohydrates) (p = 0.04) were according to the recommendations in INC group (p>0.05). The number needed to treat was 4 (95% CI, 2 to 13). The nutritional intervention and counseling weekly during radiotherapy in cervical cancer to maintain/improve muscle mass, hemoglobin, and dietary intake above 70% of the recommendations for INC group compared to the evidence. Adequate nutritional status was maintained and decrease the rate of complications, mainly gastrointestinal symptoms, in INC group. The efficacy of drug repurposing can improve through individualized nutritional therapy for preventing adverse effects of radiotherapy in patients with cervical cancer.

Phase angle and non-alcoholic fatty liver disease before and after bariatric surgery

BACKGROUND

Obesity is a global health problem that is continuing to increase in the young population. In Brazil, the frequency of obesity in 2018 was 19.8%. Several comorbidities are directly associated with obesity, such as non-alcoholic fatty liver disease (NAFLD), which is considered the most common liver disorder in Western countries and affects up to 46% of adults. Bariatric surgery is effective in treating obesity and can improve NAFLD; however, the effect of bariatric surgery on body composition, phase angle (PA), and improving NAFLD needs to be further studied.

AIM

To analyze the PA in the postoperative period of bariatric surgery and to correlate it with changes in body composition and liver disease.

METHODS

This study is a retrospective cohort study of the analysis of the medical records of patients undergoing bariatric surgery in a reference center of a teaching hospital in Porto Alegre over a 2-year period. Patients older than 18 years whose record contained all information relevant to the study were included. The data analyzed were body composition and PA through electrical bioimpedance and NAFLD through liver biopsy in the pre- and postoperative period. The level of significance adopted for the statistical analyses was 5%.

RESULTS

We evaluated 379 patients with preoperative data. Regarding PA, 169 patients were analyzed, and 33 patients had liver biopsy pre- and postoperatively with NAFLD information. In total, 79.4% were female, with a mean age of 39.1 ± 10.6 years. The average body mass index (BMI) was 45.9 ± 7.5 kg/m². The PA showed a mean of 5.8 ± 0.62° in the preoperative period and a significant reduction in the postoperative period. A postoperative reduction in body composition data (skeletal muscle mass, fat percentage, fat mass, body cell mass, BMI and visceral fat area) was shown as well. Regarding liver disease, all patients presented a reduction in the degrees and stages of liver disease in the postoperative period, and some had no degree of liver disease at all.

CONCLUSION

PA decreased after bariatric surgery, with a direct correlation with weight loss and changes in body composition. The decrease in PA was not correlated with the improvement in NAFLD.

Can Phase Angle in Newborns at Neonatal Intensive Care Units Be an Indicator of Mortality and Prognosis?

BACKGROUND

The bioelectrical impedance (BI) phase angle (PA), analyzed directly through BI analysis (BIA), is determined by tissue cellularity, representing a direct measure of cellular stability and, for this reason, has been studied and considered as an indicator of prognosis and nutrition status in adults and children.

OBJECTIVE

We aimed to determine if PA can be an indicator of mortality and prognosis in newborns admitted to the neonatal intensive care unit (NICU).

METHODS

Transversal study conducted at a public NICU in Curitiba, Paraná, Brazil. All newborns, preterm and term, were considered eligible for the study if admission to the NICU occurred by the first hour of life. The Score for Neonatal Acute Physiology II, as well as the Perinatal Extension version, were developed to assess the risk of mortality for all newborns, measured within 12 hours of admission. BIA measurements were conducted using the tetrapolar BioScan Maltron 916, with single-frequency (50 kHz) tetrapolar BI. PA was calculated as the arc tangent: (Xc/R) x 180°/π.

RESULTS

BIA was measured during the first 24 hours of admission for all newborns (n = 93), repeated between 24 and 48 hours (n = 79) and again after 7 days (n = 55), always when possible. PA measurements decreased in the first 48 hours in premature newborns, particularly among those who died. The premature newborns also showed a significant decrease from the first to the last PA measurement (P = .001). In addition, whereas full-term newborns showed an increase of PA at 1 week of life, preterm infants continued to have a decrease in values. For preterm newborns, PA measurements decreased and more sharply so for those who died. This result should be viewed with caution given the small number of deaths, but it should be investigated to understand the role of PA in the prognosis of NICU newborns.

CONCLUSIONS

The absolute value of PA during the first 24 hours of life was not a good marker for severity or mortality. However, the decrease of PA between different moments of evaluation was a good marker of severity. The decrease of PA in the first 48 hours in premature newborns, and that when the decrease is more pronounced, may be indicative of mortality. The difference in PA values between these newborns is probably a significant variable for mortality and prognosis and not a cutoff value.

Nutrition Support in Critically Ill Patients with AKI

How to cite this article: Ramakrishnan N, Shankar B. Nutrition Support in Critically Ill Patients with AKI. Indian J Crit Care Med 2020;24(Suppl 3):S135-S139.

Extracellular mass to body cell mass ratio as a potential index of wasting and fluid overload in hemodialysis patients. A case-control study

BACKGROUND & AIMS

Extracellular mass-to-body cell mass ratio (ECM/BCM ratio) which differentiates the proportion between intraextracellular compartments, could be a nutrition index of being wasted overloaded in hemodialysis (HD) patients. This study aimed to describe a cut-off point of the ECM/BCM ratio and, to find out the relationship between the nutritional-hydration status and this ratio in HD patients.

METHODS

A case-control study was carried out in 64 HD patients individually age-gender-matched to controls. Demographic, clinical and laboratory parameters were recorded. Bioelectrical impedance analysis was used to estimate ECM/BCM ratio as an indicator of the nutritional hydration status. Receiver operator characteristic (ROC) curve analysis was applied to determine the optimal cut-off point for identification of ECM/BCM ratio. An univariate and multivariate conditional logistic regression for the ECM/BCM ratio ≥1.20 was performed.

RESULTS

Median of ECM/BCM ratio was 1.50 (IQR:0.66) in HD patients, whereas 0.87 (IQR: 0.35) was found in controls (p < 0.001). HD-patients had lower body weight, serum albumin (s-albumin) and higher serum C-reactive protein (s-CRP) than controls. By ROC curve analysis, a cut-off point of 1.20 for the ECM/BCM ratio best discriminates to be wasted-overhydrated (sensitivity: 81.2%; specificity: 87.5%). Conditional logistic regression showed that for each 10%, ECM/BCM ratio increase the probability of developing fluid overload was increased 63% (OR: 1.63; 95% CI, 1.15-2.29), whereas an inverse association with s-albumin (OR: 0.15; 95% CI, 0.03-0.61) and other nutritional indicators were found.

CONCLUSIONS

The ECM/BCM ratio appears as a sensitive index that discriminates nutritional and/or hydration status in HD patients compared with age-gender-matched-controls. ECM/BCM ratios ≥1.20 are indicators of wasting and fluid overload in HD patients.

Malnutrition predicts long-term survival in hospitalized patients with gastroenterological and hepatological diseases

BACKGROUND & AIMS

Malnutrition is a common problem in hospitalized patients, influencing treatment outcomes, length of hospital stay, quality of life and overall survival. However, the association of nutritional status parameters with long-term mortality has not yet been studied systematically in gastroenterological-hepatological patients. The present study aimed to assess the association between nutritional status parameters as characterized by Nutritional Risk Screening (NRS), anthropometry, serum transferrin, bioelectrical impedance analysis (BIA) and long-term overall survival in hospitalized gastroenterological-hepatological patients.

METHODS

Nutritional status was assessed in 644 gastroenterological-hepatological patients by NRS score. In addition, body mass index (BMI) and serum transferrin were determined and BIA was performed. Mid-upper arm circumference (MUAC) and triceps skinfold thickness (TST) were measured. Patients were followed for a mean period of 67 months (mean 54.8, range 0-107 months).

RESULTS

During malnutrition screening, 475 (73.8%) patients were diagnosed as sufficiently nourished by NRS (NRS 0-2), while an increased risk of malnutrition was found in 169 (26.2%) patients (NRS≤3). Malnutrition was significantly associated with less favourable results for BMI (p < 0.001), serum transferrin (p < 0.001), BIA (p < 0.001), MUAC (p < 0.001) and TST (p < 0.05). Overall 5-year survival rates (YSR) were much shorter in malnourished patients whether with (5-YSR: 43.9%) or without (73.6%) malignancy. Overall 5-year survival rates (YSR) were much shorter in malnourished patients whether with (5-YSR: 43.9%) or without (73.6%) malignancy. By the multivariable analysis the NRS ≥3 and, phase angle (PhA) over the 5th percentile or over the mean of the cohort were found to be associated with long-term survival.

CONCLUSIONS

Malnutrition is highly prevalent in hospitalized gastroenterological-hepatological patients and is associated with distinct clinical diagnoses. In the present study we demonstrated that malnutrition characterized by the NRS, anthropometry, serum transferrin and BIA, not only predicts short-term but also significantly poor long-term outcome in these patients.

Is phase angle an appropriate indicator of malnutrition in different disease states? A systematic review

BACKGROUND & AIMS

Subjective Global Assessment (SGA) classifies malnutrition severity via a simple bedside assessment. Phase angle (PhA) is an indicator of cell integrity and has been suggested to be indicator of nutritional status.

OBJECTIVE

To explore the relationship between PhA and SGA.

METHODS

Relevant studies published through October 31, 2017 were identified using 7 electronic databases. Articles were included for review if they included comparison data between SGA and PhA within adult disease populations. Evidence quality was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) guidelines and methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool.

RESULTS

33 articles within four disease states (liver, hospitalization, oncology and renal) met inclusion criteria for review. Results were limited by restricting the database search to articles published in English only, and by the inherent difficulty of comparing 2 methods which are both influenced by the operator.

CONCLUSION

Based on GRADE guidelines, evidence quality received a grade of Low. Based on QUADAS-2, 61% of studies had high risk of bias in the index test (PhA), while all other domains had low risk. It is not possible to conclude that PhA is an accurate independent indicator of malnutrition. PROSPERO no. CRD42016050876.

Bioelectrical Impedance Analysis-Derived Phase Angle Predicts Protein-Energy Wasting in Maintenance Hemodialysis Patients

OBJECTIVE(S)

To explore the validity of using bioelectrical impedance analysis (BIA)-derived 50 kHz phase angle (PhA) in predicting protein-energy wasting (PEW) in Chinese maintenance hemodialysis (MHD) patients.

DESIGN AND METHODS

The design was a cross-sectional study. A total of 173 of MHD patients and 173 healthy adults were enrolled in the study. The prevalence of PEW in patients was performed by the International Society of Renal Nutrition and Metabolism criteria. The PhA, body cell mass, fat mass, body fat percentage, fat-free mass, and extracellular water/total body water were measured by InBody S10 body composition analyzer. The biochemical indices and anthropometric measurements were assessed using the way published elsewhere. The PhA, other values of BIA and its relationship with age, visceral protein, anthropometric measurements of the MHD patients were compared with the healthy group. The independent variables for predicting PEW and its cutoff values were explored using logistic regression model and receiver operating characteristic curve analysis, respectively.

RESULTS

The MHD patients' PhA value was significantly lower than the healthy group (4.89°± 1.19 vs. 6.32°± 2.23, P < .01). A total of 34.1% MHD patients with PEW had significantly lower PhA values compared with well-nourished patients (P < .05). The PhA decreased more significantly with age in MHD (r = -0.35, P < .001), compared with controls (r = -0.26, P < .001). The PhA values were positively associated with nutritional indices related to serum albumin, prealbumin, fat-free mass, and mid-arm muscle circumference. PhA values were not associated significantly with fat mass and body fat percentage (P > .05). Multivariate logistic regression analysis showed that PhA and body mass index were independent predictors of PEW, but the PhA was the stronger predictor (odds ratio = 4.48, P < .05). Receiver operating characteristic curve analysis suggested that the optimal PhA cutoff value to predict PEW was 4.6°.

CONCLUSIONS

BIA-derived PhA appears to be a useful bioelectrical marker for predicting PEW in Chinese hemodialysis patients with a cutoff value of 4.6°.

Bioelectrical impedance analysis; a new method to evaluate lymphoedema, fluid status, and tissue damage after gynaecological surgery - A systematic review

The aim of this descriptive review is to summarise the current knowledge of non-invasive bioelectrical impedance analysis (BIA) used with gynaecological surgical patients in regard to postoperative development of lymphoedema and determination of perioperative fluid balance, and as a prognostic factor in cancer mortality and a predictor of postoperative complications. The databases PubMed, MEDLINE, Scopus Web of Science, the Cochrane Library, and reference lists of selected articles were searched for relevant articles published during the period January 2008-April 2018. Only papers published in English were retrieved. Thirty-seven articles were evaluated. Where gynaecological studies were lacking, studies with a study population from neighbouring clinical fields were used instead. Studies on the clinical use of BIA with gynaecological surgical patients were divided into three categories: the postoperative development of lower limb lymphoedema (n = 7), perioperative hydration measuring (n = 3), and the BIA parameter phase angle as a prognostic factor in cancer survival and as predictive for postoperative complications (n = 6). Of these 16 studies only three used a pure gynaecological study population. Three different methods of BIA were used in these articles: single frequency-BIA, multifrequency-BIA and bioimpedance spectroscopy. BIA was found to detect lymphoedema with a sensitivity of 73% and a specificity of 84%. Studies indicated that BIA was able to detect lower limb lymphoedema at an early stage even before it became clinically detectable. During postoperative hydration measurements, an increase in extracellular fluid volume and extracellular fluid volume in relation to total body fluid volume, as well as a decrease in phase angle, were associated with higher frequencies of postoperative complications. Moreover, low values for the phase angle have been associated with increased mortality in cancer patients. However, the number of studies in this field was limited. From our review, BIA seems to be a useful tool for use in the clinical setting of the gynaecological surgical patient. The theoretical approach of using bioelectrical impedance values to measure the fluid distribution in the body compartments offers wide opportunities in the clinical setting. However, so far, all studies have set up cut-off limits within the study population, and reference values for a general population need to be defined. There are also rather few studies on a gynaecological study population. Hence, there is a need for further studies within gynaecological surgery focusing on early detection of lower limb lymphoedema, perioperative fluid balance, and postoperative complications in order to establish the value of BIA in clinical praxis.

Association Between Standardized Phase Angle, Nutrition Status, and Clinical Outcomes in Surgical Cancer Patients

BACKGROUND

Different nutrition assessment tools in surgical cancer patients are used in clinical practice, which results in different prevalence rates of malnutrition. This may impact the interpretation of the association between nutrition status and clinical outcomes. Reduced standardized phase angle (SPA) values are associated with adverse outcomes in patients with cancer. Thus, it is important to assess the association of SPA with nutrition status and relate it to postoperative clinical outcomes.

METHODS

This prospective observational study included 121 surgical cancer patients. Bioelectrical impedance analysis, subjective global assessment (SGA), anthropometric measurements, and assessment of muscle strength were used to provide nutrition diagnosis 1 day before surgery. The patients were followed for infectious and noninfectious postoperative complications from the first day after the operation until discharge or death.

RESULTS

The prevalence of malnutrition was higher according to SGA (63.6%). Patients with an SPA < -1.65 had a greater chance of being diagnosed as malnourished according to the SGA (3.66 [1.35-9.90]), midarm circumference (OR 4.24; CI95%; 1.72-10.43), midarm muscle area (OR 4.38; CI95%; 1.68-11.42), and low handgrip strength (3.84 [1.31-11.25]). Patients with an SPA < -1.65 presented with more infectious complications (OR 4.19; CI95%; 1.52-11.53), but there was no association between SPA and other outcomes or death. SPA was the only significant predictor of infectious complications (AUC, 0.61; 95% CI, 0.51-0.71).

CONCLUSION

SPA was associated with different nutrition status parameters, and it was able to predict postoperative infectious complications.

The Phase Angle of the Bioelectrical Impedance Analysis as Predictor of Post-Bariatric Weight Loss Outcome

BACKGROUND

Bariatric surgery is proven to be the most effective therapy for obesity. However, the targeted weight reduction is not always achieved. Reliable predictors for postoperative success are rare. Also, most available predictors, such as gender and socioeconomic status, cannot be influenced. The aim of the study was to assess the reliability of the phase angle (PhA) as a predictor of weight reduction and body composition after bariatric surgery.

METHODS

One hundred seventy-three patients (127 with Roux-en-Y gastric bypass and 46 with sleeve gastrectomy), treated between January 2004 and December 2012, were included into this prospective trial. Bioelectrical impedance analysis (BIA) was performed before and five times within the first year after the operation. Correlation between excess weight loss (EWL) was calculated using Pearson's correlation coefficient and a receiver operating characteristic (ROC) curve.

RESULTS

The average weight loss was significant with a total weight loss of 30.1 %, while the PhA did not show any significant decrease during the first 12 months after surgery. The correlation between the preoperative PhA and the postoperative EWL was significant after 6 weeks and after 6, 9, and 12 months. The ROC curve has an area of 0.7. The best point of the curve is a PhA of 3.9° with a sensitivity of 81 % and a specificity of 54 %.

CONCLUSIONS

PhA may be a useful predictor of EWL after bariatric surgery, and a PhA of 3.9° was calculated as the most suitable cut-off for a successful operation.

Applicability of the direct parameters of bioelectrical impedance in assessing nutritional status and surgical complications of women with gynecological cancer

BACKGROUND/OBJECTIVES

Bioelectrical impedance vector analysis (BIVA) has been considered a promising technique in monitoring the nutritional and hydration status of patients with different types of diseases. The aim of this study was to assess the nutritional status provided by direct parameters of bioelectrical impedance analysis (BIA), BIVA and phase angle (PA), in patients with cervical and endometrial cancer undergoing surgical treatment, associating to other parameters of nutritional status and surgical outcomes.

SUBJECTS/METHODS

In a prospective cohort, 208 women eligible to surgical treatment, admitted from January to December 2015, were enrolled. Patients were assessed according to the body mass index (BMI), Patient Generated Subjective Global Assessment (PG-SGA) and BIA. The PA was categorized as below and above percentiles 25 and 50 of studied population.

RESULTS

According to BMI and PG-SGA, most of them were classified as obese (69%) and well nourished (84%), respectively. PA was significantly lower in patients with endometrial cancer, PG-SGA B or C, and in those who remained longer in hospital. PA below 25th percentile was also associated with surgical complications. Comparison of BIVA detachment of our population with a reference population showed significant impedance vector displacement, characterized by decreased reactance value and increased resistance value in our group of patients.

CONCLUSIONS

PA was associated with other parameters of nutritional status and surgical outcomes. BIVA was associated with nutritional status and length of hospital, but did not present significant result for surgical complications.

Disorders of nutritional status in sepsis - facts and myths

The problem of diagnosing nutritional status disorders in septic patients remains unresolved. This is associated with the necessity of the introduction of newer and newer methods of assessing nutritional status, often requiring precise and expensive equipment as well as employment of professionals in this field in hospital wards, primarily including intensive care units (ICU). Methods that have been applied thus far for assessing nutritional status, also used in severely ill septic patients, have little impact on improving treatment results. This is due to the high dynamics of changes in nutritional status in these patients, healing process variability in individual patients, and the “mismatch” of methods for assessing nutritional status in relation to the patient’s clinical status. The diagnostic value of the traditional methods of assessing nutritional status, i.e. anthropometric analysis and selected laboratory tests, as markers of nutritional status disorders in septic patients, is still debatable. There is still no precise method that could become the “gold standard” allowing for early identification of malnutrition in these group of patients. Phase angle, bioelectrical impedance vector analysis (BIVA), and the “illness marker”, obtained directly from the resistance, reactance, and impedance, can be used as prognostic or nutritional indices in severely ill septic patients, but the intensity of research on this subject needs to be increased. Detailed assessment of nutritional status should include tests of selected inflammation markers (including TLC, HMGB1, IL-6, IL-10, IL-1ra, sTNFRI).

Association Between Nutrition Status and Survival in Elderly Patients With Colorectal Cancer

BACKGROUND

Aging patients with cancer have a higher risk of mortality and treatment-associated morbidity than younger patients. Nutrition status may play an important role in cancer mortality. We aimed to evaluate the survival time of elderly patients with colorectal cancer and its association with body mass index (BMI), the patient-generated subjective global assessment (PG-SGA), and phase angle (PA).

MATERIALS AND METHODS

BMI, PG-SGA, and PA were determined for all patients (n = 250) at first assessment.

RESULTS

Seventy-one (28.4%) patients were in active oncologic treatment (group 1) and 179 (71.6%) were in remission (group 2). At the time of the analysis, 73 (29.2%) patients had died and 177 (70.8%) were censored. The mean (standard deviation) age was 70.9 (7.49) years; 17.2% were undernourished, 56% normal weight, and 26.8% were overweight. According to the PG-SGA, 35.2% of patients needed some nutrition intervention and 4.4% needed it urgently. The mean PA was 4.94 ± 1°. PG-SGA, tumor stage, and PA differed significantly ( P < .001) between the groups; BMI did not ( P = .459). Severe malnutrition (PG-SGA C), compared with PG-SGA A, was associated with a relative hazard of death of 12.04 (95% confidence interval [CI], 3.43-42.19, P < .001). PA >5° was associated with better prognosis: a relative hazard of 0.456 (95% CI, 0.263-0.792; P < .005).

CONCLUSION

Among elderly patients with colorectal cancer, PA and PG-SGA were prognosis factors. PA >5° was associated with best survival and PG-SGA C with worst survival.

Bioimpedance Measurements in Adolescents with Polycystic Ovary Syndrome: A Pilot Study

Limited data are available on the body composition of adolescent women with polycystic ovary syndrome (PCOS). The aim of this study was to examine differences in body composition indices of metabolism, homeostasis and inflammation, between Greek adolescent females suffering from PCOS and age- and body mass index (BMI)-matched non-PCOS controls. Thirteen PCOS patients and nine non-PCOS controls, aged 13-24 years participated in this cross-sectional study. Study participants underwent assessment by a novel dual frequency bioimpedance device (BIA-ACC). The following body composition indices were measured in each adolescent: extra cellular water (ECW) as inflammation marker, total body water (TBW) as homeostasis marker, extracellular mass to body cell mass ratio (ECM/BCM), fat mass (FM), fat-free mass (FFM) and intracellular water (ICW) as markers of body mass composition and metabolism. Non-linear analysis showed no statistically significant differences in the body composition characteristics between PCOS patients and controls. Further studies with larger sample sizes are needed to confirm whether adolescents with PCOS actually have similar body composition profile with their non-PCOS peers.

Phase angle assessment by bioelectrical impedance analysis and its predictive value for malnutrition risk in hospitalized geriatric patients

BACKGROUND

Phase angle (PhA) value determined by bioelectrical impedance analysis (BIA) is an indicator of cell membrane damage and body cell mass. Recent studies have shown that low PhA value is associated with increased nutritional risk in various group of patients. However, there have been only a few studies performed globally assessing the relationship between nutritional risk and PhA in hospitalized geriatric patients. The aim of the study is to evaluate the predictive value of the PhA for malnutrition risk in hospitalized geriatric patients.

METHODS

One hundred and twenty-two hospitalized geriatric patients were included in this cross-sectional study. Comprehensive geriatric assessment tests and BIA measurements were performed within the first 48 h after admission. Nutritional risk state of the patients was determined with NRS-2002. Phase angle values of the patients with malnutrition risk were compared with the patients that did not have the same risk. The independent variables for predicting malnutrition risk were determined. SPSS version 15 was utilized for the statistical analyzes.

RESULTS

The patients with malnutrition risk had significantly lower phase angle values than the patients without malnutrition risk (p = 0.003). ROC curve analysis suggested that the optimum PhA cut-off point for malnutrition risk was 4.7° with 79.6 % sensitivity, 64.6 % specificity, 73.9 % positive predictive value, and 73.9 % negative predictive value. BMI, prealbumin, PhA, and Mini Mental State Examination Test scores were the independent variables for predicting malnutrition risk.

CONCLUSIONS

PhA can be a useful, independent indicator for predicting malnutrition risk in hospitalized geriatric patients.

Bioelectrical impedance phase angle as a prognostic indicator of survival in head-and-neck cancer

BACKGROUND

Phase angle could be an alternative to subjective global assessment for the assessment of nutrition status in patients with head-and-neck cancer.

METHODS

We prospectively evaluated a cohort of 75 stage iiib and iv head-and-neck patients treated at the Otolaryngology Department, Head and Neck Surgery, Medical University of Lublin, Poland. Bioelectrical impedance analysis was performed in all patients using an analyzer that operated at 50 kHz. The phase angle was calculated as reactance divided by resistance (Xc/R) and expressed in degrees. The Kaplan-Meier method was used to calculate survival.

RESULTS

Median overall survival in the cohort was 32.0 months. At the time of analysis, 47 deaths had been recorded in the cohort (62.7%). The risk of shortened overall survival was significantly higher in patients whose phase angle was less than 4.733 degrees than in the remaining patients (19.6 months vs. 45 months, p = 0.0489; chi-square: 3.88; hazard ratio: 1.8856; 95% confidence interval: 1.0031 to 3.5446).

CONCLUSIONS

Phase angle might be prognostic of survival in patients with advanced head-and-neck cancer. Further investigation in a larger population is required to confirm our results.

Prognostic nutritional index serves as a predictive marker of survival and associates with systemic inflammatory response in metastatic intrahepatic cholangiocarcinoma

OBJECTIVE

The significance of the prognostic nutritional index (PNI) has been widely reported and confirmed in many types of cancers. However, few studies are available indicating its prognostic power in patients with intrahepatic cholangiocarcinoma (ICC). Thus, we investigated its relationship with overall survival (OS) to evaluate its role in predicting survival in patients with ICC.

PATIENTS AND METHODS

Between October 2011 and October 2015, 173 consecutive patients with pathologically confirmed locally advanced or metastatic ICC were enrolled. First, the correlations between PNI and clinical factors were analyzed among these patients. Next, univariate and multivariate analyses were conducted to evaluate the association between PNI and OS among these patients with ICC. In addition, the relationships between PNI and three typical systemic inflammatory response (SIR) markers - the neutrophil/lymphocyte ratio (NLR), the platelet/lymphocyte ratio (PLR), and the lymphocyte/monocyte ratio (LMR) - were also assessed.

RESULTS

A lower PNI was linked with a shorter OS in patients with ICC, as reflected obviously in the Kaplan-Meier analyses. The patients with ICC were divided into the locally advanced group and the metastatic group. Further analyses revealed that PNI is not associated with OS in the locally advanced group. However, in the subgroup of patients with metastatic ICC, a lower PNI significantly correlated with a worsened OS. The OS for patients with a low PNI is 5 months, whereas the OS is 10.17 months for patients with a high PNI. Multivariate analyses revealed that PNI is independently correlated with OS. We finally proved that PNI is negatively proportional to NLR and PLR and positively proportional to LMR.

CONCLUSION

Our results demonstrate that decreased PNI signifies a poor OS and is associated with SIR in patients with metastatic ICC. Therefore, it may serve as a valuable predictive marker in patients with metastatic ICC.

Phase Angle and Impedance Ratio: Reference Cut-Points From the United States National Health and Nutrition Examination Survey 1999-2004 From Bioimpedance Spectroscopy Data

BACKGROUND

Raw bioimpedance parameters (eg, 50-kHz phase angle [PA] and 200-kHz/5-kHz impedance ratio [IR]) have been investigated as predictors of nutrition status and/or clinical outcomes. However, their validity as prognostic measures depends on the availability of appropriate reference data. Using a large and ethnically diverse data set, we aimed to determine if ethnicity influences these measures and provide expanded bioimpedance reference data for the U.S.

POPULATION

METHODS

The National Health and Nutrition Examination Survey (NHANES) is an ongoing compilation of studies conducted by the U.S. Centers for Disease Control and Prevention designed to monitor nutrition status of the U.S.

POPULATION

The NHANES data sets analyzed were from the years 1999-2000, 2001-2002, and 2003-2004.

RESULTS

Multivariate analysis showed that PA and IR differed by body mass index (BMI), age, sex, and ethnicity (n = 6237; R² = 41.2%, P < .0001). Suggested reference cut-points for PA stratified by age decade, ethnicity, and sex are provided.

CONCLUSION

Ethnicity is an important variable that should be accounted for when determining population reference values for PA and IR. We have provided sex-, ethnicity-, and age decade-specific reference values from PA for use by future studies in U.S.

POPULATIONS

Interdevice differences are likely to be important contributors to variability across published population-specific reference data and, where possible, should be evaluated in future research. Ultimately, further validation with physiologically relevant reference measures (eg, dual-energy x-ray absorptiometry) is necessary to determine if PA/IR are appropriate bedside tools for the assessment of nutrition status in a clinical population.

Fat-free mass at admission predicts 28-day mortality in intensive care unit patients: the international prospective observational study Phase Angle Project

PURPOSE

Phase angle as measured by bioelectrical impedance analysis reflects fat-free mass. Fat-free mass loss relates to worse prognosis in chronic diseases. Primary aim of this study was: to determine the association between fat-free mass at intensive care unit admission and 28-day mortality.

METHODS

Ten centres in nine countries participated in this multicentre prospective observational study. The inclusion criteria were age >18 years; expected length of stay >48 h; absence of pacemaker, heart defibrillator implant, pregnancy and lactation. Fat-free mass was assessed by measurement of the 50-kHz phase angle at admission. The primary endpoint was 28-day mortality. The area under the receiver operating characteristic curve (AUC) was used to assess prediction of 28-day mortality by fat-free mass at ICU admission. The variables associated with 28-day mortality were analysed by means of multivariable logistic regression.

RESULTS

Of the 3605 patients screened, 931 were analysed: age 61 ± 16 years, male 60 %, APACHE II 19 ± 9, body mass index 26 ± 6, day 1 phase angle 4.5° ± 1.9°. Day 1 phase angle was lower in patients who eventually died than in survivors (4.1° ± 2.0° vs. 4.6° ± 1.8°, P = 0.001). The day 1 phase angle AUC for 28-day mortality was 0.63 [0.58-0.67]. In multivariable analysis, the following were independently associated with 28-day mortality: age (adjusted odds ratio (aOR) 1.014 [95 % confidence interval 1.002-1.027], P = 0.03), day 1 phase angle (aOR 0.86 [0.78-0.96], P = 0.008), APACHE II (aOR 1.08 [1.06-1.11], P < 0.001), surgical patient (aOR 0.51 [0.33-0.79], P = 0.002), and admission for other diagnosis (aOR 0.39 [0.21-0.72], P = 0.003). A multivariable combined score improved the predictability of 28-day mortality: AUC = 0.79 [0.75-0.82].

CONCLUSION

Low fat-free mass at ICU admission is associated with 28-day mortality. A combined score improves mortality predictability.

TRIAL REGISTRATION

NCT01907347 ( http://www.clinicaltrials.gov ).

The impact of nutritional status and appetite on the hospital length of stay and postoperative complications in elderly patients with severe aortic stenosis before aortic valve replacement

Introduction

Severe aortic stenosis (AS) is associated with the reduction of physical activity and muscle mass and may be associated with decreased appetite.

Aim

To assess the nutritional status and the impact of nutritional status and appetite on the hospital length of stay and postoperative complications in elderly patients with severe AS before aortic valve replacement.

Material and methods

Ninety-nine patients (55 male, 44 female; 74.3 ±5.2 years old) with severe AS and an indication for aortic valve replacement (AVR) were included. The nutritional status was assessed by different questionnaires (7-point Subjective Global Assessment Score – 7-SGA, full-Mini Nutritional Assessment – full-MNA) and anthropometric measurements (body mass index (BMI) kg/m²). Body composition was estimated using multi-frequency bioelectrical impedance analysis. Appetite was assessed by the Simplified Nutrition Assessment Questionnaire (SNAQ).

Results

The average BMI of patients was 28.8 ±5.8 kg/m². Results of the 7-SGA and f-MNA questionnaires revealed that 39 patients (39.4%) were at risk of malnutrition. The mean SNAQ score was 15.8 ±1.8. The average length of hospital stay was 10 ±5.8 days. There was a positive correlation of LOS with age (r = 0.26, p = 0.03) and a negative correlation with fat mass (kg) (r = –0.28, p = 0.04) and BMI (r = –0.22, p = 0.03). Postoperative complications were observed in 37 patients (37.4%). Patients who developed complications were older and had poorer nutritional status according to the results of the 7-SGA.

Conclusions

Despite many patients undergoing AVR being overweight and obese, a considerable proportion displayed clinical signs of malnutrition. The results suggest that an assessment of nutritional status and appetite in this group of patients should be conducted regularly and that the 7-SGA scale could represent a reliable tool to assess malnutrition.

Body composition of Slovak midlife women with cardiovascular complications

The aim of this study was to analyse differences in body composition of women with and without cardiovascular complications. Bioelectrical parameters were measured with bioimpedance monofrequency analyser (BIA 101) and tissue electric properties were analysed by bioelectric impedance vector analysis (BIVA). The clinical sample (with CVD) consisted of 254 women ranging in age between 39 and 65 years. The sample of women without CVD consisted of 318 women in the same age range and was created from database of our previous studies. Statistical analysis adjusted for age showed significant differences in body composition characteristics of the studied samples. The results of vector analysis showed significantly different tissue electric properties of women in studied groups, what was confirmed by the Hotelling T2- test (p=0.0000). More women with CVD attained risky mean values of obesity indices of BMI and WHR than their “healthy” counterparts. Among women with CVD 80.2% had higher value of the BMI index than optimal one (>24.9 kg/m2) and 74.4% of women had higher value of the WHR index than optimal (>0.80). From the BIA parameters strong correlation coefficient was found between BMI and FM in both groups (r=0.962 for women with CVD; r=0.968 for relatively healthy women). Our data confirmed that cardiovascular disease complications are strongly linked in body composition changes. The cross-sectional nature of our study makes it difficult to draw conclusions regarding causal pathways, though variables of obesity are in line with unhealthy conditions.

Evaluation of Bioelectrical Impedance Analysis in Critically Ill Patients: Results of a Multicenter Prospective Study

BACKGROUND

In critically ill patients, muscle loss is associated with adverse outcomes. Raw bioelectrical impedance analysis (BIA) parameters (eg, phase angle [PA] and impedance ratio [IR]) have received attention as potential markers of muscularity, nutrition status, and clinical outcomes. Our objective was to test whether PA and IR could be used to assess low muscularity and predict clinical outcomes.

METHODS

Patients (≥18 years) having an abdominal computed tomography (CT) scan and admitted to intensive care underwent multifrequency BIA within 72 hours of scan. CT scans were landmarked at the third lumbar vertebra and analyzed for skeletal muscle cross-sectional area (CSA). CSA ≤170 cm² for males and ≤110 cm² for females defined low muscularity. The relationship between PA (and IR) and CT muscle CSA was evaluated using multivariate regression and included adjustments for age, sex, body mass index, Charlson Comorbidity Index, and admission type. PA and IR were also evaluated for predicting discharge status using dual-energy x-ray absorptiometry-derived cut-points for low fat-free mass index.

RESULTS

Of 171 potentially eligible patients, 71 had BIA and CT scans within 72 hours. Area under the receiver operating characteristic (c-index) curve to predict CT-defined low muscularity was 0.67 ( P ≤ .05) for both PA and IR. With covariates added to logistic regression models, PA and IR c-indexes were 0.78 and 0.76 ( P < .05), respectively. Low PA and high IR predicted time to live ICU discharge.

CONCLUSION

Our study highlights the potential utility of PA and IR as markers to identify patients with low muscularity who may benefit from early and rigorous intervention.

Assessment of the Addition of Hypoalbuminemia to ACS-NSQIP Surgical Risk Calculator in Colorectal Cancer

The aim of this study was to evaluate the benefit of adding hypoalbuminemia to the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) Surgical Risk Calculator when predicting postoperative outcomes in colorectal cancer patients.The ACS-NSQIP Surgical Risk Calculator offers qualified risk evaluation in surgical decision-making and informed patient consent. To date, malnutrition defined as hypoalbuminemia, an important independent surgical risk factor in colorectal cancer, is not included.This is a retrospective, multi-institutional study of ACS-NSQIP patients (n = 18,532) who received colorectal surgery from 2009 to 2012. Models were constructed for predicting postoperative mortality and morbidity using the risk factors of the ACS-NSQIP Surgical Risk Calculator before and after adding hypoalbuminemia as a risk factor. The 2 models' performance was then compared using c-statistics and Brier scores. The ACS-NSQIP database in 2008 was used for validation of the created models.The prevalence of hypoalbuminemia (27.8%) is higher in colorectal cancer, when compared with other most common cancers. In univariate analyses, hypoalbuminemia was significantly associated with postoperative mortality and morbidity in colorectal cancer patients. In multivariate logistic regression analyses, 15 postoperative complications, including mortality and serious morbidities, were significantly predicted by hypoalbuminemia. Most of the models with hypoalbuminemia showed better performance and validation in predicting postoperative complications than those without hypoalbuminemia.In colorectal cancer, hypoalbuminemia, with levels below 3.5 g/dL, serves as an excellent assessment tool and preoperative predictor of postoperative outcomes. When combined with hypoalbuminemia as a risk factor, the ACS-NSQIP Surgical Risk Calculator offers more accurate information and estimation of surgical risks to patients and surgeons when choosing treatment options.

Analysis of body composition and nutritional status in Brazilian phenylketonuria patients

Background

Phenylketonuria (PKU) is characterized by phenylalanine (Phe) accumulation to toxic levels due to the low activity of phenylalanine-hydroxylase. PKU patients must follow a Phe-restricted diet, which may put them in risk of nutritional disturbances. Therefore, we aimed to characterize body composition parameters and nutritional status in Brazilian PKU patients also considering their metabolic control.

Methods

Twenty-seven treated PKU patients older than 5 years, and 27 age- and gender-matched controls, were analyzed for anthropometric features and body composition by bioelectrical impedance (BIA). Patients' metabolic control was assessed by historical Phe levels.

Results

There was no effect of PKU type, time of diagnosis, or metabolic control for any analyzed parameter. About 75% of patients and controls were eutrophic, according to their BMI values. There were no difference between groups regarding body composition and other BIA-derived parameters.

Conclusions

Brazilian PKU patients do not show differences in body composition and nutritional status in comparison with controls, regardless metabolic control. Although similar to controls, PKU patients may be in risk of disturbed nutritional and metabolic markers as seen for the general population.

Bioelectrical Impedance of Vectorial Analysis and Phase Angle in Adolescents

OBJECTIVES

Bioelectrical impedance can be interpreted by vector analysis using direct measures of the impedance vector; thus, collecting information about resistance (R), reactance (Xc), and phase angle (PA) makes it possible to classify an individual's nutritional status. The aim of this study was to investigate these values and construct bioelectrical references for healthy Brazilian adolescents.

METHODS

This is a cross-sectional study that included 567 healthy adolescents, aged 10 to 18 years. The bioelectrical impedance was performed to collect data for R and Xc. In addition, weight and height were also collected. The PA was calculated, and thereby the tolerance and confidence ellipses were constructed using specific software.

RESULTS

For boys the mean vectors of 11 and 12 years, 12 and 13 years, 13 and 14 years, and 15 and 16 years were different from each other (p < 0.05). For girls the only mean vectors with significant differences were 11 and 12 years (p = 0.0071). The results differ from those in the literature, possibly due to ethnic differences in body composition.

CONCLUSION

The present study provides an important tool for monitoring the nutritional status of adolescents of different ages, without previous knowledge of some anthropometric measures such as body weight.