The use of bioelectrical impedance analysis to predict post-operative complications in adult patients having surgery for cancer: A systematic review

Phase angle as a prognostic factor in patients with cancer: a systematic review of the existing evidence via a meta-analysis

BACKGROUND

the phase angle (PA) is expressed via bioelectrical impedance and an indicator of cell membrane health, integrity, hydration, and nutritional status. The associations between PA and cancer survival are inconsistent and unclear. This study aimed to assess PA's role as a prognostic marker of cancer survival.

METHODS

we searched PubMed and EMBASE to identify all relevant studies up to December 2023. A meta-analysis was performed to clarify PA's prognostic role for cancer patients.

RESULTS

a total of 30 studies covering 6587 participants were included in this study. There was a significant prognostic role for PA in the context of cancer patients' survival (HR = 0.73; 95 % CI, 0.66-0.81, p < 0.0001, I2 = 0.0 %). Patients with low PA values were 27 % less likely to survive than patients with high values. Our subgroup analyses showed that geographical population (American: HR = 0.66, 95 % CI: 0.55-0.79, I2 = 0.0 %; European: HR = 0.63, 95 % CI: 0.47-0.84, I2 = 23.2 %; Asian: HR = 0.48, 95 % CI: 0.31-0.74), the type of cancer (head and neck, colorectal, lung, or pancreatic cancer), and type of therapy (palliative vs. non-palliative treatment) did not change the prognostic value.

CONCLUSIONS

the findings highlight the potential of PA to be a non-invasive, cost-effective prognostic tool in oncological care.

Phase angle is a useful predicting indicator for protein-energy wasting and cardiovascular risk among maintenance hemodialysis patients

Protein-energy wasting (PEW) is a major contributor to the high mortality among maintenance hemodialysis (MHD) patients. Cardiovascular disease (CVD) is the leading cause of death in dialysis patients, and PEW can significantly increase cardiovascular mortality in MHD patients. Previous studies have confirmed that PA may be a good objective indicator for determining the nutritional status and prognosis of MHD patients. Our study aimed to determine the predictive value of phase angle (PA) as detected by bioelectrical impedance analysis (BIA) on PEW and cardiovascular (CV) risk among MHD patients. Our retrospective observational study involved 161 adult patients with HD. The Cardiovascular risk score is a risk model based on the Japan Dialysis Outcome and Practice Patterns Study (J-DOPPS). We established LASSO logistic regression analysis model to identify key parameters related to body composition that can predict PEW in MHD patients. The area under the curve (AUC) values for PA, appendicular skeletal muscle mass index (ASMI), body cell mass (BCM), and mid-arm circumference (MAC) in predicting PEW in male MHD patients were relatively large, with 0.708, 0.674, 0.663, and 0.735, respectively. The predicted PEW values of these parameters were slightly lower in female patients than in men. We incorporated PA, ASMI, BCM, and MAC into a model that predicted the incidence of PEW in maintenance hemodialysis patients using LASSO technology. We discovered that the model predicted a greater AUC of PEW occurrence than any single factor, 0.877 for men and 0.76 for women. The results of the univariate logistic regression analysis showed that the low PA tertile array group had a greater incidence of PEW than the high PA group (P < 0.001). Additionally, we also found that lower PA was associated with higher CV risk scores. The PA detected by bioelectrical impedance analysis could predict the risk of PEW and cardiovascular events among patients with MHD. When used in conjunction, PA, ASMI, BCM, and MAC have a high diagnostic efficacy for PEW in patients on maintenance hemodialysis.

Preoperative bioelectrical impedance, measured phase angle, and hand-grip strength as predictors of postoperative outcomes in patients undergoing cardiac surgery: a systematic review

BACKGROUND

Postoperative problems are a major danger for patients after heart surgery. Predicting postoperative outcomes for cardiac surgery is limited by current preoperative evaluations. Handgrip strength (HGS) testing and bioelectrical impedance analysis (BIA) may provide extra ways to identify individuals at risk of surgical problems, enhancing risk assessment and results.

OBJECTIVE

The purpose of this systematic review is to assess the utility of measured phase angle (PA), HGS, and bioelectrical impedance as perioperative risk markers in adult patients undergoing elective heart surgery.

METHOD

The PRISMA principles were followed in this review. We searched all available electronic databases, including the Science Direct search engine and PubMed, MEDLINE, EMBASE, Cochrane Library, Web of Science, PsycINFO, CINAHL, Google Scholar, Scopus, and the Science Direct search engine, from their creation to the present, as well as the medRxiv pre-print site. We considered studies with adult subjects undergoing elective heart surgery who were monitored for problems after surgery and had perioperative BIA and HGS testing.

RESULTS

As a result, out of the 1544 pieces of research that were discovered, eight studies were deemed suitable for inclusion in the review and supplied data from 2781 people. The findings demonstrated a substantial correlation between poor preoperative PA and a higher risk of serious postoperative morbidity, as well as prolonged hospital stays. Furthermore, poor HGS and low PA were linked to greater death rates. Additionally, there was a strong correlation found between low PA and HGS and longer stays in the ICU, as well as an increased chance of dying from all causes in a year. In conclusion these results imply that preoperative HGS and PA may be significant indicators of postoperative results and may assist in identifying patients who are more vulnerable to problems and death.

The early prognostic value of the 1-4-day BCM/PA trend after admission in neurocritical patients

The purpose of this study was to investigate early stage dynamic changes in relevant indicators in neurocritical patients to identify biomarkers that can predict a poor prognosis at an early stage (1-4 days after admission). This study retrospectively collected clinical data, inflammatory indicators, and nutritional indicators from 77 patients at the neurology intensive care unit. The 3-month modified Rankin scale score was used as the outcome indicator. A linear mixed model was used to analyze changes in inflammatory indicators and nutritional indicators in neurocritical patients over time from 1-4 days after admission. Logistic regression was used to determine the independent risk factors for a poor prognosis in neurocritical patients and to construct a predictive model. The predictive efficacy of the model was verified using leave-one-out cross-validation and decision curve analysis methods. The analysis results showed that 1-4 days after admission, the inflammatory indicators of white blood cell and absolute monocyte counts and the nutritional indicators of body cell mass(BCM), fat-free mass, body cell mass/phase angle (BCM/PA), intracellular water, extracellular water, and skeletal muscle index increased overall, while the nutritional indicators of albumin and visceral fat area decreased overall. The logistic multivariate regression model showed that the Charlson comorbidity index (CCI) (odds ratio (OR) = 2.526, 95% CI [1.202, 5.308]), hemoglobin (Hb)(on admission)-Hb(min) (OR = 1.049, 95% CI [1.015, 1.083), BCM(on admission) (OR = 0.794, 95% CI [0.662, 0.952]), and the change in BCM/PA 1-4 days after admission (OR = 1.157, 95% CI [1.070, 1.252]) were independent risk factors for a poor prognosis in neurocritical patients. The predictive analysis showed that the predictive power of Model 1 with BCM/PA (area under the curve (AUC) = 0.95, 95% CI (0.90, 0.99)) was 93%, 65%, 141%, and 133% higher than that of Model 2 without BCM/PA, the CCI, the APACHE II score, and the NRS2002 score (all P < 0.05), respectively. The CCI, Hb(on admission)-Hb(min), BCM(on admission), and an increase in BCM/PA 1-4 days after admission were independently associated with a poor prognosis in neurocritical patients. Of these variables, BCM/PA may be a valid indicator for early stage prediction of a poor prognosis in neurocritical patients.

Predicting the Risk of Morbidity by GLIM-Based Nutritional Assessment and Body Composition Analysis in Oncologic Abdominal Surgery in the Context of Enhanced Recovery Programs : The PHase Angle Value in Abdominal Surgery (PHAVAS) Study

BACKGROUND

Preoperative nutritional status and body structure affect short-term prognosis in patients undergoing major oncologic surgery. Bioimpedance vectorial analysis (BIVA) is a reliable tool to assess body composition. Low BIVA-derived phase angle (PA) indicates a decline of cell membrane integrity and function. The aim was to study the association between perioperative PA variations and postoperative morbidity following major oncologic upper-GI surgery.

PATIENTS AND METHODS

Between 2019 and 2022 we prospectively performed BIVA in patients undergoing surgical resection for pancreatic, hepatic, and gastric malignancies on the day before surgery and on postoperative day (POD) 1. Malnutrition was defined as per the Global Leadership Initiative on Malnutrition criteria. The PA variation (ΔPA) between POD1 and preoperatively was considered as a marker for morbidity. Uni and multivariable logistic regression models were applied.

RESULTS

Overall, 542 patients with a mean age of 64.6 years were analyzed, 279 (51.5%) underwent pancreatic, 201 (37.1%) underwent hepatobiliary, and 62 (11.4%) underwent gastric resections. The prevalence of preoperative malnutrition was 16.6%. The overall morbidity rate was 53.3%, 59% in those with ΔPA < -0.5 versus 46% when ΔPA ≥ -0.5. Age [odds ratio (OR) 1.11; 95% confidence interval (CI) (1.00; 1.22)], pancreatic resections [OR 2.27; 95% CI (1.24; 4.18)], estimated blood loss (OR 1.20; 95% CI (1.03; 1.39)], malnutrition [OR 1.77; 95% CI (1.27; 2.45)], and ΔPA [OR 1.59; 95% CI (1.54; 1.65)] were independently associated with postoperative complications in the multivariate analysis.

CONCLUSIONS

Patients with preoperative malnutrition were significantly more likely to develop postoperative morbidity. Moreover, a decrease in PA on POD1 was independently associated with a 13% increase in the absolute risk of complications. Whether proactive interventions may reduce the downward shift of PA and the complication rate need further investigation.

Phase angle - A screening tool for malnutrition, sarcopenia, and complications in gastric cancer

BACKGROUND

Patients with gastric cancer (GC) are more likely to experience malnutrition and muscle wasting. This study aims to investigate the potential of phase angle (PhA) as a screening tool for identifying malnutrition and sarcopenia in GC patients, as well as its association with short-term outcomes after radical gastrectomy.

METHODS

This cross-sectional study enrolled patients diagnosed with GC at The Affiliated People's Hospital of Jiangsu University from October 2021 to September 2022. PhA was measured using bioelectrical impedance analysis. Computed tomography scan images were analyzed for body composition at the level of the third lumbar vertebra. Malnutrition was diagnosed using Global Leadership Initiative on Malnutrition (GLIM) criteria. Sarcopenia diagnosis was based on the Asian Working Group for Sarcopenia (AWGS) 2019 criteria.

RESULTS

A total of 248 patients with GC were analyzed, including 188 patients who underwent radical gastrectomy. Of these, 71.4 % (n = 177) were male and 28.6 % (n = 71) were female and the median overall age was 68 years (IQR: 61-72 years). According to GLIM criteria, 49.2 % (n = 122) of patients were malnourished and 19.8 % (n = 49) had sarcopenia based on AWGS criteria. A one-degree decrease in PhA was significantly associated with GLIM malnutrition (Odds Ratio [OR] = 8.108, 95 % CI:3.181-20.665) and sarcopenia (OR = 2.903, 95 % CI:1.170-7.206). PhA exhibited fair to good diagnostic accuracy in identifying GLIM malnutrition (male: AUC = 0.797; female: AUC = 0.816) and sarcopenia (male: AUC = 0.814; female: AUC = 0.710). Low PhA (OR = 3.632, 95 % CI: 1.686-7.824) and operation time (OR = 2.434, 95 % CI:1.120-5.293) were independently associated with the risk of postoperative complications.

CONCLUSIONS

PhA can serve as a reliable screening tool for identifying patients at risk of malnutrition, sarcopenia, and postoperative complications in GC.

Preoperative Body Composition Correlates with Postoperative Muscle Volume and Degeneration after Total Hip Arthroplasty

Impaired muscle recovery after total hip arthroplasty (THA) may affect gait and activities of daily living. Bioelectrical impedance analysis (BIA) can assess body composition and muscle volume, and computed tomography (CT) can assess muscle volume and the fatty degeneration of muscle. This study aimed to explore the effectiveness of BIA, and the correlation between preoperative body composition and postoperative muscle volume and degeneration after THA using BIA and CT. Thirty-eight patients who underwent THA and had BIA and CT performed pre- and postoperatively were retrospectively assessed. The BIA-derived measurements of preoperative body composition (fat mass index, fat-free mass index, and phase angle) were correlated with the CT-derived measurements (pre- and postoperative muscle volume and gluteus maximus and quadriceps Hounsfield Units of the affected hip). The preoperative fat mass index negatively correlated with the postoperative muscle volume of the gluteus maximus (p = 0.02) and quadriceps (p < 0.001) and the Hounsfield Units of the gluteus maximus (p = 0.03) and quadriceps (p = 0.03). The preoperative fat-free mass index positively correlated with the postoperative muscle volume of the quadriceps (p = 0.02). The preoperative phase angle positively correlated with the postoperative muscle volume of the quadriceps (p = 0.001) and the Hounsfield Units of the gluteus maximus (p = 0.03) and quadriceps (p = 0.001). In patients who underwent THA, preoperative body composition correlated with postoperative muscle volume and the fatty degeneration of the affected lower limb. Preoperative body composition may help predict postoperative muscle volume and fatty degeneration and thus, postoperative recovery.

Preparing for and Not Waiting for Surgery

Cancer surgery is an essential treatment strategy but can disrupt patients' physical and psychological health. With worldwide demand for surgery expected to increase, this review aims to raise awareness of this global public health concern, present a stepwise framework for preoperative risk evaluation, and propose the adoption of personalised prehabilitation to mitigate risk. Perioperative medicine is a growing speciality that aims to improve clinical outcome by preparing patients for the stress associated with surgery. Preparation should begin at contemplation of surgery, with universal screening for established risk factors, physical fitness, nutritional status, psychological health, and, where applicable, frailty and cognitive function. Patients at risk should undergo a formal assessment with a qualified healthcare professional which informs meaningful shared decision-making discussion and personalised prehabilitation prescription incorporating, where indicated, exercise, nutrition, psychological support, 'surgery schools', and referral to existing local services. The foundational principles of prehabilitation can be adapted to local context, culture, and population. Clinical services should be co-designed with all stakeholders, including patient representatives, and require careful mapping of patient pathways and use of multi-disciplinary professional input. Future research should optimise prehabilitation interventions, adopting standardised outcome measures and robust health economic evaluation.

Phase Angle as a Reliable Biomarker of Frailty to Predict Postoperative Outcomes in Patients Undergoing Off-Pump Coronary Artery Grafting: A Prospective Observational Study

OBJECTIVE

To elucidate the association between phase angle (PA) and a composite adverse outcome in patients requiring off-pump coronary artery bypass grafting (OPCAB).

DESIGN

A prospective observational study.

SETTING

High-volume single center.

PARTICIPANTS

A total of 229 adult patients who underwent OPCAB from May 2019 to October 2020.

INTERVENTIONS

Each patient underwent bioelectrical impedance analysis, including PA assessment before surgery (PApre), immediately postoperatively (PApost), and 1 day postoperatively (PAPOD1), using an Inbody S10. Frailty index and nutritional assessments also were obtained before surgery.

MEASUREMENTS AND MAIN RESULTS

Patient outcomes were assessed using a composite adverse outcome comprising death, myocardial infarction, revascularization, new-onset atrial fibrillation, acute kidney injury, stroke, postoperative pulmonary complications, wound complications, sepsis, reoperation, and/or delirium occurring during hospitalization and over the following year. Patients for whom composite adverse outcomes were reported had lower PApre than those without complications (5.4 ± 0.9 v 6.0 ± 0.9, p < 0.001). The PA was significantly associated with in-hospital and 1-year composite postoperative outcomes. The odds ratios (OR, [95% confidence interval]) for PApre by time were in-hospital complications (0.435 [0.314, 0.604], p < 0.001; 1-year complications: 0.459 [0.330, 0.638], p < 0.001) and PAPOD1 (OR, in-hospital complications: 0.400 [0.277, 0.576], 1-year complications: 0.429 [0.298, 0.619], p < 0.001). The PApre was significantly associated with days alive and out of hospital until 1 year. The cut-off value of PApre for optimal prediction of in-hospital complications was 6.0 (area under the curve: 0.691 [0.623-0.758], p < 0.001).

CONCLUSION

Low PA as an indicator of frailty is associated with adverse postoperative outcomes after OPCAB. Low PA may be employed as a noninvasive and practical tool for the prediction of prognosis in patients with coronary artery disease.

Bioelectrical Impedance Analysis (BIA) for the Assessment of Body Composition in Oncology: A Scoping Review

Bioelectrical Impedance Analysis (BIA) is a reliable, non-invasive, objective, and cost-effective body composition assessment method, with high reproducibility. This scoping review aims to evaluate the current scientific and clinical evidence on BIA for body composition assessment in oncology patients, under active treatment. Literature search was conducted through MEDLINE, CINAHL, Scopus and Web of Science databases, following PRISMA-ScR Guidelines. Inclusion criteria comprised studies reporting the use of BIA for body composition evaluation in adults with cancer diagnosis. Studies including non-cancer pathology or only assessing nutritional status were excluded. This scoping review comprised a total of 36 studies: 25 were original studies including 18 prospective studies, six cross-sectional studies and one retrospective study and 11 were systematic reviews. Population size for the included original articles ranged from 18 to 1217 participants, comprising a total of 3015 patients with cancer with a mean baseline Body Mass Index (BMI) ranging from 20.3 to 30.0 kg/m2 and mean age ranging between 47 and 70 years. Review articles included a total of 273 studies, with a total of 78,350 participants. The current review considered studies reporting patients with head and neck cancer (HNC) (n = 8), breast cancer (BC) (n = 4), esophageal cancer (EC) (n = 2), liver cancer (n = 2), pancreatic cancer (PC) (n = 3), gastric cancer (GC) (n = 3), colorectal cancer (CRC) (n = 8), lung cancer (LC) (n = 1), skin cancer (SK) (n = 1) and multiple cancer types (n = 6). BIA is a suitable and valid method for the assessment of body composition in oncology. BIA-derived measures have shown good potential and relevant clinical value in preoperative risk evaluation, in the reduction of postoperative complications and hospital stay and as an important prognostic indicator in persons with cancer. Future research on the diagnostic value and clinical applications of BIA and BIA-derived phase angle (PhA) should be conducted in order to predict its impact on patient survival and other clinical outcomes.

Bioimpedance Spectroscopy in Heart Transplantation: Posttransplant Changes in Body Composition and Effects in Outcomes

BACKGROUND

Bioimpedance spectroscopy yields measurements of fat-free mass, fat mass, phase angle, and other measures. Bioimpedance spectroscopy has been validated as a preoperative assessment tool in cardiac surgical studies, in which low phase angle predicted morbidity and mortality. No studies have evaluated bioimpedance spectroscopy following heart transplantation.

METHODS

We evaluated body composition, nutrition status (Subjective Global Assessment, body mass index, midarm muscle circumference, and triceps skinfolds), and functional status (handgrip strength and 6-min walk test) in 60 adults. Body composition measurements via a 256-frequency bioimpedance spectroscopy device included fat and fat-free mass as well as phase angle calculated at 50 kHz. Testing was completed at baseline and 1, 3, 6, and 12 mo following heart transplantation. Mortality and hospital readmissions were analyzed.

RESULTS

Phase angle and fat mass increased while fat-free mass decreased; grip strength and 6-min walk test improved after transplantation (all P <  0.001). Improvement in phase angle in the first month postoperatively was associated with reduced risk of readmission. Low perioperative and 1-mo phase angles were associated with prolonged posttransplant length of stay (median: 13 versus 10 d, P =  0.03), increased infection-related readmissions (40% versus 5%, P =  0.001), and increased 4-y mortality (30% versus 5%, P =  0.01).

CONCLUSIONS

Phase angle, grip strength, and 6-min walk test distance improved after heart transplantation. Low phase angle appears to be associated with suboptimal outcomes and may be a feasible and affordable method to predict outcomes. Further research should ascertain whether preoperative phase angle can predict outcomes.

Influence of hand dominance, gender, and body mass index on hand grip strength

Background

Hand grip strength (HGS) measurements serve as an objective measure of upper extremity function. Reliable hand strength evaluation is vital for assessing treatment effectiveness.

Objectives

To determine the influence of hand dominance, gender, and body mass index (BMI) on HGS among university students in Ghana.

Method

In our cross-sectional study of 304 participants, height, weight, and BMI were measured using a stadiometer and weighing scale. Hand grip strength was assessed with a dynamometer. We compared HGS in dominant and non-dominant hands for males and females using a paired t-test and analysed the correlation between grip strength and weight, height, and BMI using Pearson's correlation coefficient.

Results

The mean HGS for right-hand dominant (RHD) male participants was 35.62 kg (± 7.36) for the right hand compared with 32.84 kg (± 7.36) for the left hand. For females RHD the mean HGS in the right hand was 24.60 kg (± 6.42) compared to 22.12 kg (± 5.37) in the left hand. The mean weight, height and BMI of participants were 62.86 kg (± 10.30), 1.67 m (± 0.09) and 22.9 kg/m2 (± 4.9), respectively. A significant relationship existed between HGS and height (r = 0.492; p < 0.01) as well as HGS and BMI (r = 0.290; p < 0.01). However, no notable connection was found between HGS and weight (r = 0.001; p = 0.982).

Conclusion

Hand grip strength was significantly stronger in the dominant hand of both males and females.

Clinical implications

Physiotherapists should test HGS objectively and quantitatively for use in disease evaluation, diagnosis, and therapy.

Future lines of research on phase angle: Strengths and limitations

Bioelectrical impedance analysis (BIA) is the most widely used technique in body composition analysis. When we focus the use of phase sensitive BIA on its raw parameters Resistance (R), Reactance (Xc) and Phase Angle (PhA), we eliminate the bias of using predictive equations based on reference models. In particular PhA, have demonstrated their prognostic utility in multiple aspects of health and disease. In recent years, as a strong association between prognostic and diagnostic factors has been observed, scientific interest in the utility of PhA has increased. In the different fields of knowledge in biomedical research, there are different ways of assessing the impact of a scientific-technical aspect such as PhA. Single frequency with phase detection bioimpedance analysis (SF-BIA) using a 50 kHz single frequency device and tetrapolar wrist-ankle electrode placement is the most widely used bioimpedance approach for characterization of whole-body composition. However, the incorporation of vector representation of raw bioelectrical parameters and direct mathematical calculations without the need for regression equations for the analysis of body compartments has been one of the most important aspects for the development of research in this area. These results provide new evidence for the validity of phase-sensitive bioelectrical measurements as biomarkers of fluid and nutritional status. To enable the development of clinical research that provides consistent results, it is essential to establish appropriate standardization of PhA measurement techniques. Standardization of test protocols will facilitate the diagnosis and assessment of the risk associated with reduced PhA and the evaluation of changes in response to therapeutic interventions. In this paper, we describe and overview the value of PhA in biomedical research, technical and instrumental aspects of PhA research, analysis of Areas of clinical research (cancer patients, digestive and liver diseases, critical and surgical patients, Respiratory, infectious, and COVID-19, obesity and metabolic diseases, Heart and kidney failure, Malnutrition and sarcopenia), characterisation of the different research outcomes, Morphofunctional assessment in disease-related malnutrition and other metabolic disorders: validation of PhA with reference clinical practice techniques, strengths and limitations. Based on the detailed study of the measurement technique, some of the key issues to be considered in future PhA research. On the other hand, it is important to assess the clinical conditions and the phenotype of the patients, as well as to establish a disease-specific clinical profile. The appropriate selection of the most critical outcomes is another fundamental aspect of research.

Phase Angle, Handgrip Strength, and Other Indicators of Nutritional Status in Cancer Patients Undergoing Different Nutritional Strategies: A Systematic Review and Meta-Analysis

Malnutrition in cancer patients is one of the most influential factors in the evolution and mortality of such patients. To reduce the incidence of malnutrition, it is necessary to establish a correct nutritional intervention. For this purpose, precise tools and indicators must be developed to determine the patient’s condition. The main objective of this systematic review and meta-analysis was to analyze the relationship between different nutritional strategies, phase angle (PA), and handgrip strength in patients with cancer, with the secondary objectives being the modification of other indicators of nutritional status, such as weight and body mass index (BMI). A systematic review of randomized clinical trials was carried out in March 2023 in the databases PubMed, Web of Science, Cochrane, and Scopus. As a risk-of-bias tool, RoB 2.0 was utilized. A total of 8 studies with a total of 606 participants were included in the analysis. A significant increase in PA was observed after the different nutritional strategies (SMD: 0.43; 95% CI: 0.10 to 0.77; p = 0.01; I2 = 65.63%), also detecting a significant increase in handgrip strength (SMD: 0.27, 95% CI: 0.08 to 0.47; p = 0.01; I2 = 30.70%). A significant increase in PA and handgrip were observed in cancer patients subjected to different nutritional strategies. These results suggest that these indicators could be used in the nutritional and functional assessment of the patients.

Association of indirect measurement of cell function by bioimpedance analysis with complications in oncologic hepatic surgery

BACKGROUND

Bioelectric impedance vector analysis (BIVA) is a reliable tool to assess body composition. The aim was to study the association of BIVA-derived phase angle (PA) and standardized PA (SPA) values and the occurrence of surgery-related morbidity.

METHODS

Patients undergoing hepatectomy for cancer in two Italian centers were prospectively enrolled. BIVA was performed the morning of surgery. Patients were then stratified for the occurrence or not of postoperative morbidity.

RESULTS

Out of 190 enrolled patients, 76 (40%) experienced postoperative complications. Patients with morbidity had a significant lower PA, SPA, body cell mass, and skeletal muscle mass, and higher extracellular water and fat mass. At the multivariate analysis, presence of cirrhosis (OR 7.145, 95% CI:2.712-18.822, p < 0.001), the Charlson comorbidity index (OR 1.236, 95% CI: 1.009-1.515, p = 0.041), the duration of surgery (OR 1.004, 95% CI:1.001-1.008, p = 0.018), blood loss (OR 1.002. 95% CI: 1.001-1.004, p = 0.004), dehydration (OR 10.182, 95% CI: 1.244-83.314, p = 0.030) and SPA < -1.65 (OR 3.954, 95% CI: 1.699-9.202, p = 0.001) were significantly and independently associated with the risk of complications.

CONCLUSION

Introducing BIVA before hepatic resections may add valuable and independent information on the risk of morbidity.

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.

The Role of Standardized Phase Angle in the Assessment of Nutritional Status and Clinical Outcomes in Cancer Patients: A Systematic Review of the Literature

Compared with the phase angle (PA), the predictive ability of the standardized phase angle (SPA) in assessing nutritional status and clinical outcomes in cancer patients remains uncertain. This review aimed to assess (1) the relationship between SPA and nutritional status and clinical outcomes (including complications and survival) in cancer patients; (2) the predictive ability of SPA alone and in comparison with the predictive ability of PA; and (3) the cut-off value of SPA in cancer patients. Studies that addressed the relationship of SPA use to nutritional status, complications, and survival in cancer patients were searched and identified from six electronic databases (PubMed, Medline, CINAHL, Embase, Web of Science, and the Cochrane Library). The included studies were considered to meet the following criteria: English studies with original data that reflected the effects of SPA on nutritional status and clinical outcomes (including complications and survival) and reported a cut-off value of SPA in cancer patients aged ≥18. Thirteen studies that included a total of 2787 participants were evaluated. Five studies assessed the relationship between SPA and nutritional status, and four of them reported a positive relationship between SPA and nutritional status in cancer patients, even considering SPA as a predictor. Twelve studies assessed the relationship between SPA and clinical outcomes in cancer patients. Two-thirds of the studies that evaluated complications reported the predictive ability of SPA; 30% of survival studies reported a positive relationship, 40% reported SPA as a predictor, and 30% reported no relationship. The standard cut-off value for SPA has not yet been determined. Data from the selected studies suggest that SPA might be a predictor of nutritional status. Further studies are needed to determine the value of SPA in predicting nutritional status and clinical outcomes in cancer patients.

Sex differences in the association of phase angle and lung cancer mortality

Background

Lung cancer is a lethal malignant tumor that is common worldwide and is associated with a high incidence of malnutrition. Phase angle (PA) is a simple, objective, and non-invasive indicator of body composition that has increasingly attracted attention as an indicator of the nutritional status and prognosis of patients with malignant tumors. This study aimed to investigate the association between the PA and overall survival in patients with lung cancer.

Methods

This study prospectively analyzed 804 lung cancer patients in the Investigation on Nutrition Status and its Clinical Outcome of Common Cancers (INSCOC) project from 40 hospitals in China. We used a restricted cubic spline to analyze the sex-specific association between PA and mortality in men and women with lung cancer. Cox regression analysis was used to evaluate the independent association between PA and mortality in men and women. Sensitivity analysis was performed. The Kaplan-Meier method was used to evaluate the survival of patients with high and low PA values.

Results

There was an L-shaped association between PA and survival in both men and women with lung cancer (p = 0.019 and p = 0.121, respectively). Kaplan-Meier survival analysis suggested that patients with a high PA showed a better survival than patients with a low PA (p = 0.007 for men and p < 0.001 for women). Multivariate-adjusted Cox regression analysis showed that PA was an independent risk factor for mortality in men (HR = 0.79, 95% CI = 0.65-0.95, p = 0.015), but not in women (HR = 0.83, 95% CI = 0.67-1.04, p = 0.105).

Conclusion

Phase angle is an independent risk factor for the mortality of male lung cancer patients. However, its role in predicting the mortality of female lung cancer patients seems to be limited.

Diagnostic and prognostic utility of phase angle in patients with cancer

Patients with cancer experience dynamic and longitudinal changes in nutritional status and body composition along the disease trajectory. They often want to know about their outlook with regard to treatment outcomes and overall survival. One of the commonly used measures for body composition is bioelectrical impedance analysis (BIA). BIA is an easy-to-use, quick, inexpensive, noninvasive, and reproducible technique that is often incorporated in daily clinical practice. Phase angle (PA), which is derived from BIA, is an indicator of cell membrane health and integrity. Higher PA values reflect better cell function, higher muscle mass, and lower fat mass. PA is also thought to be a proxy of water distribution (ratio between extracellular water [ECW] and intracellular water [ICW]) and body cell mass. In this narrative review, we discuss studies examining the diagnostic and prognostic value of PA regarding nutritional status, body composition and physical function, complications of cancer treatments, overall survival, symptoms, and quality of life (QOL) in patients with cancer. The literature suggests that PA is moderately to strongly correlated with body composition and physical function but only weakly correlated with nutritional status, complications, survival, symptoms, and QOL. Furthermore, the PA cutoff values vary significantly according to study and patient population with the diversity of bioelectrical impedance technology and electrode composition and placement. Thus, PA has yet to be routinely incorporated into clinical practice for patients with cancer. Future research is needed to determine how to translate scientific understanding of PA to clinical practice.

Nutrition Therapy Promotes Overall Survival in Cachectic Cancer Patients through a New Proposed Chemical-Physical Pathway: The TiCaCONCO Trial (A Randomized Controlled Single-Blinded Trial)

Cancer threatens nutritional status, and many patients will become cachectic with a negative impact on prognosis. In the TiCaCo pilot trial, we showed a positive effect of calorie matching Nutrition Therapy on both morbidity and mortality. We attempt to validate these results in the TiCaCONCO trial. In a prospective, randomized, single-blinded, controlled trial, patients were treated with either intensive, individual biometric parameter-oriented dietary counseling (nutrition therapy or NT) for a maximum period of three months, or regular dietary counseling (control or CT), before and during conventional cancer treatment. Sixty patients were enrolled over a two-year period, with 30 receiving nutrition therapy and 30 being controls. The primary endpoint was overall survival (OS). Overall survival at 12 months in all patients was 47% (14/30 patients) in the CT group with a median OS of 45.5 weeks, and 73% (22/30 patients) in the NT group with a median OS that was undefined (i.e., cannot be calculated, as >50% of patients in the NT group were still alive at the end of the study) (p = 0.0378). The survival difference still exists when only male patients are analyzed, but is not observed in female patients. Biophysical measurements were performed at 0, 3, and 12 months in all patients. In men, the differences between CT vs NT were statistically significant for body hydration (p = 0.0400), fat mass (p = 0.0480), total energy expenditure (p = 0.0320), and median overall survival at 12 months (p = 0.0390). At 3 months (end of the intervention), the differences between CT vs NT for body hydration were 73 ± 3% vs. 75 ± 5%, for fat mass 14 ± 4% vs. 19 ± 5%, and for total energy expenditure 2231 ± 637 Kcal vs. 2408 ± 369 Kcal. In women, the differences between CT vs NT were not statistically significant for body hydration (p = 1.898), fat mass (p = 0.9495), total energy expenditure (p = 0.2875) and median overall survival at 12 months (p = 0.6486). At 3 months (end of the intervention), the differences between CT vs. NT for body hydration were 74 ± 2% vs. 78 ± 5%, for fat mass 25 ± 7% vs. 29 ± 19%, and for TEE 1657 ± 297 Kcal vs. 1917 ± 120 Kcal. Nutrition Therapy, based on patient-specific biophysical parameters, including the measurement of metabolism by indirect calorimetry and body composition measurements by BIA, improves overall survival, at least in men. The mechanism would be increasing extra energy for the body, which is necessary to fight off cancer.

Acute Water Supplementation Improved the Body Composition of Young Female Adults After Water Restriction of 12 h in Baoding, China: A Randomized Controlled Trial (RCT)

Insufficient intake of water may influence the balance of water in the human body. In this study, we explore the impacts of water supplementation on body composition indices among young adults after 12 h of water restriction, with the aim to determine the optimum volume of water for improving body water composition. A randomized controlled trial study was conducted among 64 young men and women in Baoding, China. After fasting overnight for 12 h, anthropometric measurements and urine and blood samples were collected as a baseline test at 8:00 a.m. of Day 2. Body composition was determined by measuring the ECW (extracellular water), ICW (intracellular water), and TBW (total body water) through bioelectrical impedance analysis (BIA). The participants were randomly divided into four groups, including water supplementation (WS) groups 1, 2, and 3, with 500, 200, and 100 mL of water, respectively, and a no water supplementation (NW) group. After 90 min, they were reassessed in a rehydration test (at 10:00 a.m. of Day 2). Repeated measurement ANOVA was used to assess the impact of water supplementation on body composition. Comparing the baseline and rehydration tests, interactions between time and volume were not significant among the men (all p > 0.05). Among women, a significant interaction was only found in ECW (p = 0.043), with TBW tending toward being significant (p = 0.055). Comparing the baseline and rehydration tests, the ECW in WS group 1, WS group 3, and the NW group all decreased (p = 0.028, p = 0.001, and p = 0.029), with reductions of 0.1, 0.3, and 0.2 kg, respectively; however, no significant decrease was observed in WS group 2 (p = 0.329). Furthermore, comparing the WS groups with the NW group in the rehydration test, the differences were not significant (p = 1.000, p = 1.000, and p = 0.288, respectively). Between men and women within groups, all of the body composition indices differed significantly, both at baseline and rehydration tests (all p < 0.05). Water supplementation led to changes in the distribution of the water content in young female adults in this study-but not men-after 12 h of water restriction, with no decrease in ECW. Finally, we found that 200 mL was the minimum volume capable of improving the water content distribution in participants in this study.

Trial Registration

[www.chictr.org.cn], identifier [ChiCTR-IOR-17011568].

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.

Bioelectrical Phase Angle in Patients with Breast Cancer: A Systematic Review

Simple Summary

Breast cancer (BC) patients suffer from loss of muscle tissue and fluid alterations during the whole trajectory of the disease. Such alterations might be reflected by phase angle (PhA) measures, but its use in the oncologic setting is still limited. Therefore, the aim of this systematic review was to assess PhA in BC patients, since it has been proven to be a reliable index for predicting nutritional status and survival. Findings reveal that PhA decreases after chemotherapy in BC patients, with high results in women with a better nutritional status, and these changes may persist even after five years. However, PhA remains stable, or can increase in some cases, when patients are supported by targeted lifestyle interventions. Thus, PhA can be useful to identify and monitor changes in body compartments and the nutritional status of BC patients over time.

Abstract

Breast cancer (BC) is the most common cancer diagnosed among women worldwide. Phase angle (PhA), a proxy measure of membrane integrity and function, has gained relevance in clinical practice and it has been suggested to be a prognostic and nutritional indicator. This systematic review aimed to explore PhA and its relationship with nutritional status and survival in BC patients. Four databases (PubMed, EMBASE, Web of Science, and CINAHL) were systematically searched until September 2021 for studies evaluating PhA in BC patients. A total of 16 studies met the inclusion criteria, where 11 were observational studies and 5 were interventional studies. Baseline PhA-value varied from 4.9 to 6.30 degrees, showing a great variability and heterogeneity across the selected studies. Available data suggested that PhA decreased by 5–15% after completing chemotherapy, and those effects might persist in the long term. However, the use of tailored nutritional and/or exercise programs during and after therapy could prevent PhA reduction and body derangement. High PhA values were found in women displaying a better nutritional status, while inconsistent data were found on survival. Therefore, further studies are needed to focus on the clinical relevance of PhA in BC patients, evaluating its association with disease outcomes and survival.