NIH ImageJ and Slice-O-Matic computed tomography imaging software to quantify soft tissue

Quantification of Skeletal Muscle at the First Lumbar Level for Prognosis in Amyotrophic Lateral Sclerosis

BACKGROUND

Skeletal muscle parameters at the first lumbar vertebra (L1) level on computed tomography (CT) are common indicators for muscle mass. However, their relationship with the severity and prognosis of amyotrophic lateral sclerosis (ALS) patients remains unclear.

METHODS

This cohort study included ALS patients who underwent chest CT scans between January 2018 and January 2022 and healthy controls (HCs) matched for gender and age. Overall survival (OS) was determined from the date of chest CT to death, tracheal intubation or 1 January 2024. Using ImageJ software, skeletal muscle area and density (L1 SMA/SMD), skeletal muscle index (L1 SMI), paraspinal muscle area and density (L1 PMA/PMD) and subcutaneous fat area and density (L1 SFA/SFD) at L1 were quantified. The relationships between the quantified muscle parameters and both King's clinical stages and the Revised ALS Functional Rating Scale (ALSFRS-R) were analysed. The Cox proportional hazard model was used to evaluate the hazard ratio (HR) of skeletal muscle parameters as risk factors for outcome events, and to construct a nomogram.

RESULTS

Muscle parameters in ALS patients (n = 102; 36.27% female; mean age, 60.85 ± 10.58 years) were significantly lower compared with HCs (p < 0.001). L1 SMD (p = 0.047) and L1 PMD (p = 0.003) both differed significantly across the King's clinical stages. ALSFRS-R scores correlated with L1 SMA (r = 0.35, p < 0.001), L1 SMI (r = 0.34, p < 0.001), L1 PMA (r = 0.27, p = 0.007) and L1 PMD (r = 0.27, p = 0.007). Multivariate Cox regression analysis revealed that L1 SMA (HR = 0.96, 95% confidence interval [CI] = 0.94-0.98, p = 0.001), L1 SMD (HR = 0.92, 95% CI = 0.88-0.96, p < 0.001) and L1 PMA (HR = 1.06, 95% CI = 1.01-1.11, p = 0.022) significantly influenced ALS survival, with area under the curves (AUCs) of 0.687 and 0.851 for 1- and 3-year OS prediction. The consistency index (C-index) for the nomogram was 0.72 (95% CI = 0.641-0.793).

CONCLUSIONS

Skeletal muscle parameters at L1 level on CT are significantly associated with clinical severity and prognosis in ALS.

TRIAL REGISTRATION

Chinese Clinical Trial Registration Center: ChiCTR230078702.

Association of sarcopenia assessed by CT/MRI with treatment response and clinical outcomes in noncirrhotic primary biliary cholangitis patients

BACKGROUND AND OBJECTIVE

Sarcopenia is a common complication in patients with cirrhosis. However, research on sarcopenia in patients with noncirrhotic primary biliary cholangitis (PBC) is limited. This study aimed to investigate the prevalence of sarcopenia and the associations between concomitant sarcopenia and the biochemical response to ursodeoxycholic acid (UDCA) treatment and clinical outcomes in patients with noncirrhotic PBC.

METHODS

This retrospective study enrolled consecutive patients whose baseline visits occurred between January 2009 and December 2023. Sarcopenia was assessed via pretreatment CT or MRI at the mid-L3 level through the skeletal muscle index (SMI). Baseline characteristics, response rate after UDCA administration, liver-related events were compared. And baseline liver and plasma C-reactive protein (CRP) and IL-6 levels in a subset of patients were also evaluated.

RESULTS

A total of 164 patients were included and sarcopenia was identified in 66 (40.2 %) patients. The median duration of follow-up was 4.75 (1.71, 6.40) years. The PBC patients with sarcopenia had a lower biochemical response rate (45.9 % vs. 65.9 %; P = 0.014) after 12 months of UDCA treatment and a higher incidence of liver-related events (24.2 % vs. 11.2 %, P = 0.027) during follow-up. Furthermore, higher levels of baseline CRP and IL-6 in the plasma and liver were also observed(P < 0.05).

CONCLUSIONS

Sarcopenia was highly prevalent in patients with noncirrhotic PBC. Concomitant sarcopenia may adversely affect the biochemical response to UDCA treatment and the occurrence of liver-related adverse events in PBC patients without cirrhosis.

[Body composition analysis on computed tomography scans using easy-to-access segmentation software]

Computed tomography (CT) is a direct and reference technique for body composition analysis with interesting possibilities in clinical nutrition. Segmentation is the automatic or semi-automatic software-based process by which different metabolic tissues of interest (muscle tissue, subcutaneous adipose tissue, visceral adipose tissue and intermuscular adipose tissue) that are part of the current diagnoses of malnutrition, sarcopenia and sarcopenic obesity are delimited, separated and quantified. The Alberta protocol is the most common segmentation guide, being applicable in most software. In this paper, we review the main characteristics of the most common open-source segmentation software, their degree of agreement, and some precautions and limitations of this process.

Prognostic value of CT-based skeletal muscle and adipose tissue mass and quality parameters in patients with liver metastases and intrahepatic cholangiocarcinoma undergoing Yttrium-90 radioembolization

OBJECTIVES

To investigate baseline patient characteristics associated with the risk of computed tomography (CT)-based sarcopenia and assess whether sarcopenia and other morphometric parameters influence survival outcomes in patients with liver metastases and cholangiocarcinoma after Yttrium-90 radioembolization.

MATERIALS AND METHODS

We retrospectively analyzed 120 cancer patients (mean age, 62 ± 13.3 years, 61 men) who underwent preprocedural CT. Skeletal muscle index (SMI) was measured at the L3 vertebral level to identify sarcopenia. The Cox proportional hazard model was performed to assess the prognostic value of the variables, and Kaplan-Meier analysis with log-rank text was used for overall survival (OS) assessment.

RESULTS

Sarcopenia was diagnosed in 70 patients (58.3%). The multivariate regression analysis demonstrated that male sex, body mass index (BMI), visceral fat radiation attenuation (VFRA), skeletal muscle radiation attenuation (SMRA), and subcutaneous fat radiation attenuation (SFRA) were associated with the incidence of sarcopenia with the odds ratio of 8.81 (95% CI, 2.09-37.1, p = 0.003), 0.64 (95% CI, 0.48-0.85, p = 0.002), 1.23 (95% CI, 1.06-1.42, p = 0.006), 0.79 (95% CI, 0.69-0.91, p = 0.001) and 0.84 (95% CI, 0.76-0.93, p = 0.001), respectively. Age, skeletal muscle index, and tumor subtypes were independent prognostic factors for OS with the hazard ratio of 1.03 (95% CI, 1.01-1.05, p = 0.01), 0.92 (95% CI, 0.86-0.99, p = 0.021) and 2.09 (95% CI, 1.31-3.33 p = 0.002), respectively. In patients with intrahepatic cholangiocarcinoma, median OS was significantly longer in the non-sarcopenic group than in the sarcopenic patient (25.9 versus 6.5 months, p = 0.029).

CONCLUSION

Male sex, BMI, VFRA, SMRA, and SFRA were associated with the incidence of sarcopenia. SMI value could be used as a biomarker for OS in patients treated with Yttrium-90 radioembolization.

KEY POINTS

Question The prognostic significance of CT-based sarcopenia and other morphometric parameters in patients with liver metastases and cholangiocarcinoma undergoing Yttrium-90 radioembolization remains unclear. Findings A high skeletal muscle index has been identified as an independent protective factor for overall survival in cancer patients treated with Yttrium-90 radioembolization. Clinical relevance The negative impact of CT-based sarcopenia has been confirmed in the context of Yttrium-90 radioembolization. Clinicians should strive to prevent the progression of sarcopenia or maintain skeletal muscle index in perioperative management.

Body Composition Analysis in Metastatic Non-Small-Cell Lung Cancer: Depicting Sarcopenia in Portuguese Tertiary Care

Background/Objectives: Sarcopenia is an emergent prognostic biomarker in clinical oncology. Albeit increasingly defined through skeletal muscle index (SMI) thresholding, the literature cut-offs fail to discern heterogeneous baseline muscularity across populations. This study assesses the prognostic impact of using cohort-specific SMI thresholds in a Portuguese metastatic non-small-cell lung cancer (mNSCLC) cohort. Methods: Retrospective study including mNSCLC patients treated between January 2017 and December 2022. ImageJ v1.54 g was used to assess cross-sectional CT imaging at the third lumbar vertebra (L3) and calculate L3SMI. Sarcopenia was defined both according to Prado et al. and L3SMI thresholds derived from receiver operating characteristic analysis. Overall survival (OS) was the primary endpoint. Secondary endpoints included first-line (1L) progression-free survival (PFS) and sarcopenia subgroup analysis regarding body mass index impact on OS. Results: The initial cohort included 197 patients. Mean age was 65 years (±11.31). Most tumors were adenocarcinomas (n = 165) and presented with metastasis (n = 154). SMI was evaluable in 184 patients: cohort-specific thresholds (<49.96 cm2/m2 for men; <34.02 cm2/m2 for women) yielded 46.74% sarcopenic patients (n = 86) versus 66.30% (n = 122) per the literature definition. Cohort-specific thresholds predicted both OS (12.75 versus 21.13 months, hazard ratio [HR] 1.654, p = 0.002) and PFS (7.92 versus 9.56 months, HR 1.503, p = 0.01). Among sarcopenic patients, overweight (HR 0.417, p = 0.01) and obesity (HR 2.723, p = 0.039) had contrasting impacts on OS. Conclusions: Amid reclassification of nearly one-fifth of the cohort, cohort-specific thresholds improved sarcopenia prognostication in mNSCLC. Homogeneity regarding both cancer treatment setting and ethnicity could be key to defining sarcopenia based on SMI.

Prognostic impact of adipose tissue loss at 1 month after surgery in patients with gastric cancer

BACKGROUND

The postoperative impact of short-term changes in skeletal muscle loss (SML) and adipose tissue loss (ATL) on treatment outcomes is unclear in patients with gastric cancer (GC). We investigate the role of SML and ATL at 1 month after surgery in determining postoperative survival and recurrence rates in patients with GC.

METHODS

We analyzed 540 patients with GC and assessed their skeletal muscle mass, visceral fat mass, and subcutaneous fat mass using computed tomography scans preoperatively and 1 month postoperatively. Patients were categorized into high and low groups based on their levels of SML, visceral ATL (v-ATL), and subcutaneous ATL (s-ATL). Additionally, they were classified into three groups (high ATL, intermediate ATL, and low ATL) based on their v-ATL and s-ATL measurements.

RESULTS

Patients with higher v-ATL and s-ATL had lower overall survival (OS) and recurrence-free survival (RFS) rates. High ATL was an independent prognostic factor for decreased OS (hazard ratio [HR] 2.27; 95% confidence interval [CI] 1.16-4.42; and P = 0.02) and RFS (HR 2.51; 95% CI 1.34-4.71; and P = 0.004) rates.

CONCLUSION

A reduction in adipose tissue volume shortly after surgery (1 month) could potentially indicate an increased risk of recurrence and mortality in patients with GC.

Predictive Value of Epicardial Adipose Tissue for Hemorrhagic Transformation and Functional Outcomes in Acute Ischemic Stroke Patients Undergoing Intravenous Thrombolysis Therapy

Purpose

Hemorrhagic transformation (HT) is a severe complication in patients with acute ischemic stroke (AIS) undergoing intravenous thrombolysis therapy (IVT). Epicardial adipose tissue (EAT) contributes to the development of AIS and the disruption of the blood-brain barrier. This study aims to investigate the relationship between EAT and the risk of HT, as well as functional outcomes, in AIS patients treated with IVT.

Patients and Methods

230 AIS patients were included. Epicardial adipose tissue volume (EATV) and EAT attenuation were measured from chest CT scans. Follow-up cranial CT or magnetic resonance imaging (MRI) assessed HT occurrence. Patients were stratified into groups based on the presence of HT or parenchymal hematoma (PH), and their 90-day functional outcomes (evaluated by the modified Rankin Scale).

Results

HT occurred in 52 (22.61%) patients, including 28 (12.17%) patients with PH, 85 (37.00%) patients had poor 90-day functional prognosis. Compared to the first quartile of EATV, the third quartile (OR 9.254, 95% CI 1.533-55.853) and the fourth quartile (OR 11.117, 95% CI 1.925-64.211) of EATV were independent predictors of HT; and EATV as a continuous variable (OR 1.022, 95% CI 1.005-1.040) was an independent risk factor for PH. Higher EAT attenuation was independently associated with poor prognosis (OR 1.170, 95% CI 1.056-1.297). The area under curve for predicting HT, PH and 90-day poor functional outcome was 0.705 (95% CI 0.632-0.778), 0.693 (95% CI 0.597-0.789), and 0.720 (95% CI 0.653-0.787).

Conclusion

The study demonstrates that EAT is associated with HT and poor 90-day outcomes in AIS patients undergoing IVT.

Wnt Signaling Modulators Exhibit Neuroprotective Effects via Combating Astrogliosis and Balancing Synaptic Density at Early and Late Stage Temporal Lobe Epilepsy

Temporal Lobe Epilepsy (TLE) is a severe neurological condition characterized by recurrent seizures that often do not respond well to available anti-seizure medications. TLE has been associated with epileptogenesis, a process that starts during the latent period following a neurologic insult and is followed by chronic phase. Recent research has linked canonical Wnt signaling to the pathophysiology of epileptogenesis and TLE. Our previous study demonstrated differential regulation of canonical Wnt signaling during early and late stage post status epilepticus (SE) induction. Building on these findings, our current study utilized Wnt modulators: GSK-3β inhibitor 6-bromoindirubin-3'-oxime (6-Bio) and disheveled inhibitor niclosamide and investigated their impact on canonical Wnt signaling during the early (30 days) and later stages (60 days) following SE induction. We assessed several parameters, including seizure frequency, astrogliosis, synaptic density, and neuronal counts in hippocampal tissue. We used immunohistochemistry and Nissl staining to evaluate gliosis, synaptic density, and neuronal counts in micro-dissected hippocampi. Western blotting was used to examine the expression of proteins involved in canonical Wnt/β-catenin signaling, and real-time PCR was conducted to analyze their relative mRNA expression. Wnt modulators, 6-Bio and Niclosamide were found to reduce seizure frequency and various other parameters including behavioral parameters, hippocampal morphology, astrogliosis and synaptic density at different stages of TLE.

Prognostic value of computed tomography‑derived skeletal muscle index and radiodensity in patients with gastric cancer after curative gastrectomy

The association of computed tomography (CT)-derived skeletal muscle index (SMI) and skeletal muscle radiodensity (SMD) with postoperative prognosis in patients with gastric cancer (GC) remains unknown. Therefore, the present study aimed to assess the association between SMI and SMD with 5-year overall survival (OS) and recurrence-free survival (RFS) in patients with GC. SMI and SMD were measured preoperatively in patients who underwent gastrectomy. Patients were categorized into Groups 1 (high SMI and SMD), 2 (high SMI or SMD) and 3 (low SMI and SMD). OS and RFS rates were assessed using Kaplan-Meier analysis and the log-rank test. Among 459 patients, OS and RFS rates were significantly lower in the low-SMD group than in the high-SMD group (OS, 83.4% vs. 88.8%, respectively; P=0.04 and RFS, 80.5% vs. 87.2%, respectively; P=0.02). OS and RFS rates were also significantly lower in Group 3 than in Groups 2 and 1 (P=0.006). Multivariate analysis revealed that a low SMI and SMD (Group 3) was a significant independent prognostic factor for OS [hazard ratio (HR), 2.32; 95% confidence interval (CI), 1.17-4.59; P=0.016] and RFS (HR, 2.28; 95% CI, 1.19-4.37; P=0.013). In summary, low SMI and SMD values may be useful postoperative prognostic indicators for patients with GC.

Different impacts of adipose tissue dynamics on prognosis in patients with resectable locally advanced rectal cancer treated with and without neoadjuvant treatment

Background

Body composition is recognized to be associated with clinical outcomes in patients with locally advanced rectal cancer (LARC). This study aimed to determine the prognostic role of regional adipose tissue distribution in patients with resectable LARC treated with or without neoadjuvant chemoradiotherapy (nCRT).

Methods

This retrospective study included 281 consecutive patients who underwent radical surgery for LARC with or without preoperative nCRT between 2013 and 2019. Patients underwent contrast-enhanced CT scans before nCRT and before surgery. Visceral adipose tissue (VAT), abdominal subcutaneous adipose tissue (aSAT), and gluteal subcutaneous adipose tissue (gSAT) were quantified on the CT images. The association of adipose tissue distribution with progression-free survival (PFS) was analyzed using Cox proportional hazards analysis.

Results

A total of 102 nCRT-treated and 179 primarily resected patients were included. During a median follow-up period of 24 months, 74 (26.3%) patients experienced local recurrence or metastasis. Multivariable analysis showed that VAT was associated with PFS in all patients (hazard ratio [HR] 1.28, 95% confidence interval [CI] 1.04-1.57; P = 0.021). This association was only maintained in primarily resected patients (HR 1.31, 95% CI 1.02-1.69; P = 0.037). For patients receiving preoperative nCRT, VAT was not significantly associated with PFS, while the dynamic change in gSAT (ΔgSAT) between nCRT and surgery was associated with PFS (HR 0.43, 95%CI 0.27-0.69, P = 0.001).

Conclusion

Visceral obesity is an adverse prognostic factor in patients with resectable LARC treated by primary resection, while increased gluteal subcutaneous adiposity during preoperative nCRT may indicate favorable clinical outcomes.

Computed tomography-measured body composition can predict long-term outcomes for stage I-III colorectal cancer patients

Background

There remains a pressing need to identify biomarkers capable of reliably predicting prognostic outcomes for colorectal cancer (CRC) patients. As several body composition parameters have recently been reported to exhibit varying levels of prognostic significance in particular cancers, the present study was devised to assess the ability of body composition to predict long-term outcomes for CRC patients with different stages of disease.

Methods

In total, this retrospective analysis enrolled 327 stage I-III CRC patients whose medical records were accessed for baseline demographic and clinical data. Primary outcomes for these patients included disease-free and overall survival (DFS and OS). The prognostic performance of different musculature, visceral, and subcutaneous fat measurements from preoperative computed tomography (CT) scans was assessed.

Results

Over the course of follow-up, 93 of the enrolled patients experienced recurrent disease and 39 died. Through multivariate Cox regression analyses, the visceral/subcutaneous fat area (V/S) ratio was found to be independently associated with patient DFS (HR=1.93, 95% CI: 1.24-3.01, P=0.004), and the skeletal muscle index (SMI) as an independent predictor for OS (HR=0.43, 95% CI: 0.21-0.89, P=0.023). Through subgroup analyses, higher V/S ratios were found to be correlated with reduced DFS among patients with stage T3/4 (P=0.011), lymph node metastasis-positive (P=0.002), and TNM stage III (P=0.002) disease, whereas a higher SMI was associated with better OS in all T stages (P=0.034, P=0.015), lymph node metastasis-positive cases (P=0.020), and in patients with TNM stage III disease (P=0.020).

Conclusion

Both the V/S ratio and SMI offer potential utility as clinical biomarkers associated with long-term CRC patient prognosis. A higher V/S ratio and a lower SMI are closely related to poorer outcomes in patients with more advanced disease.

Relationship between visceral obesity and prognosis in patients with stage IVB cervical cancer receiving radiotherapy and chemotherapy

Background

Concurrent chemoradiotherapy is the preferred treatment for stage IVB cervical cancer; however, some patients experience a poor prognosis. The prognostic significance of body composition indicators, including visceral obesity, has been extensively investigated in patients with cancer. This study aimed to assess the impact of body composition indicators, specifically pretreatment fat content, on the survival outcomes of patients with stage IVB cervical cancer.

Methods

We retrospectively analyzed clinical information from patients diagnosed with stage IVB cervical cancer between 2010 and 2018. We measured visceral obesity (visceral-to-subcutaneous adipose tissue area ratio [VSR]) and skeletal muscle index (SMI) on pretreatment computed tomography (CT) images. We evaluated the impact of these body composition parameters on the prognosis of patients with cervical cancer.

Results

Overall, 116 patients were included, 81 of whom had complete clinical and imaging information. Based on the cut-off values from X-tile analysis, we categorized patients into high and low VSR and SMI groups. The overall survival (OS) rate of patients with a high VSR was significantly higher than that of patients with a low VSR (P = 0.022). Multivariate Cox regression analysis showed that a low VSR was an independent risk factor for the prognosis of patients with stage IVB cervical cancer.

Conclusion

Visceral obesity before radiotherapy and chemotherapy has a protective effect on the prognosis of patients with stage IVB cervical cancer, while low muscle index and VSR are associated with poor prognosis.

Objective comparison of commonly used computed tomography body composition analysis software

OBJECTIVES

Sarcopenia is defined as an age-related, involuntary loss of skeletal muscle mass and strength. This condition is increasingly gaining clinical attention, as it has proved a predictor of complications and unfavorable outcomes in several diseases. For analysis of body composition on computed tomography images, several different software packages are used. Extensive research is being conducted globally to establish general cutoff values for different patient groups by combining the results of different studies with meta-analysis. Therefore, it is important that the measurements are independent of the software used. However, clinical software comparisons suggest there are differences between analysis packages, which would complicate establishment of cutoff values. For this study, we compared the eight most used analysis software programs in an objective manner, using a phantom image, to assess if their results can be readily compared.

METHODS

Eight software packages (sliceOmatic, OsiriX, ImageJ/Fiji, Mimics, CoreSlicer, SarcoMeas, 3D Slicer, and Aquarius iNtuition) were objectively evaluated, by performing measurements in a standardized synthetic image, containing fixed muscle and fat compartments with homogeneous radiodensities. For all programs, the measured areas and radiodensities of the regions of interest were assessed.

RESULTS

For sliceOmatic, OsiriX, ImageJ/Fiji, Mimics, CoreSlicer, SarcoMeas, and 3D Slicer, identical results were found, all reporting correct values for muscle and fat areas as well as correct radiodensity values, whereas values reported by Aquarius iNtuition deviated ≤ 5% for area measurements and had slight variation in radiodensity measurements.

CONCLUSIONS

Seven of eight software packages (sliceOmatic, OsiriX, ImageJ/Fiji, Mimics, CoreSlicer, SarcoMeas, and 3D Slicer) perform identically, so their results can be readily compared and combined when assessing body composition in computed tomography images. Area measurements acquired with Aquarius iNtuition may differ slightly (≤ 5%) from the other packages.

Exploring the effect of 6-BIO and sulindac in modulation of Wnt/β-catenin signaling pathway in chronic phase of temporal lobe epilepsy

The prospective involvement of the Wnt/β-catenin signaling pathway in epilepsy, with the proposed therapeutic uses of its modulators, has been suggested; however, comprehensive knowledge in this regard is currently limited. Despite postulations about the pathway's significance and treatment potential, a systematic investigation is required to better understand its implications in chronic epilepsy. We investigated the role of key proteins like β-catenin, GSK-3β, and their modulators sulindac and 6-BIO, in Wnt/β-catenin pathway during chronic phase of temporal lobe epilepsy. We also evaluated the role of modulators in seizure score, seizure frequency and neurobehavioral parameters in temporal lobe epilepsy. We developed status epilepticus model using lithium-pilocarpine. The assessment of neurobehavioral parameters was done followed by histopathological examination and immunohistochemistry staining of hippocampus as well as RT-qPCR and western blotting to analyse gene and protein expression. In SE rats, seizure score and frequency were significantly high compared to control rats, with notable changes in neurobehavioral parameters and neuronal damage observed in hippocampus. Our study also revealed a substantial upregulation of the Wnt/β-catenin pathway in chronic epilepsy, as evidenced by gene and protein expression studies. Sulindac emerged as a potent modulator, reducing seizure score, frequency, neuronal damage, apoptosis, and downregulating the Wnt/β-catenin pathway when compared to 6-BIO. Our findings emphasize the potential of GSK-3β and β-catenin as promising drug targets for chronic temporal lobe epilepsy, offering valuable treatment options for chronic epilepsy. The promising outcomes with sulindac encourages further exploration in clinical trials to assess its therapeutic potential.

Association of body composition and survival in patients with locally advanced breast cancer: a historical cohort study

BACKGROUND

Altered body composition has been attributed to major health problems globally, particularly in patients with cancer. To date, there have not been sufficient indices for body compositions in predicting the survival of locally advanced breast cancer (LABC).

PURPOSE

To assess the association between body composition and overall survival (OS) as well as disease-free survival (DFS) in patients with LABC.

MATERIAL AND METHODS

A retrospective study was conducted of patients with LABC diagnosed between 2010 and 2018. Body composition parameters, including skeletal muscle and adiposity parameters, were measured using computed tomography at the L3 vertebra using in-house software developed by MATLAB and freeware Python 3.6.13. The association between body composition and OS and DFS were analyzed using a log-rank test and multivariate Cox-proportional hazard regression.

RESULTS

Of 199 patients, 72 (36%) died during the follow-up period (range = 3.8-150.7 months). Median survival was 101 months. Low visceral-to-subcutaneous ratio ≤0.3 (adjusted hazard ratio [aHR] = 2.57, 95% confidence interval [CI] = 1.51-4.37; aHR = 2.46, 95% CI = 1.33-4.56), and high composite fat (aHR = 3.26, 95% CI = 1.69-6.29; aHR = 2.19, 95% CI = 1.11-4.3) were associated with lower OS and DFS. Positive lymph nodes ≥3, progesterone receptor negative, and total radiation dose >5000 cGy significantly decreased both OS and DFS. A history of previous treatment before body composition assessment and surgery had a protective effect on OS and DFS. No association of sarcopenia, body mass index, and adiposity areas with survival outcomes was observed.

CONCLUSION

Low visceral-to-subcutaneous ratio and high composite fat were independent prognostic factors for OS and DFS in patients with LABC. However, other body composition parameters showed no effect on survival.

Manganese homeostasis modulates fungal virulence and stress tolerance in Candida albicans

Due to the scarcity of transition metals within the human host, fungal pathogens have evolved sophisticated mechanisms to uptake and utilize these micronutrients at the infection interface. While considerable attention was turned to iron and copper acquisition mechanisms and their importance in fungal fitness, less was done regarding either the role of manganese (Mn) in infectious processes or the cellular mechanism by which fungal cells achieve their Mn-homeostasis. Here, we undertook transcriptional profiling in the pathogenic fungus Candida albicans experiencing both Mn starvation and excess to capture biological processes that are modulated by this metal. We uncovered that Mn scarcity influences diverse processes associated with fungal fitness including invasion of host cells and antifungal sensitivity. We show that Mn levels influence the abundance of iron and zinc emphasizing the complex crosstalk between metals. The deletion of SMF12, a member of Mn Nramp transporters, confirmed its contribution to Mn uptake. smf12 was unable to form hyphae and damage host cells and exhibited sensitivity to azoles. We found that the unfolded protein response (UPR), likely activated by decreased glycosylation under Mn limitation, was required to recover growth when cells were shifted from an Mn-starved to an Mn-repleted medium. RNA-seq profiling of cells exposed to Mn excess revealed that UPR was also activated. Furthermore, the UPR signaling axis Ire1-Hac1 was required to bypass Mn toxicity. Collectively, this study underscores the importance of Mn homeostasis in fungal virulence and comprehensively provides a portrait of biological functions that are modulated by Mn in a fungal pathogen.

IMPORTANCE

Transition metals such as manganese provide considerable functionality across biological systems as they are used as cofactors for many catalytic enzymes. The availability of manganese is very limited inside the human body. Consequently, pathogenic microbes have evolved sophisticated mechanisms to uptake this micronutrient inside the human host to sustain their growth and cause infections. Here, we undertook a comprehensive approach to understand how manganese availability impacts the biology of the prevalent fungal pathogen, Candida albicans. We uncovered that manganese homeostasis in this pathogen modulates different biological processes that are essential for host infection which underscores the value of targeting fungal manganese homeostasis for potential antifungal therapeutics development.

Evaluation of Wnt/β-catenin signaling and its modulators in repeated dose lithium-pilocarpine rat model of status epilepticus: An acute phase study

The role of the Wnt/β-catenin signaling pathway in epilepsy and the effects of its modulators as efficacious treatment options, though postulated, has not been sufficiently investigated. We evaluated the involvement of β-catenin and GSK-3β, the significant proteins in this pathway, in the lithium chloride-pilocarpine-induced status epilepticus model in rodents to study acute phase of temporal lobe epilepsy (TLE). The modulators studied were 6-BIO, a GSK-3β inhibitor and Sulindac, a Dvl protein inhibitor. The disease group exhibited increased seizure score and seizure frequency, and the assessment of neurobehavioral parameters indicated notable alterations. Furthermore, histopathological examination of hippocampal brain tissues revealed significant neurodegeneration. Immunohistochemical study of hippocampus revealed neurogenesis in 6-BIO and sulindac groups. The gene and protein expression by RT-qPCR and western blotting studies indicated Wnt/β-catenin pathway downregulation and increased apoptosis in the acute phase of TLE. 6-BIO was very efficient in upregulating the Wnt pathway, decreasing neuronal damage, increasing neurogenesis in hippocampus and decreasing seizure score and frequency in comparison to sulindac. This suggests that both GSK-3β and β-catenin are potential and novel drug targets for acute phase of TLE, and treatment options targeting these proteins could be beneficial in successfully managing acute epilepsy. Further evaluation of 6-BIO to explore its therapeutic potential in other models of epilepsy should be conducted.

Blockade of angiotensin II modulates insulin-like growth factor 1-mediated skeletal muscle homeostasis in experimental steatohepatitis

Sarcopenia is associated with mortality in patients with nonalcoholic steatohepatitis (NASH). Angiotensin II receptor blocker (ARB) has been suggested to prevent sarcopenia, but reports on its effect on NASH-derived skeletal muscle atrophy in conjunction with insulin-like growth factor 1 (IGF-1)-mediated muscle homeostasis are few. Our aim was to examine the combined effect of the ARB losartan and IGF-1 replacement on skeletal muscle atrophy in a methionine-choline deficient (MCD) diet-fed murine steatohepatitis model. The MCD-fed mice developed steatohepatitis and skeletal muscle atrophy, as indicated by the reduction of psoas muscle mass and attenuation of forelimb and hindlimb grip strength. Significantly suppressed steatohepatitis and skeletal muscle atrophy was observed after single treatment with ARB or IGF-1, and these effects were augmented after combination treatment. Treatment with ARB and IGF-1 effectively inhibited ubiquitin proteasome-mediated protein degradation by reducing forkhead box protein O1 (FOXO1) and FOXO3a transcriptional activity in the skeletal muscle. Combined ARB and IGF-1 decreased the intramuscular expression of proinflammatory cytokines (i.e., TNFα, IL6, and IL1β) and increased the Trolox equivalent antioxidant capacity and antioxidant enzymes (CAT, GPX1, SOD2, and CYTB). This antioxidant effect was based on downregulation of NADPH oxidase (NOX) 2, normalization of mitochondrial biogenesis and dynamics. Moreover, ARB increased the hepatic and plasma IGF-1 levels and improved steatohepatitis, leading to enhanced skeletal muscle protein synthesis mediated by IGF-1/ AKT/ mechanistic target of rapamycin signaling. Collectively, combined ARB and IGF-1 replacement could be a promising new therapeutic target for NASH-derived skeletal muscle wasting.

Visceral Fat Associated with Worsening of Recurrent Esophageal Varices in Alcoholic/Nonalcoholic Steatohepatitis-Related Liver Cirrhosis

BACKGROUND

Alcoholic steatohepatitis and nonalcoholic steatohepatitis-related liver cirrhosis (ASH/NASH-LC) are major causes of esophageal varices (EVs). However, the association between high visceral fat and exacerbation of EVs remains unclear. The aim of this study was to clarify the association of visceral fat and recurrence rate of EVs in ASH/NASH-LC and to identify independent predictors associated with recurrence.

METHODS

We retrospectively evaluated data from 94 patients who underwent endoscopic injection sclerotherapy for EVs with ASH/NASH-LC. Using the receiver operating characteristic curve for the cut-off value of visceral fat index (VFI; 46.4 cm2/m2), we classified patients as having a high VFI (n = 53) or low VFI (n = 41). Propensity score matching was used to align for background factors, and the recurrence rate of EVs was compared between the two groups. Predictors associated with esophageal variceal recurrence were identified by multivariate analysis. The recurrence rate in patients with viral LC was also investigated.

RESULTS

In the overall analysis, the recurrence rate was significantly higher in the high VFI group than in the low VFI group (P = 0.023). The recurrence rate was also higher in the high VFI group than in the low VFI group after propensity score matching, in which 19 patients were matched in each group (P = 0.048). VFI and Child-Pugh score were independently associated with recurrence. Recurrence rates were comparable between the two groups in viral LC patients.

CONCLUSIONS

Worsening of variceal recurrence was observed in high visceral fat patients in ASH/NASH-LC but not in viral LC. Furthermore, high visceral fat was an independent predictor associated with variceal recurrence.

Differential Regulation of Wnt/β-catenin Signaling in Acute and Chronic Epilepsy in Repeated Low Dose Lithium-Pilocarpine Rat Model of Status Epilepticus

Epilepsy is a chronic neurological complication characterized by unprovoked seizure episodes due to the imbalance between excitatory and inhibitory neurons. The epileptogenesis process has been reported to be involved in chronic epilepsy however, the mechanism underlying epileptogenesis remains unclear. Recent studies have shown the possible involvement of Wnt/β-catenin signaling in the neurogenesis and neuronal reorganization in epileptogenesis. In this study, we used repeated low dose lithium-pilocarpine model of status epilepsy (SE) to study the involvement of Wnt/β-catenin signaling at acute and chronic stages post SE induction. The acute study ranged from day 0 to day 28 post SE induction and the chronic study ranged from day 0 to day 56 post SE induction. Several neurobehavioral parameters and seizure score and seizure frequency was analysed until the end of the study. The proteins involved in the regulation of Wnt/β-catenin signaling and downstream cascading were analysed using western blot and quantitative real-time PCR analysis. The Wnt/β-catenin pathway was found inactive in acute SE, while the same was found activated at the chronic stage. Our findings suggest that the activated Wnt/β-catenin signaling in chronic epilepsy might be the possible mechanism underlying epileptogenesis as indicated by increased neuronal count, increased synaptic density, astrogliosis and apoptosis in chronic epilepsy. These findings can help target the Wnt/β-catenin pathway differentially depending upon the type of epilepsy. The acute stage characterized by SE can be improved by targeting GSK-3β levels and the chronic stage characterized by temporal lobe epilepsy can be improved by targeting β-catenin and disheveled proteins.

Autologous blood products: Leucocyte and Platelets Rich Fibrin (L-PRF) and Platelets Rich Plasma (PRP) gel to promote cutaneous ulcer healing - a systematic review

OBJECTIVE

To summarise evidence on the effectiveness of Platelet-Rich Plasma (PRP) gel and Leucocyte and Platelet Rich Fibrin (L-PRF) gel as agents promoting ulcer healing compared with the standard wound dressing techniques alone.

DESIGN

Systematic review.

ELIGIBILITY CRITERIA

Individual patient randomised controlled trials on skin ulcers of all types excluding traumatic lesions.Intervention group: treatment with topical application of L-PRF gel or PRP gel to the wound surface.

CONTROL GROUP

treatment with standard skin ulcer care using normal saline, normgel or hydrogel dressings.

INFORMATION SOURCES

Medline (Ovid), Excerpta Medica Database (EMBASE), Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science and manual search of studies from previous systematic reviews and meta-analyses. The papers published from 1946 to 2022 with no restriction on geography and language were included. The last date of the search was performed on 29 August 2022.

DATA EXTRACTION AND SYNTHESIS

Independent reviewers identified eligible studies, extracted data, assessed risk of bias using V.2 of the Cochrane risk-of-bias tool for randomised trials tool and assessed certainty of evidence by using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

MAIN OUTCOME MEASURES

Time to complete healing, proportion healed at a given time and rate of healing.

RESULTS

Seven studies met the inclusion criteria, five using PRP gel and two using L-PRF gel. One study showed a better proportion of complete healing, three reported reduced meantime to complete healing and five showed improved rate of healing per unit of time in the intervention group. The risk of bias was high across all studies with one exception and the GRADE showed very low certainty of evidence.

CONCLUSION

The findings show potential for better outcomes in the intervention; however, the evidence remains inconclusive highlighting a large research gap in ulcer treatment and warrant better-designed clinical trials.

PROSPERO REGISTRATION NUMBER

CRD42022352418.

Leptin-mediated meta-inflammation may provide survival benefit in patients receiving maintenance immunotherapy for extensive-stage small cell lung cancer (ES-SCLC)

BACKGROUND

Only few ES-SCLC patients experience long-term survival benefit by maintenance IT. Adipokines-induced metabolic meta-inflammation has been related to enhanced responsiveness to IT in obese patients; however, their prognostic role in SCLC is currently controversial.

METHODS

Pre-treatment CT scan was used for determining distribution of abdominal adiposity, and blood samples were collected at fasting for measuring glycemia, insulin, ghrelin, leptin and adipokines (TNF-α, IFN-γ, IL-6 and MCP-1). Patients with known history of DM type II or metabolic syndrome with HOMA index > 2.5 were considered insulin resistant (IR).

RESULTS

In ES-SCLC pts receiving maintenance IT, increased leptin concentration and higher leptin/visceral adipose tissue (VAT) ratio were significantly associated with prolonged PFS. By applying a hierarchical clustering algorithm, we identified a cluster of patients characterized by higher leptin values and lower pro-inflammatory cytokines (TNF-α, IFN-γ and IL-6) who experienced longer PFS (13.2 vs 8.05 months; HR: 0.42 [0.18-0.93] p = 0.02) and OS (18.04 vs 12.09 mo; HR: 0.53 [0.25-1.29] p = 0.07).

CONCLUSIONS

Adipokines can play a crucial role to determining effectiveness of anti-cancer immunotherapy. The role of metabolic immune dysfunctions needs further pre-clinical validation and is currently investigated in the larger prospective cohort.

CT Scan-Derived Muscle, But Not Fat, Area Independently Predicts Mortality in COVID-19

BACKGROUND

COVID-19 has demonstrated a highly variable disease course, from asymptomatic to severe illness and eventually death. Clinical parameters, as included in the 4C Mortality Score, can predict mortality accurately in COVID-19. Additionally, CT scan-derived low muscle and high adipose tissue cross-sectional areas (CSAs) have been associated with adverse outcomes in COVID-19.

RESEARCH QUESTION

Are CT scan-derived muscle and adipose tissue CSAs associated with 30-day in-hospital mortality in COVID-19, independent of 4C Mortality Score?

STUDY DESIGN AND METHODS

This was a retrospective cohort analysis of patients with COVID-19 seeking treatment at the ED of two participating hospitals during the first wave of the pandemic. Skeletal muscle and adipose tissue CSAs were collected from routine chest CT-scans at admission. Pectoralis muscle CSA was demarcated manually at the fourth thoracic vertebra, and skeletal muscle and adipose tissue CSA was demarcated at the first lumbar vertebra level. Outcome measures and 4C Mortality Score items were retrieved from medical records.

RESULTS

Data from 578 patients were analyzed (64.6% men; mean age, 67.7 ± 13.5 years; 18.2% 30-day in-hospital mortality). Patients who died within 30 days demonstrated lower pectoralis CSA (median, 32.6 [interquartile range (IQR), 24.3-38.8] vs 35.4 [IQR, 27.2-44.2]; P = .002) than survivors, whereas visceral adipose tissue CSA was higher (median, 151.1 [IQR, 93.6-219.7] vs 112.9 [IQR, 63.7-174.1]; P = .013). In multivariate analyses, low pectoralis muscle CSA remained associated with 30-day in-hospital mortality when adjusted for 4C Mortality Score (hazard ratio, 0.98; 95% CI, 0.96-1.00; P = .038).

INTERPRETATION

CT scan-derived low pectoralis muscle CSA is associated significantly with higher 30-day in-hospital mortality in patients with COVID-19 independently of the 4C Mortality Score.

Preoperative Subcutaneous Fat is an Useful Indicator for Learning Totally Extraperitoneal Repair

BACKGROUND

Totally extraperitoneal (TEP) repair is a recommended procedure for inguinal hernia repair in European hernia guidelines. However, technical challenges have limited its uptake in Japan, where transabdominal preperitoneal (TAPP) repair is more common. We evaluated the association of preoperative subcutaneous fat area (preSFA) with surgical outcomes and identified factors associated with the difficulty of TEP repair.

METHODS

Clinical data from 62 patients undergoing TEP repair were collected retrospectively. Using the median for the preoperative subcutaneous fat index (preSFI; 45.9 cm²/m²), we classified patients as having a high SFI (HSFI) (n=31) and low SFI (LSFI) (n=31). Surgical outcomes and perioperative complications were then compared between these groups. Additionally, TEP repair was divided into five phases (e.g., Phase 1: dissection of the caudal side of the preperitoneal space), and operative time was measured during each phase. Phase 1 was divided into two sub-phases (1A: insertion of the first port, 1B: reaching Cooper's ligament).

RESULTS

Operative time was longer (133 min vs 111 min, P = 0.028) and the peritoneal injury rate was higher (35.5% vs 9.7%, P = 0.015) for the HSFI patients. Furthermore, operative time for HSFI patients was significantly longer during Phase 1 (P = 0.014) and Phase 1A (P = 0.022).

CONCLUSIONS

preSFA was associated with a higher peritoneal injury rate and longer operative time in HSFI patients, suggesting that the presence of abundant subcutaneous fat increases the difficulty of TEP repair.

Quality of Life after Transcatheter Aortic Valve Replacement in Sarcopenic Patients Using the Toronto Aortic Stenosis Quality of Life Questionnaire

BACKGROUND

Sarcopenia is the core component of frailty; however, its role in patients undergoing transcatheter aortic valve replacement (TAVR) is a matter of debate. The Toronto Aortic Stenosis Quality of Life Questionnaire (TASQ) is a validated instrument for assessing quality of life (QoL) in patients with severe aortic stenosis (AS).

AIMS

We aim to evaluate the QoL of sarcopenic and non-sarcopenic patients with severe AS undergoing TAVR.

METHODS

TASQ was prospectively administered to patients undergoing TAVR. All patients completed the TASQ before TAVR and at a 3-month follow-up. The study population was divided in two groups according to sarcopenic status. The primary endpoint was the TASQ score in the sarcopenic and non-sarcopenic cohorts.

RESULTS

In total, 99 patients were eligible for the analysis. In both sarcopenic (n = 56) and non-sarcopenic (n = 43) cohorts, significant changes were observed in the overall TASQ score and in all but one (i.e., health expectations) of the individual domains (p < 0.01). Sarcopenic and non-sarcopenic patients showed substantial improvements across TASQ subscores. The mean change in overall TASQ score at three months revealed a significant improvement in both cohorts (p < 0.01). Health expectations worsened in sarcopenic patients at the 3-month follow-up (p = 0.06).

CONCLUSIONS

The TASQ questionnaire revealed changes in QoL after TAVR, regardless of patients' sarcopenic status. Health status improved substantially in both sarcopenic and non-sarcopenic patients following TAVR. Lack of improvement in health expectations seems to depend on patients' expectations regarding the procedure and specific aspects in the evaluation of the outcome.

Determinants of in-hospital muscle loss in acute ischemic stroke - Results of the Muscle Assessment in Stroke Study (MASS)

BACKGROUND & AIMS

There is a change in the mass and composition of paretic and non-paretic skeletal muscles in the chronic phase of stroke. The multi-center, prospective, and observational Muscle Assessment in Stroke Study (MASS) was performed to evaluate the degree of muscle loss during the in-hospital acute stroke setting and determine factors contributing to this loss.

METHODS

Acute dysphagic ischemic stroke patients (n = 107) admitted to neuro-intensive care units were evaluated by computed tomography on days 1 and 14 after admission to determine the cross-sectional muscle area (CSMA) at the level of the mid-humerus, mid-thigh, and third lumbar vertebra. The percentage change in CSMA and variables associated with this change were evaluated by univariate and multivariate analyses.

RESULTS

There were significant reductions in CSMA in all the muscle groups analyzed; the most prominent change was observed in the arms (both: 14.2 ± 10.7%; paretic: 17.7 ± 11.6%; non-paretic: 10.1 ± 12.5%), followed by the muscles in the legs (both: 12.4 ± 8.7%; paretic: 12.9 ± 9.9%; non-paretic: 12.0 ± 9.3%) and L3-vertebra level (5.6 ± 9.8%) (P < 0.001 for all). Higher calorie (r = -0.378, P < 0.001) or protein (r = -0.352, P < 0.001) intake was negatively associated with the decrease in CSMA of upper extremities. A substantial protein (≥0.4 g/kg/d) or calorie (≥5 kcal/kg/d) gap between targeted or actual intake was related to a larger decrease in CSMA in all the anatomic regions (P ≤ 0.05 for all). Other significant predictors of muscle loss included history of diabetes mellitus, male sex, higher BMI, in-hospital infections, and the necessity for invasive mechanical ventilation.

CONCLUSIONS

There is a considerable degree of loss in the global muscle mass in acute ischemic stroke patients over a two-week period. Along with several factors, falling significantly behind the daily protein or calorie targets was related to the decrease in the muscle area. TRIAL REGISTRATION INFORMATION: clinicaltrials.gov identifier NCT03825419.

2D shear wave elastography of the rectus femoris muscle in patients with cirrhosis: Feasibility and clinical findings. A pilot study

BACKGROUND AND AIMS

Frailty is frequent in cirrhosis and associated with skeletal muscle abnormalities and worse prognosis. 2D shear-wave elastography (2D-SWE) could mirror biomechanical properties of skeletal muscle reflecting muscle quality. However, there is no data on 2D-SWE on skeletal muscle stiffness assessment in cirrhosis and on frailty.

METHODS

Outpatients with cirrhosis were prospectively included in a single center. Skeletal muscle stiffness was studied at the rectus femoris by 2D-SWE. Ileo-psoas area and index (area/height²), and antero-posterior diameter of rectus femoris (RF) was measured on ultrasound.

RESULTS

We included 44 patients (24 male, age 59 [IQR 49-66]) with a median liver frailty index (LFI) of 3.7 (IQR 3.2-4.0). Measurement of RF muscle stiffness (RFMS) was feasible in all with high inter-measurement reproducibility. RFMS did not correlate with LFI, liver function and skeletal muscle diameters. Ileo-psoas index was lower in frail patients (1.7 vs 1.0 cm²/m², p = 0.024). RF antero-posterior diameter inversely correlated with LFI (r -0.578: p<0.001).

CONCLUSION

RFMS by 2D-SWE is feasible and reproducible in cirrhosis and is independent of liver function and LFI, and warrants further studies in this setting. RF antero-posterior diameter could be reported as an objective parameter mirroring sarcopenia and frailty.

Prediction of whole body composition utilizing cross-sectional abdominal imaging in pediatrics

BACKGROUND

Although body composition is an important determinant of pediatric health outcomes, we lack tools to routinely assess it in clinical practice. We define models to predict whole-body skeletal muscle and fat composition, as measured by dual X-ray absorptiometry (DXA) or whole-body magnetic resonance imaging (MRI), in pediatric oncology and healthy pediatric cohorts, respectively.

METHODS

Pediatric oncology patients (≥5 to ≤18 years) undergoing an abdominal CT were prospectively recruited for a concurrent study DXA scan. Cross-sectional areas of skeletal muscle and total adipose tissue at each lumbar vertebral level (L1-L5) were quantified and optimal linear regression models were defined. Whole body and cross-sectional MRI data from a previously recruited cohort of healthy children (≥5 to ≤18 years) was analyzed separately.

RESULTS

Eighty pediatric oncology patients (57% male; age range 5.1-18.4 y) were included. Cross-sectional areas of skeletal muscle and total adipose tissue at lumbar vertebral levels (L1-L5) were correlated with whole-body lean soft tissue mass (LSTM) (R²= 0.896-0.940) and fat mass (FM) (R²= 0.874-0.936) (p < 0.001). Linear regression models were improved by the addition of height for prediction of LSTM (adjusted R² = 0.946-0^.971; p < 0.001) and by the addition of height and sex (adjusted R² = 0.930-0.953) (p < 0^.001)) for prediction of whole body FM. High correlation between lumbar cross-sectional tissue areas and whole-body volumes of skeletal muscle and fat, as measured by whole-body MRI, was confirmed in an independent cohort of 73 healthy children.

CONCLUSION

Regression models can predict whole-body skeletal muscle and fat in pediatric patients utilizing cross-sectional abdominal images.

Cirrhosis and Sarcopenia

Sarcopenia is a progressive muscle wasting syndrome involving loss in skeletal muscle mass, strength, and function. It is closely associated with cirrhosis and its complications with up to more than half of cirrhotic patients demonstrating imaging findings of sarcopenia. The pathogenesis of this syndrome remains complex, including multiple factors involved in skeletal muscle homeostasis, systemic inflammation, and energy dysregulation. Many modalities exist in assessing and measuring sarcopenia. The use of cross-sectional imaging, such as computed tomography and magnetic resonance imaging, with accurate and clinically proven assessment software should be considered the gold standard. Sarcopenia has become the focus of ongoing extensive research with initial findings highlighting increased mortality and complication rates in patient with cirrhosis and hepatocellular carcinoma. Additional studies have demonstrated reversal and improved survival in sarcopenic patients who have undergone transjugular intrahepatic portosystemic shunt placement. Thus, accounting for sarcopenia can help risk stratify patients prior to interventional procedures to allow for better outcomes and improved survival.

Comparison of perinephric fat measurements between malignant and benign renal tumours

Objective

To investigate different parameters derived from the quantity and quality of perinephric fat, and to compare their effectiveness in predicting the malignant pathology of renal tumours.

Methods

Data from patients diagnosed with renal tumour between April 2014 and December 2020 were retrospectively reviewed, and patients were categorized into malignant or benign tumour groups. Fat parameters, including perinephric fat volume (PFV), perinephric fat area (PFA), perinephric fat thickness (PFT), and Mayo adhesive probability (MAP) score were measured using abdominal computed tomography scans. Between-group differences were assessed by analysis of variance and χ²-test. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the performance of perinephric fat parameters in diagnosing malignancy.

Results

A total of 109 patients were included. MAP score, PFV, PFA, and PFT were significantly increased in the malignant versus benign tumour group, and after correction for body mass index (BMI), the indexed PFV/BMI, PFA/BMI, and PFT/BMI values remained significantly higher in the malignant tumour group. All parameters showed fair predictivity of malignancy, with comparable area under the curve values in the ROC curve.

Conclusion

An increased amount of perinephric fat is predictive of malignant pathology for renal tumours. The predictive accuracy for each perinephric fat parameter remained fair after correcting for BMI.

Relationship between pre‑operative glycated haemoglobin and surgical site infection in patients undergoing elective colon cancer surgery

Surgical site infections remain a significant cause of morbidity following colon cancer surgery. Although diabetes has been recognised as a risk factor, patients with asymptomatic diabetes are likely underdiagnosed. The aim of the present study was to determine the relationship between preoperative glycated haemoglobin (HbA1C), clinicopathological characteristics and the influence on surgical site infection in a cohort of patients undergoing potentially curative colon cancer surgery. Patients who underwent elective, potentially curative colon cancer surgery between January 2011 and December 2014 were assessed for HbA1C levels (mmol/mol) measured within 3 months preoperatively. Clinicopathological data were recorded in a maintained database. A multivariate binary logistic regression model was used to assess the relationship between HbA1C, clinicopathological characteristics and surgical site infections. A total of 362 patients had HbA1C levels preoperatively recorded. HbA1C was significantly associated with body mass index (BMI), diabetes, smoking status, visceral fat area and skeletal muscle index. As determined by multivariate analysis, preoperative HbA1C levels remained independently associated with an increased risk of surgical site infections (OR 1.69, 95% CI 1.05-2.7; P=0.031) together with BMI (OR 1.91, 95% CI 1.36-2.67; P<0.001). Notably, in the present study, tumour-based factors, such as tumour location and TNM status, were not associated with infective complications. By contrast, host factors, such as BMI and pre-operative HbA1C were associated with surgical site infections suggesting that these factors were of more importance in determining short-term outcomes. In conclusion, objective measurements of BMI and HbA1C effectively stratified the risk of developing surgical site infection from 8 to 59%; therefore, HbA1C levels should be determined to allow for preoperative optimisation.

Subcutaneous and visceral adipose tissue in patients with primary and recurrent incisional hernia

PURPOSE

Visceral obesity rather than body mass index has been reported to be associated with a higher incidence of incisional hernias. The aim of this study was to examine the relationship between CT measured adipose tissue and muscle in primary and recurrent incisional hernia.

METHODS

Patients with a 'Primary' or 'Recurrent incisional hernia' were obtained from a prospective cohort of patients who were being assessed for incisional hernia repair over a 2-year period. Computerised tomography (CT)-images were analysed using NIH Image-J software to quantify adipose tissue and skeletal muscle cross-sectional areas at the level of lumber vertebra 3/4 using standard Hounsfield units. To test inter-observer 'absolute agreement', each parameter was measured independently by two investigators and reliability analysis performed.

RESULTS

Thirty-six patients were included in the study: 15 had a Primary while 21 had a Recurrent incisional hernia. Both groups had similar baseline characteristics. Reliability analysis for CT-measured areas showed very high interclass correlation coefficient (ICC) between observers. Patients in the recurrent group had significantly greater subcutaneous adipose tissue (SAT) [median = 321.9cm2 vs 230.9cm2, p = 0.04] and visceral adipose tissue (VAT) [median = 221.1cm2 vs 146.8cm2, p = 0.03] than those in the primary group. There was no difference in skeletal muscle areas for right [median = 2.8cm2 vs 2.9cm2] and left [median = 3.7cm2 vs 4.1cm2] rectus muscles between groups.

CONCLUSION

Our study shows that patients with a recurrent incisional hernia have significantly more subcutaneous and visceral adipose tissue than those with a primary incisional hernia. Further studies in this area are required if we are to reduce the burden of recurrent hernia following repair of a primary incisional hernia.

Piloting a training program in computed tomography (CT) skeletal muscle assessment for Registered Dietitians

BACKGROUND

Consensus definitions for disease-associated malnutrition and sarcopenia include reduced skeletal muscle mass as a diagnostic criterion. There is a need to develop and validate techniques to assess skeletal muscle in clinical practice. Skeletal muscle mass can be precisely quantified from computed tomography (CT) images. This pilot study aimed to train Registered Dietitians (RD) to complete precise skeletal muscle measurements using CT.

METHODS

Purposive sampling identified RDs employed in clinical areas where CT scans are routinely performed. CT training included: 1) a 3-day training session focused on manual segmentation of skeletal muscle cross-sectional areas (cm² ) from abdominal CT images at the third lumber (L3) vertebra, using SliceOmatic® software, and 2) a precision assessment to quantify the intra- and inter-observer precision error of repeated skeletal muscle measurements (30 images in duplicate). Precision error is reported as the root mean standard deviation (cm² ) and % coefficient of variation (%CV), our primary performance indicator was defined as a precision error <2%.

RESULTS

Five RDs completed CT training. RDs were from three clinical areas (cancer care (N=1), surgery (N=2), and critical care (N=1). RDs precision error was low and below the minimal acceptable error of <2%; intra-observer error was ≤1.8 cm² (range 0.8 - 1.8 cm² ) or ≤1.5% (range 0.8 - 1.5%) and inter-observer error was 1.2 cm² or 1.1%.

CONCLUSION

RDs can be trained to perform precise CT skeletal muscle measurements. Increasing capacity to assess skeletal muscle is a first step toward developing this technique for use in clinical practice.

CLINICAL RELEVANCE STATEMENT

There is significant interest from both researchers and clinicians to undertake the measurement of skeletal muscle. Reduced skeletal muscle mass places individuals at risk of experiencing adverse outcomes and is a diagnostic criterion for disease-associated malnutrition and sarcopenia. In this study we piloted a training program in computed tomography (CT)-skeletal muscle assessments for RDs, and demonstrated after completion of the program RDs were able to perform CT skeletal muscle measurements with high precision. The addition of new tools to the comprehensive nutrition assessment tool box may benefit clinical practice in multiple ways including improved identification of patients with reduced skeletal muscle mass, individualization of interventions, and monitoring effectiveness of interventions over time. Other clinicians may also benefit from knowing about their patients' skeletal muscle mass to help identify risk and make treatment decisions. This article is protected by copyright. All rights reserved.

Impact of Body Composition on Prognosis and Dose-Limiting Toxicities on Metastatic Colorectal Cancer

Sarcopenia is a progressive skeletal muscle disease, often present in oncological patients, that is associated with multiple adverse events such as worse prognosis, physical performance, and quality of life. Body composition evaluation by CT cross-section at the L3 vertebrae region appears to be a precise method to quantify skeletal muscle. The optimal cut-off for the definition of sarcopenia is not yet established, therefore the incidence of sarcopenia varies according to different studies. The main goal was to evaluate the presence of sarcopenia in patients with metastatic colorectal cancer (mCRC) and its impact on overall survival (OS) and dose-limiting toxicities (DLT). A retrospective cohort study of 178 patients with mCRC under first-line chemotherapy (ChT) in association with target therapy, in two hospital units, between January 2015 and December 2018. Skeletal mass area (SMA) was quantified with the NIH ImageJ software in CT cross-sectional images at the L3 vertebrae region. Statistical analysis was performed with IBM SPSS v25 software https://www.ibm.com/analytics/spss-statistics-software. The median age was 62 (SD ± 11) years old, 65% were men and 62.9% had an Eastern Cooperative Oncology Group (ECOG) performance status of 0. The cut-off value was established based on ROC analysis, with sarcopenia defined as SMI < 49.12 cm2/m2 for men and < 35.85 cm2/m2 for women. Despite the mean body mass index (BMI) of 25.71 (± 4.71) kg/m2, half of the patients presented sarcopenia. In a multivariate analysis using a Cox regression model, an association was observed between OS and higher ECOG PS (p = 0.014; HR 5.46, CI 95% [1.42-21.10]), neutrophil-to-lymphocyte ratio (NLR) >2.80 (p = 0.038; HR 2.20, CI 95% [1,05-4.62]), and sarcopenia (p = 0.01; HR 4.73, CI 95% [1.85-12.09]). Additionally, in a logistic regression model, age (p = 0.014; OR 1.09, IC 95% [1.02-1.16]) and sarcopenia (p= 0.030, OR 4.13, IC 95% [1.15-14.8]) were associated with higher incidence of DLT. The CT evaluation of the body composition at the L3 region allows for the quantification of sarcopenia, providing prognostic information and predictive value of DLT in patients with mCRC, although the establishment of optimal cut-off values are required for implementation in clinical practice. A multimodal strategy to delay muscle waste should be considered in these patients.

Short and long-term impact of sarcopenia on outcomes from emergency laparotomy

PURPOSE

Emergency laparotomy (EL) carries a high risk of morbidity and mortality, that is greater among older patients. Sarcopenia refers to an age- or pathology-associated muscle loss and has been demonstrated to correlate with poorer outcomes in several surgical conditions. This study assessed the impact of sarcopenia on morbidity and mortality in elderly patients undergoing EL.

METHODS

Patients aged ≥ 65 years-old undergoing EL between May 2012-June 2017 with a pre-operative abdominal computerised tomography (CT) scan at Middlemore Hospital (New Zealand) were included. Psoas and Skeletal Muscle Index (PMI and SMI) were calculated from abdominal CT measurements after standardisation based on height. Validated cut-offs for sarcopenia were used. Frailty was estimated using the 11-point modified frailty index (mFI). The primary outcome was 30-day, 1-year, and 4-year post-operative mortality. Secondary outcomes included correlations between mFI and sarcopenic measures, unplanned readmissions, and post-operative complications.

RESULTS

A total of 167 patients (84 sarcopenic; 83 non-sarcopenic) were included. Sarcopenic and non-sarcopenic patients had similar 30-day (14.2 vs. 12.0%; p = 0.84), 1-year (23.8 vs. 25.3%; p = 0.96), and 4-year (39.3 vs. 47.0%; p = 0.40) mortality rates following an EL. Survivors had a higher mean PMI at 1-year (p = 0.0078) and 4-year (p = 0.013) but not 30-day (p = 0.40) follow-up. Sarcopenia performed poorly in discriminating between 30-day (AUC 0.51) and 1-year (AUC 0.53) mortality. The mFI did not correlate with PMI (p = 0.85) nor SMI (p = 0.18). Rates of readmissions and post-operative complications did not differ between sarcopenic and non-sarcopenic cohorts.

CONCLUSION

Sarcopenia does not provide useful short-term prognostic information in elderly EL patients.

Angiotensin Receptor Blockers Potentiate the Protective Effect of Branched-Chain Amino Acids on Skeletal Muscle Atrophy in Cirrhotic Rats

SCOPE

This study investigated the combined effect of the angiotensin II (AT-II) receptor blocker losartan and branched-chain amino acids (BCAAs) on skeletal muscle atrophy in rats with cirrhosis and steatohepatitis.

METHOD AND RESULTS

Fischer 344 rats are fed a choline-deficient l-amino acid-defined (CDAA) diet for 12 weeks and treated with oral losartan (30 mg kg-1 day-1 ) and/or BCAAs (Aminoleban EN, 2500 mg kg-1 day-1 ). Treatment with losartan and BCAAs attenuated hepatic inflammation and fibrosis and improved skeletal muscle atrophy and strength in CDAA-fed rats. Both agents reduced intramuscular myostatin and pro-inflammatory cytokine levels, resulting in inhibition of the ubiquitin-proteasome system (UPS) through interference with the SMAD and nuclear factor-kappa B pathways, respectively. Losartan also augmented the BCAA-mediated increase of skeletal muscle mass by promoting insulin growth factor-I production and mitochondrial biogenesis. Moreover, losartan decreased the intramuscular expression of transcription factor EB (TFEB), a transcriptional inducer of E3 ubiquitin ligase regulated by AT-II. In vitro assays illustrated that losartan promoted mitochondrial biogenesis and reduced TFEB expression in AT-II-stimulated rat myocytes, thereby potentiating the inhibitory effects of BCAAs on the UPS and caspase-3 cleavage.

CONCLUSION

These results indicate that this regimen could serve as a novel treatment for patients with sarcopenia and liver cirrhosis.

Feasibility of augmented rectangle technique in laparoscopic distal gastrectomy: comparison with hemi-double stapling technique in a single-center retrospective cohort study

PURPOSE

Augmented rectangle technique (ART) anastomosis is a totally intracorporeal anastomosis of laparoscopic distal gastrectomy (LDG), Billroth I (B1) reconstruction for gastric cancer, which secures a wide anastomotic stoma. Since the conventional extracorporeal hemi-double stapling technique (HD) may have a narrow anastomotic stoma, our aim of this study was to evaluate the feasibility and usefulness of ART anastomosis by comparing the surgical outcomes with HD anastomosis.

METHODS

Clinical data of 89 patients undergoing LDG with B1 reconstruction were retrospectively collected. Patients were divided into ART group (n = 40) and HD group (n = 49). Surgical outcomes including short-term outcomes, postoperative endoscopic findings, and nutritional factors 1 year after surgery were compared between the groups.

RESULTS

Baseline characteristics were similar between the groups. In terms of short-term outcomes, blood loss was less (11.5 mL vs 40 mL, P = 0.011) and postoperative hospital stay was shorter (10 days vs 12 days, P = 0.022) in the ART group. In terms of endoscopic findings, residual food was less (P = 0.032) in the ART group. In terms of nutritional factors, percent decrease of visceral fat area (- 27.6% vs - 40.5%, P = 0.049) and subcutaneous fat area (- 25.7% vs - 39.3%, P = 0.050) 1 year after surgery attenuated in the ART group.

CONCLUSIONS

ART anastomosis is superior in perioperative course such as postoperative hospital stay. Moreover, a better nutritional recovery is expected by securing a wide anastomotic stoma leading to a favorable food passage.

The combination of body composition conditions and systemic inflammatory markers has prognostic value for patients with gastric cancer treated with adjuvant chemoradiotherapy

OBJECTIVE

The aim of this study was to explore the prognostic value of the association between systemic inflammation response markers (red blood cell distribution width, neutrophil platelet score, prognostic nutritional index, neutrophil-to-lymphocyte ratio, neutrophil-to-platelet ratio, lymphocyte-to-monocyte ratio, and systemic immune-inflammation index) and poorer body composition conditions (sarcopenia, myosteatosis, and sarcopenic obesity) among patients with gastric cancer who underwent adjuvant chemoradiotherapy after radical gastrectomy.

METHODS

A computed tomography scan was performed within 2 wk of prechemoradiotherapy to identify sarcopenia, myosteatosis and sarcopenic obesity. Tumor and systemic inflammatory response information was recorded. Logistic analysis was used to explore the potential risk factors associated with body composition. Univariate and multivariate Cox analyses were performed for survival analysis. A nomogram was constructed to serve as a prognostic prediction tool for the 3- and 5-y overall survival rates.

RESULTS

The study included 223 patients (74 women and 149 men) with gastric cancer treated with adjuvant chemoradiotherapy after radical gastrectomy. The incidences of sarcopenia, myosteatosis, and sarcopenic obesity were 30%, 39%, and 16%, respectively. Logistic analysis demonstrated that a low prognostic nutritional index is a risk factor for sarcopenia, myosteatosis, and sarcopenic obesity. Based on survival analysis, stage (hazard ratio [HR], 0.44; 95% confidence interval [CI], 0.23-0.84; P = 0.01), the neutrophil platelet score (HR, 0.50; 95% CI, 0.31-0.82; P = 0.01), the prognostic nutritional index (HR, 0.40; 95% CI, 0.24-0.68; P = 0.00) and sarcopenic obesity (HR, 0.54; 95% CI, 0.31-0.93; P = 0.03) remained independent prognostic factors for overall survival. Accuracy was improved when systemic inflammation markers were incorporated into the nomogram compared with when they were excluded, and the predicted C indexes of the nomogram with and without systemic inflammatory markers were 0.71 (95% CI, 0.67-0.73) and 0.63 (95% CI, 0.57-0.68), respectively.

CONCLUSION

The systemic inflammatory response associated with progressive nutritional conditions and body composition conditions with systemic inflammation markers incorporated presented better prognostic value.

The prognostic value of weight and body composition changes in patients with non-small-cell lung cancer treated with nivolumab

BACKGROUND

It is not well known to what extent effectiveness of treatment with immune checkpoint inhibitors in stage IV non-small-cell lung cancer (NSCLC) is influenced by weight loss and changes in body composition. Therefore, the goal of this study was to evaluate body composition changes in relation to early weight change and overall survival (OS) in stage IV NSCLC patients treated with second-line nivolumab.

METHODS

All patients with stage IV NSCLC, who were treated with second-line nivolumab between June 2015 and December 2018 at Maastricht University Medical Center, were evaluated. Skeletal muscle mass (SMM), visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT) were assessed at the first lumbar level on computed tomography images obtained before initiation of nivolumab and at week 6 of treatment. The contribution of changes in body weight (defined as >2% loss), SMM, VAT, and SAT to OS was analysed by Kaplan-Meier method and adjusted for clinical confounders in a Cox regression analysis. The results from the study cohort were validated in another Dutch cohort from Erasmus Medical Center, Rotterdam.

RESULTS

One hundred and six patients were included in the study cohort. Loss of body weight of >2% at week 6 was an independent predictor for poor OS (hazard ratio 2.39, 95% confidence interval 1.51-3.79, P < 0.001) when adjusted for gender, >1 organ with metastasis, pretreatment hypoalbumenaemia, and pretreatment elevated C-reactive protein. The result was confirmed in the validation cohort (N = 62). Loss of SMM as a feature of cancer cachexia did not significantly predict OS in both cohorts. Significant (>2%) weight loss during treatment was reflected by a significant loss of VAT and SAT, while loss of SMM was comparable between weight-stable and weight-losing patients.

CONCLUSIONS

Weight loss, characterized by loss of subcutaneous and visceral adipose tissues, at week 6 of treatment with nivolumab, is a significant poor prognostic factor for survival in patients with Stage IV NSCLC.

Both muscle quantity and quality are predictors of waiting list mortality in patients with end-stage liver disease

BACKGROUND AND AIMS

Malnutrition is highly prevalent in patients with end-stage liver disease (ESLD) and associated with impaired clinical outcome. Previous studies focused on one component of body composition and not in combination with nutritional intake, while both are components of the nutritional status. We aimed to evaluate the most important risk factors regarding body composition (muscle mass, muscle quality and fat mass) and nutritional intake (energy and protein intake) for waiting list mortality in patients with ESLD awaiting liver transplantation (LTx).

METHODS

Consecutive patients with ESLD listed for LTx between 2007 and 2014 were investigated. Muscle mass quantity (Skeletal Muscle Mass Index, SMI), and muscle quality (Muscle Attenuation, MA), and various body fat compartments were measured on computed tomography using SliceOmatic. Nutritional intake (e.g. energy and protein intake) was assessed. Multivariable stepwise forward Cox regression analysis was used for statistical analysis.

RESULTS

261 Patients (mean age 54 years, 74.7% male) were included. Low SMI and MA were found to be statistically significant predictors of an increased risk for waiting list mortality in patients with ESLD, with a HR of 2.580 (95%CI 1.055-6.308) and HR of 9.124 (95%CI 2.871-28.970), respectively. No association between percentage adipose tissue, and protein and energy intake with waiting list mortality was found in this study.

CONCLUSION

Both low muscle quantity and quality, and not nutritional intake, were independent risk factors for mortality in patients with ESLD.

The Prognostic Impact of Body Composition for Locally Advanced Breast Cancer Patients Who Received Neoadjuvant Chemotherapy

Simple Summary

We aimed to determine the prognostic role of body composition in patients with breast cancer who received neoadjuvant chemotherapy. Previous studies suggested that body composition is a better indicator of breast cancer treatment outcome than body mass index. A comprehensive body composition analysis found that a low ratio of total visceral adipose tissue to subcutaneous adipose tissue was associated with shorter overall survival. This finding will lead to further investigation of the role of body composition in outcomes for patients with locally advanced breast cancer.

Abstract

Our previous study indicated that a high amount of visceral adipose tissue was associated with poor survival outcomes in patients with early breast cancer who received neoadjuvant chemotherapy. However, inconsistency was observed in the prognostic role of body composition in breast cancer treatment outcomes. In the present study, we aimed to validate our previous research by performing a comprehensive body composition analysis in patients with a standardized clinical background. We included 198 patients with stage III breast cancer who underwent neoadjuvant chemotherapy between January 2007 and June 2015. The impact of body composition on pathologic complete response and survival outcomes was determined. Body composition measurements had no significant effect on pathologic complete response. Survival analysis showed a low ratio of total visceral adipose tissue to subcutaneous adipose tissue (V/S ratio ≤ 34) was associated with shorter overall survival. A changepoint method determined that a V/S ratio cutoff of 34 maximized the difference in overall survival. Our study indicated the prognostic effect of body composition measurements in patients with locally advanced breast cancer compared to those with early breast cancer. Further investigation will be needed to clarify the biological mechanism underlying the association of V/S ratio with prognosis in locally advanced breast cancer.

Visceral adipose tissue area predicts intensive care unit admission in COVID-19 patients

We retrospectively investigated, in 62 consecutive hospitalised COVID-19 patients (aged 70 ± 14 years, 40 males), the prognostic value of CT-derived subcutaneous adipose tissue and visceral adipose tissue (VAT) metrics, testing them in four predictive models for admission to intensive care unit (ICU), with and without pre-existing comorbidities. Multivariate logistic regression identified VAT score as the best ICU admission predictor (odds ratios 4.307–12.842). A non-relevant contribution of comorbidities at receiver operating characteristic analysis (area under the curve 0.821 for the CT-based model, 0.834 for the one including comorbidities) highlights the potential one-stop-shop prognostic role of CT-derived lung and adipose tissue metrics.

Changes in spinal bone density, back muscle size, and visceral adipose tissue and their interaction following a multi-component exercise program in older men: secondary analysis of an 18-month randomized controlled trial

In middle-aged and older men, an 18-month multi-component exercise program improved spinal trabecular BMD, paraspinal, and psoas muscle cross-sectional area (CSA) but not visceral adipose tissue (VAT). However, changes in both muscle and VAT CSA were associated with changes in spinal BMD, independent of the exercise intervention.

INTRODUCTION

In older men, we previously reported that a multi-component exercise program improved lumbar spine (LS) trabecular volumetric BMD (Tb.vBMD) compared with no exercise. This study aimed to investigate the following: (1) the effect of the exercise program on paraspinal and psoas (back) muscle CSA and VAT, and 2) if any exercise-related changes in muscle CSA and/or VAT were associated with changes in spinal BMD.

METHODS

Men (n = 180) aged 50-79 years were randomized to an exercise or no-exercise group. Exercise involved high-intensity progressive resistance training (60-85% max) with weight-bearing impact exercise (3 days/week) for 18 months. Quantitative computed tomography was used to assess L1-L3 Tb.vBMD, paraspinal, and psoas muscle CSA and VAT.

RESULTS

Exercise resulted in a 2.6% ((95% CI, 1.1, 4.1), P < 0.01) net gain in back muscle CSA, but no effect on VAT (-1.6% (95% CI, -7.3, 4.2)) relative to no exercise. Robust regression indicated that percentage changes in Tb.vBMD were positively associated with changes (expressed as z-scores) in back muscle CSA in both the exercise (beta (β)-coefficient = 1.9, 95% CI 0.5, 3.2, P = 0.007) and no-exercise (β = 2.6, 95% CI, 1.1, 4.1, P = 0.001) group, and negatively with the changes in VAT (β = -2.0, 95% CI -3.3, -0.7, P = 0.003) in the exercise only group. There were no group differences in the slopes for the muscle-bone or VAT-bone relationships. Regression analysis (pooled data) revealed that back muscle CSA and VAT were independent predictors of the change in Tb.vBMD, explaining 14% of the variance.

CONCLUSION

A multi-component exercise program in middle-aged and older men improved spinal BMD and back muscle size but not visceral fat. However, changes in back muscle size and VAT were associated with the changes in spinal BMD, independent of exercise.

TRIAL REGISTRATION

ACTRN 12617001224314, 22/08/2017 retrospectively registered.

A Bioactive compound Shatavarin IV-mediated longevity as revealed by dietary restriction-induced autophagy in Caenorhabditis elegans

Plant-based dietary supplements that delay aging are of significant interest now a days because these naturally occurring bioactive molecules effectively provide pharmaceuticals/neutraceuticals to deal with diseases related to the advanced life expectancy. In this paper, we aimed to investigate the effect of Shatavarin IV (SIV), a steroidal saponin isolated from Asparagus racemosus Willd. on dietary restriction (DR) induced longevity in Caenorhabditis elegans. SIV significantly increased the lifespan to 18% which is independent of antimicrobial activity and reduced the aging by-product, lipofuscin along with increased locomotion, and chemotaxis behavior in wild type worms. The longevity effect has been dependent on eat-2, which was further validated via reduced pharyngeal pumping rate that established the effect similar to DR induced longevity. Moreover, like eat-2 mutant worms, SIV reduces the total progeny number of wild type worm along with a significant alleviation of stored fat, which reconfirms the involvement of eat-2 mediated longevity. Further, it was also observed that DR induced longevity mechanism by SIV requires mTOR which works in PHA-4/FOXA dependent manner. In addition to this, the role of autophagy mechanism concerning SIV mediated DR was confirmed via bec-1, unc-51, and lgg-1. The longevity effect achieved by SIV was also dependent on SKN-1/NRF-2 and partially dependent on DAF-16/FOXO. Furthermore, the DR-induced longevity by SIV was found to be independent of hsf-1 exhibiting non-significant alteration in the mRNA expression of downstream target genes hsp-16.2 and hsp-70. Altogether, this study provides first-hand information on the pro-longevity effect of SIV in worms that have been mediated by the DR-regulating gene induced autophagy.

Use of Skeletal Muscle Index as a Predictor of Wait-List Mortality in Patients With End-Stage Liver Disease

The aim of this study is to validate a proposed definition of sarcopenia in predicting wait-list mortality. We retrospectively evaluated 355 adults (age ≥18 years) with cirrhosis listed for first-time LT from January 1, 2010, to April 1, 2018 from our center. Demographic, laboratory, and outcome data were collected in conjunction with computed tomography scans performed within 3 months of listing. Using imaging analysis software, the skeletal muscle index (SMI), which is a marker for sarcopenia-related mortality, was calculated. A survival analysis was performed to evaluate the association of the proposed sarcopenia definition of SMI <50 cm² /m² for men or <39 cm² /m² for women with wait-list mortality or delisting. Median SMI was 54.1 cm² /m² (range, 47-60 cm² /m² ). A total of 61 (17.2%) patients exhibited sarcopenia according to the proposed threshold, and 24.6% (57/232) of men were sarcopenic compared with 3.3% (4/123) of women (P < 0.001). Mean (standard deviation [SD]) SMI was also higher for men (56.6 ± 9.6 cm² /m² ) than for women (50.7 ± 8.0 cm² /m² ; P < 0.001). Median follow-up time among patients was 2.1 months (0-12 months), and 30 events were observed (hazard ratio, 0.98; 95% confidence interval, 0.95-1.02; P = 0.41). There was no statistically significant difference in time on the waiting list between patients with and without sarcopenia (P = 0.89) as defined at the threshold. Using the prespecified definitions of sarcopenia based on SMI, there was no statistically significant difference in mortality and delisting from the transplant waiting list between patients with and without sarcopenia in this population. Practice and region-specific patterns for pretransplant selection and median Model for End-Stage Liver Disease at transplant may affect SMI as a predictor of wait-list mortality.

Identifying sarcopenia in advanced non-small cell lung cancer patients using skeletal muscle CT radiomics and machine learning

Background

Sarcopenia has been confirmed as a poor prognostic indicator of lung cancer. However, the lack of abdominal computed tomography (CT) hindered the application to assess the status of sarcopenia. The purpose of this study was to assess the ability of chest CT radiomics combined with machine learning classifiers to identify sarcopenia in advanced non‐small cell lung cancer (NSCLC) patients.

Methods

This study retrospectively analyzed CT images of 99 patients with NSCLC. Skeletal muscle radiomics were extracted from a single axial slice of the chest CT scan at the 12th thoracic vertebrae level. In total, 854 radiomic and clinical features were obtained from each patient. Feature selection was conducted with FeatureSelector module, optimal key features were fed into the lightGBM classifier for model construction, and Bayesian optimization was adopted to tune hyperparameters. The model's performance was evaluated by specificity, sensitivity, accuracy, precision, F1‐score, Matthew's correlation coefficient (MCC), Cohen's kappa coefficient (Kappa), and AUC.

Results

A total of 40 patients were found to have sarcopenia. Five optimal features were selected. In the base lightGBM model, the specificity, sensitivity, accuracy, precision, F1‐score, AUC, MCC, Kappa of validation set were 0.889, 0.750, 0.833, 0.818, 0.783, 0.819, 0.649, 0.648, respectively. After Bayesian hyperparameter tuning, the optimized lightGBM model achieved better prediction performance, and the corresponding values were 0.944, 0.833, 0.900, 0.909, 0.870, 0.889, 0.791, 0.789, respectively.

Conclusions

Chest CT‐based radiomics has the potential to identify sarcopenia in NSCLC patients with the lightGBM classifier, and the optimal lightGBM model via Bayesian hyperparameter tuning demonstrated better performance.

Key points

Significant findings of the study

Our study demonstrates that chest CT‐based radiomics combined with lightGBM classifier has the ability to identify sarcopenia in NSCLC patients.

What this study adds

Skeletal muscle radiomics would be a potential biomarker for sarcopenia identity in NSCLC patients.

Abnormal body composition is a predictor of adverse outcomes after autologous haematopoietic cell transplantation

BACKGROUND

The number of patients undergoing autologous haematopoietic cell transplant (HCT) is growing, but little is known about the factors that predict adverse outcomes. Low muscle mass and obesity are associated with disability and premature mortality in individuals with non-malignant diseases and may predict outcomes after autologous HCT.

METHODS

This was a retrospective cohort study of 320 patients who underwent autologous HCT for Hodgkin or non-Hodgkin lymphoma between 2009 and 2014. Sarcopenia {skeletal muscle index male: <43 cm/m2 [body mass index (BMI) < 25 kg/m2 ] or < 53 cm/m2 [BMI ≥ 25 kg/m2 ] and female: <41 cm/m2 [regardless of BMI]) and obesity [total abdominal adiposity ≥450.0 cm2 (male), ≥396.4 cm2 (female)] were assessed from single-slice abdominal pre-HCT computed tomography images. Length of hospital stay, first unplanned intensive care unit admission, and 30-day unplanned readmission were evaluated based on body composition using multivariable regression analysis, and mortality was evaluated with Kaplan-Meier analysis and Gray's test.

RESULTS

Median age at HCT was 53.3 years (range, 18.5 to 78.1 years); 26.3% were sarcopenic and an additional 7.8% were sarcopenic obese pre-HCT. Sarcopenic obesity was associated with increased risk of prolonged hospitalization [odds ratio (OR) = 3.6, 95% confidence interval (CI) 1.3-9.8], intensive care unit admission (OR = 4.7, 95% CI 1.5-16.1), and unplanned readmission after HCT (OR = 13.6, 95% CI 2.5-62.8). Patients who were sarcopenic obese also had the highest mortality risk at 1 year [hazard ratio (HR): 3.9, 95% CI 1.1-11.0] and 5 years (HR: 2.5, 95% CI 1.1-5.5), compared with patients with normal body composition. Sarcopenia alone, but not obesity alone, was associated with an increased risk of these outcomes, albeit with a lower magnitude of risk than in patients who were sarcopenic obese.

CONCLUSIONS

Sarcopenic obesity was an important predictor of outcomes in patients undergoing autologous HCT. These findings could inform targeted prevention strategies in patients at highest risk of complications after HCT.

Impact of Sarcopenia on Adverse Outcomes After Allogeneic Hematopoietic Cell Transplantation

BACKGROUND

High intensity treatments such as hematopoietic cell transplantation (HCT) can be curative for patients with hematologic malignancies, but this needs to be balanced by the high risk of nonrelapse mortality (NRM) during the first 2 years after HCT. Sarcopenia (low muscle mass) is associated with physical disability and premature mortality in individuals with nonmalignant diseases and may be a predictor of NRM and poor overall survival in patients undergoing HCT.

METHODS

This was a retrospective cohort study of 859 patients with acute leukemia or myelodysplastic syndrome who underwent a first HCT as adults (≥18 years) between 2007 and 2014. Sarcopenia was assessed from pre-HCT abdominal computed tomography scans. Two-year cumulative incidence of NRM was calculated, with relapse/progression considered as a competing risk event. Fine-Gray subdistribution hazard ratio estimates and 95% confidence intervals (CI) were obtained and adjusted for relevant covariates. Kaplan-Meier method was used to examine overall survival. All statistical tests were two-sided.

RESULTS

Median age at HCT was 51 years (range = 18-74 years); 52.5% had a high [≥3] HCT-comorbidity index; 33.7% had sarcopenia pre-HCT. Sarcopenia was an independent predictor of higher NRM risk (hazard ratio = 1.58, 95% CI = 1.16 to 2.16) compared with patients who were not. The 2-year incidence of NRM approached 30% in patients with sarcopenia and high (≥3) HCT-comorbidity index. Patients with sarcopenia had on average a longer hospitalization (37.2 days vs 31.5 days, P < .001) and inferior overall survival at 2 years (55.2%, 95% CI = 49.5% to 61.0% vs 66.9%, 95% CI = 63.0% to 70.8%, P < .001).

CONCLUSIONS

Sarcopenia is an important and independent predictor of survival after HCT, with potential additional downstream impacts on health-economic outcomes. This information can be used to facilitate treatment decisions prior to HCT and guide interventions to decrease the risk of treatment-related complications after HCT.

Computed tomography-defined sarcopenia: prognostic predictor of nonrelapse mortality after allogeneic hematopoietic stem cell transplantation: a multicenter retrospective study

We analyzed clinical cutoffs for defining computed tomography (CT) methods for sarcopenia and examined the prognostic value of CT for allogeneic hematopoietic stem cell transplantation (allo-HCST) outcomes of patients with myeloid malignancy. One hundred twenty-five adult patients with acute myeloid leukemia and myelodysplastic syndrome who underwent first allo-HSCT between 2000 and 2017 were included. Sarcopenia was assessed using CT-based skeletal muscle index (SMI) and mean muscle attenuation at L3. A statistical difference in SMI was confirmed between sarcopenia (n = 52) and nonsarcopenia (n = 73) patients. There were no significant correlations of muscularity with age, performance status, or other characteristics of HSCT. After 2 years, overall survival (OS) was 43.5% and 70.1%, disease-free survival was 52.9% and 68.6%, nonrelapse mortality (NRM) was 20.8% and 8.4%, incidence of acute GVHD (≥ grade 2) was 38.8% and 39.1%, that of chronic GVHD was 53.2% and 37.3%, and median duration of hospitalization was 88 days and 74 days (P = 0.026), respectively, in the sarcopenia and nonsarcopenia groups. Multivariate analysis showed that presence of sarcopenia is a novel adverse factor for high NRM and poor OS. Pretransplant CT-defined sarcopenia is correlated with decreased OS, increased NRM, and prolonged hospitalization.