Update on body composition tools in clinical settings: computed tomography, ultrasound, and bioimpedance applications for assessment and monitoring

Advancing body composition assessment in patients with cancer: First comparisons of traditional versus multicompartment models

BACKGROUND AND AIMS

Measurement of body composition using computed tomography (CT) scans may be a viable clinical tool for low muscle mass assessment in oncology. However, longitudinal assessments are often infeasible with CT. Clinically accessible body composition technologies can be used to track changes in fat-free mass (FFM) or muscle, though their accuracy may be impacted by cancer-related physiological changes. The purpose of this study was to examine the agreement among accessible body composition method with criterion methods for measures of whole-body FFM measurements and, when possible, muscle mass for the classification of low muscle in patients with cancer.

METHODS

Patients with colorectal cancer were recruited to complete measures of whole-body DXA, air displacement plethysmography (ADP), and bioelectrical impedance analysis (BIA). These measures were used alone, or in combination to construct the criterion multicompartment (4C) mode for estimating FFM. Patients also underwent abdominal CT scans as part of routine clinical assessment. Agreement of each method with 4C model was analyzed using mean constant error (CE = criterion - alternative), linear regression including root mean square error (RMSE), Bland-Altman limits of agreement (LoA) and mean percentage difference (MPD). Additionally, appendicular lean soft tissue index (ALSTI) measured by DXA and predicted by CT were compared for the absolute agreement, while the ALSTI values and skeletal muscle index by CT were assessed for agreement on the classification of low muscle mass.

RESULTS

Forty-five patients received all measures for the 4C model and 25 had measures within proximity of clinical CT measures. Compared to 4C, DXA outperformed ADP and BIA by showing the strongest overall agreement (CE = 1.96 kg, RMSE = 2.45 kg, MPD = 98.15 ± 2.38%), supporting its use for body composition assessment in patients with cancer. However, CT cutoffs for skeletal muscle index or CT-estimated ALSTI were lower than DXA ALSTI (average 1.0 ± 1.2 kg/m2) with 24.0% to 32.0% of patients having a different low muscle classification by CT when compared to DXA.

CONCLUSIONS

Despite discrepancies between clinical body composition assessment and the criterion multicompartment model, DXA demonstrates the strongest agreement with 4C. Disagreement between DXA and CT for low muscle mass classification prompts further evaluation of the measures and cutoffs used with each technique. Multicompartment models may enhance our understanding of body composition variations at the individual patient level and improve the applicability of clinically accessible technologies for classification and monitoring change over time.

Non invasive techniques for direct muscle quality assessment after exercise intervention in older adults: a systematic review

BACKGROUND

The aging process induces neural and morphological changes in the human musculoskeletal system, leading to a decline in muscle mass, strength and quality. These alterations, coupled with shifts in muscle metabolism, underscore the essential role of physical exercise in maintaining and improving muscle quality in older adults. Muscle quality's morphological domain encompasses direct assessments of muscle microscopic and macroscopic aspects of muscle architecture and composition. Various tools exist to estimate muscle quality, each with specific technical requirements. However, due to the heterogeneity in both the studied population and study methodologies, there is a gap in the establishment of reference standards to determine which are the non-invasive and direct tools to assess muscle quality after exercise interventions. Therefore, the purpose of this review is to obtain an overview of the non-invasive tools used to measure muscle quality directly after exercise interventions in healthy older adults, as well as to assess the effects of exercise on muscle quality.

MAIN TEXT

To address the imperative of understanding and optimizing muscle quality in aging individuals, this review provides an overview of non-invasive tools employed to measure muscle quality directly after exercise interventions in healthy older adults, along with an assessment of the effects of exercise on muscle quality.

RESULTS

Thirty four studies were included. Several methods of direct muscle quality assessment were identified. Notably, 2 studies harnessed CT, 20 utilized US, 9 employed MRI, 2 opted for TMG, 2 adopted myotonometry, and 1 incorporated BIA, with several studies employing multiple tests. Exploring interventions, 26 studies focus on resistance exercise, 4 on aerobic training, and 5 on concurrent training.

CONCLUSIONS

There is significant diversity in the methods of direct assessment of muscle quality, mainly using ultrasound and magnetic resonance imaging; and a consistent positive trend in exercise interventions, indicating their efficacy in improving or preserving muscle quality. However, the lack of standardized assessment criteria poses a challenge given the diversity within the studied population and variations in methodologies.. These data emphasize the need to standardize assessment criteria and underscore the potential benefits of exercise interventions aimed at optimizing muscle quality.

Revisiting the beyond BMI paradigm in excess weight diagnosis and management: A call to action

Adolphe Quételet, a 19th-century Belgian sociologist and statistician, pioneered the incorporation of statistics into social sciences. He initiated the development of anthropometry since he was interested in identifying the proportions of the 'ideal man'. He devised a ratio between weight and height, originally termed the Quételet Index, and today widely known and used as the body mass index or BMI. In 1835, he demonstrated that a normal curve accommodates the distribution of human traits articulating his reasoning on human variance around the average. Quételet's long-lasting legacy of the establishment of a simple measure to classify people's weight relative to an ideal for their height endures today with minor variations having dramatically influenced public health agendas. While being very useful, the limitations of the BMI are well known. Thus, revisiting the beyond BMI paradigm is a necessity in the era of precision medicine with morphofunctional assessment representing the way forward via incorporation of body composition and functionality appraisal. While healthcare systems were originally designed to address acute illnesses, today's demands require a radical rethinking together with an original reappraisal of our diagnosis and treatment approaches from a multidimensional perspective. Embracing new methodologies is the way forward to advance the field, gain a closer look at the underlying pathophysiology of excess weight, keep the spotlight on improving diagnostic performance and demonstrate its clinical validity. In order to provide every patient with the most accurate diagnosis together with the most appropriate management, a high degree of standardization and personalization is needed.

Morphofunctional Assessment beyond Malnutrition: Fat Mass Assessment in Adult Patients with Phenylketonuria-Systematic Review

Morphofunctional assessment was developed to evaluate disease-related malnutrition. However, it can also be used to assess cardiometabolic risk, as excess adiposity increases this risk. Phenylketonuria (PKU) is the most prevalent inherited metabolic disease among adults, and obesity in PKU has recently gained interest, although fat mass correlates better with cardiometabolic risk than body mass index. In this systematic review, the objective was to assess whether adult patients with PKU have higher fat mass than healthy controls. Studies of adult PKU patients undergoing dietary treatment in a metabolic clinic reporting fat mass were included. The PubMed and EMBASE databases were searched. Relevance of articles, data collection, and risk of bias were evaluated by two independent reviewers. Ten articles were evaluated, six with a control group, including 310 subjects with PKU, 62 with mild hyperphenylalaninemia, and 157 controls. One study reported a significant and four a tendency towards an increased fat mass in all patients or only females with PKU. Limitations included not having a healthy control group, not reporting sex-specific results and using different techniques to assess fat mass. Evaluation of fat mass should be included in the morphofunctional assessment of cardiometabolic risk in adult patients with PKU.

Emergence of imaging technology beyond the clinical setting: Utilization of mobile health tools for at-home testing

Body composition assessment plays a pivotal role in understanding health, disease risk, and treatment efficacy. This narrative review explores two primary aspects: imaging techniques, namely ultrasound (US) and dual-energy x-ray absorptiometry (DXA), and the emergence of artificial intelligence (AI) and mobile health apps in telehealth for body composition. Although US is valuable for assessing subcutaneous fat and muscle thickness, DXA accurately quantifies bone mineral content, fat mass, and lean mass. Despite their effectiveness, accessibility and cost remain barriers to widespread adoption. The integration of AI-powered image analysis may help explain tissue differentiation, whereas mobile health apps offer real-time metabolic monitoring and personalized feedback. New apps such as MeThreeSixty and Made Health and Fitness offer the advantages of clinic-based imaging techniques from the comfort of home. These innovations hold the potential for individualizing strategies and interventions, optimizing clinical outcomes, and empowering informed decision-making for both healthcare professionals and patients/clients. Navigating the intricacies of these emerging tools, critically assessing their validity and reliability, and ensuring inclusivity across diverse populations and conditions will be crucial in harnessing their full potential. By integrating advancements in body composition assessment, healthcare can move beyond the limitations of traditional methods and deliver truly personalized, data-driven care to optimize well-being.

Agreement between bioimpedance analysis and ultrasound scanning in body composition assessment

OBJECTIVES

This study aimed at evaluating the agreement between bioelectrical impedance analysis (BIA) using ABC-02 Medas and A-mode ultrasound (AUS) using BodyMetrix™ BX2000 for fat mass (FM), fat free mass (FFM), and body fat percentage (%BF) in females.

METHODS

The cross-sectional, single-center, observational study was performed in 206 female subjects aged 18-67 years. The examination program included measurements of body height and weight along with waist, hip circumferences, and body composition analysis. The measurements were performed by ultrasound scanner and bioimpedance analyzer.

RESULTS

We found that 20.9% of women were obese based on BMI (≥30 kg/m2), which was significantly lower when using a criterion based on body fat percentage (%BF ≥ 30%) measured with US (53.4%, p = .0056) or BIA (54.8%, p = .0051). At the group level, both methods were found interchangeable and showed practically negligible differences (0.1% for %BF, 0.5 kg for FM, and 0.4 kg for FFM). Agreement analysis conducted in the whole sample revealed a low level of agreement in estimating %BF (CCC = 0.72 0.77 0.82) and FFM (CCC = 0.81 0.84 0.86), and medium level of agreement in estimating FM (CCC = 0.91 0.93 0.94). The level of agreement in estimating %BF and FFM was improved to the medium level with the use of newly generated prediction equations.

CONCLUSION

Thus, the proposed equations can be used for conversion of body composition results obtained by AUS into the BIA data.

Validity of bioelectric impedance analysis for body composition assessment in interstitial lung disease patients

BACKGROUND

changes in body composition (BC) are common in interstitial lung disease, which leads to an increased risk of complications and infections, and are associated with poor quality of life and worse outcomes. BC assessment is important to identify malnutrition and sarcopenia. However, gold-standard techniques are not available in all clinical settings.

AIMS

this study aimed to evaluate the agreement and reliability of body composition estimated by bioelectric impedance analysis (BIA) and measured using dual-energy x-ray absorptiometry (DEXA) in women with interstitial lung disease.

METHODS

this is a cross-sectional study. BC (fat mass and appendicular skeletal muscle mass) were assessed using BIA multifrequency and DEXA in standardized conditions. Agreement and reliability between techniques were evaluated using Bland-Altman plots and the intraclass correlation coefficient (ICC).

RESULTS

a total of 50 women were evaluated. No differences were observed for FM (BIA, 25.8 ± 10.2 kg and DEXA, 26.3 ± 10.0 kg, p = 0.77) and ASMM (BIA, 14.1 ± 2.7 kg and DEXA, 13.9 ± 2.3 kg, p = 0.83). Based on ICC, good reliability was observed for FM (ICC, 0.98) and ASMM (ICC, 0.93).

CONCLUSION

BC estimated by BIA showed good agreement and reliability with DEXA measurements. In the absence of this method, BIA can replace the DEXA technique for body composition assessment.

Muscularity of older trauma patients at intensive care unit admission, association with functional outcomes, and relationship with frailty: A retrospective observational study

BACKGROUND

Older individuals are at an increased risk of delayed recovery following a traumatic injury. Measurement of muscularity and frailty at hospital admission may aid with prognostication and risk stratification.

OBJECTIVE

This study aimed to describe muscularity at intensive care unit (ICU) admission in patients admitted following trauma and assess the relationship between muscularity and clinical, long-term functional outcomes and frailty at ICU admission.

METHODS

This retrospective study utilised data from a prospective observational study investigating frailty in patients aged ≥50 years, admitted to the ICU following trauma. Patients were eligible if they had a Computed Tomography (CT) scan including the third lumbar vertebra at ICU admission. Specialist software was used to quantify CT-derived skeletal muscle cross-sectional area. Muscularity status was classified as normal or low using published sex-specific cut-points. Demographic data, frailty, clinical, and long-term functional outcomes (Glasgow Outcome Scale-Extended and EQ-5DL-5L Visual analogue scale and utility score) were extracted from the original study.

RESULTS

One hundred patients were screened; 71 patients had a CT scan on admission with 66 scans suitable for muscle assessment. Patients with low muscularity (n = 25, 38%) were older and had a higher Acute Physiology and Chronic Health Evaluation II score and lower body mass index than patients with normal muscularity. Low muscularity was associated with frailty at admission (32% vs 5%, p = 0.005) but not with long term outcomes at 6 or 12 months. As a continuous variable, lower muscle cross-sectional area was associated with a poorer outcome on the Glasgow Outcome Scale-Extended at 6 months (mean [standard deviation]: 150 [43] and 180 [44], respectively; p = 0.014), no association was observed after adjustment for age p = 0.43).

CONCLUSION

In a population of older adults hospitalised following trauma, low muscularity at ICU admission was prevalent. Low muscularity was associated with frailty but not long-term functional outcomes. Larger studies are warranted to better understand the relationship between muscularity and long-term functional outcomes.

Evolution of the diagnosis of malnutrition in adults: a primer for clinicians

During the last two decades, the definition, diagnosis, and management of malnutrition have significantly evolved. Malnutrition is generally defined as deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients. While malnutrition is associated with a significantly increased risk of morbidity, mortality, and healthcare cost, it is often underdiagnosed both in healthcare and community settings. One contributing factor is the lack of a consensus on its definition and appropriate diagnostic indicators. In the current article, we review the evolution of frameworks for the diagnosis of malnutrition. Recently published consensuses by prominent clinical nutrition societies have established a trajectory for the uniform global diagnosis of malnutrition. Limiting the use of body mass index (BMI) as a diagnostic criterion while emphasizing the use of muscle mass enables a more consistent and accurate diagnosis of malnutrition in the clinical setting. Guidance for the unified methodology and terminology for diagnosing malnutrition, such as the one proposed in the current article will enable policy makers to systematically address the two faces of malnutrition, starvation- and disease-related malnutrition applicable to both pediatric and adult populations. Policies and programs that could address issues of food insecurity and scarcity as well as early diagnosis and management of disease-related malnutrition will empower better care of community nutrition.

Ultrasound for measurement of skeletal muscle mass quantity and muscle composition/architecture in critically ill patients: A scoping review on studies' aims, methods, and findings

AIMS

This scoping review aimed to identify, explore, and map the objectives, methodological aspects, and results of studies that used ultrasound (US) to assess skeletal muscle (SM) in critically ill patients.

METHODS

A scoping review was conducted according to the Joanna Briggs Institute's methodology. All studies that evaluated SM parameters from the US in patients admitted to the intensive care unit (ICU) were considered eligible. We categorized muscle thickness and cross-sectional area as parameters for assessing SM quantity, while echogenicity, fascicle length, and pennation angle analysis were used to evaluate muscle "quality" (composition/architecture). A literature search was conducted using four databases for articles published until December 2022. Independent reviewers selected the studies and extracted data. Descriptive statistics were calculated to present the results.

RESULTS

A total of 107 studies were included, the majority of which were prospective cohort studies (59.8 %) conducted in general ICUs (49.5 %). The most frequent objective of the studies was to evaluate SM quantity depletion during the ICU stay (25.2 %), followed by determining whether a specific intervention would modify SM (21.5 %). Most studies performed serial SM evaluations (76.1 %). The rectus femoris muscle thickness was evaluated in most studies (67.9 %), followed by the rectus femoris cross-sectional area (54.3 %) and the vastus intermedius muscle thickness (40.2 %). The studies demonstrated the feasibility and reproducibility of US for SM evaluation, especially related to quantitative parameters. Most studies (70.3 %) reported significant SM quantity depletion during hospitalization. However, the accuracy of the US in measuring SM varied across the studies.

CONCLUSIONS

The lack of detailed description and standardization in the protocols adopted by the studies included in this scoping review precludes the translation of the evidence related to US for SM assessment into clinical practice.

Body Composition Evaluation and Clinical Markers of Cardiometabolic Risk in Patients with Phenylketonuria

Cardiovascular diseases are the main cause of mortality worldwide. Patients with phenylketonuria (PKU) may be at increased cardiovascular risk. This review provides an overview of clinical and metabolic cardiovascular risk factors, explores the connections between body composition (including fat mass and ectopic fat) and cardiovascular risk, and examines various methods for evaluating body composition. It particularly focuses on nutritional ultrasound, given its emerging availability and practical utility in clinical settings. Possible causes of increased cardiometabolic risk in PKU are also explored, including an increased intake of carbohydrates, chronic exposure to amino acids, and characteristics of microbiota. It is important to evaluate cardiovascular risk factors and body composition in patients with PKU. We suggest systematic monitoring of body composition to develop nutritional management and hydration strategies to optimize performance within the limits of nutritional therapy.

Ultrasound utilized by registered dietitians for body composition measurement, nutritional assessment, and nutritional management

BACKGROUND AND AIMS

Ultrasound has been used primarily as a tool for body composition measurement in the field of clinical nutrition. Although many recent reports have demonstrated that ultrasound could be a useful tool for nutritional assessment, it is not well incorporated into registered dietitians' (RDs) practice. The aim of this review was to summarize the usefulness of ultrasound in assessing body composition and nutritional status and in nutritional management by RDs.

METHODS

Studies on ultrasonography, nutritionists, body composition, nutritional assessment, and diet therapy was searched using the MEDLINE databases.

RESULTS

After reviewing the articles, we categorized them into the following topics; 1) principles of muscle measurement using the ultrasound, types of muscle that can be measured, 2) indices of muscle and muscle mass and quality as assessed using ultrasound and its relationship to nutritional indicator, 3) diagnosis of the Global Leadership Initiative on Malnutrition (GLIM) criteria malnutrition using ultrasound, 4) practical nutritional management using ultrasound and 5) education and issues for ultrasound implementation. Ultrasound can evaluate low body mass index, unintentional loss of body weight, low skeletal muscle mass index, decreased food intake/assimilation, and disease burden/inflammation, all which are essential items of the phenotypic and etiologic criteria of the GLIM.

CONCLUSION

Ultrasound may be useful for RDs to perform body composition measurement, nutritional assessment, and nutritional management. It will be important to identify the cutoff values for ultrasound-based measurements of muscle mass. In order for RDs to perform a body composition measurement, nutritional assessment, and nutritional management using ultrasound, educational issues need to be addressed.

Survey on Endocrinology and Nutrition undergraduate teaching in Spain-2021

OBJECTIVES

Advances in endocrinology and nutrition (E&N) and the importance of its associated disorders require that its teaching within the medical degree meets adequate standards of quality and homogeneity Our objective was to expand the data on E&N undergraduate teaching in Spain.

METHODS

We designed an observational, cross-sectional web-based study addressed to the coordinators of E&N teaching at the 42 faculties of medicine that had taught the subject during the 2020-2021 academic year.

RESULTS

One in three faculties had a professor who was an E&N specialist, but less than half had a full professor of E&N. There is great variability in teaching programmes, although most of them dedicate 6 ECTS credits to the subject. Over two-thirds of the faculties maintain theoretical lessons with over 50 students per class. Most programmes dedicate between four and six hours to hypothalamic pituitary disorders, thyroid diseases and adrenal gland disorders. However, there is great variability in the time dedicated to diabetes and nutrition. In one-third of the faculties, students are not required to do a rotation in the E&N department. Teachers at the universities widely participate in undergraduate/master's students' final projects and master's degree studies.

CONCLUSIONS

The E&N specialty maintains a good position within universities, but there is still great heterogeneity in the teaching structure of the subject.

High physical activity in persons with psoriatic arthritis is associated with reduced visceral fat mass and percentage body fat: the Trøndelag Health study

The associations of physical activity (PA) with body composition among persons with psoriatic arthritis (PsA) are not well described. The objective was to investigate associations of PA with visceral fat mass and percentage body fat in persons with PsA of different age groups. Persons with PsA (CASPAR criteria, n = 356), and controls (n = 47,470) from the Trøndelag Health Study (HUNT4, 2017-2019) were included. Visceral fat mass and percentage body fat measured using bioelectrical impedance were primary outcomes in multivariable linear regression analysis. PsA, PA (questionnaire data), and age were explanatory variables, with adjustment for sex, smoking, heart disease, lung disease, and height. An interaction term between PsA and age was included in both models. Persons with PsA had altered body composition, including higher visceral fat mass and percentage body fat, especially those < 40 years of age (p ≤ 0.01). Moderate or high PA was associated with significantly lower values of the primary outcomes. Differences were Moderate compared to low PA: 1.4 kg (95% CI 1.3, 1.5 kg) lower visceral fat mass, and 2.0% (95% CI 1.8, 2.1) lower percentage body fat. Differences were High compared to low PA: 3.2 kg (95% CI 3.1, 3.3) lower visceral fat mass and 5.0% (95% CI 4.8, 5.1%) lower percentage body fat. Persons with PsA had higher visceral fat mass and percentage body fat, especially if < 40 years, and PA was associated with lower values of both endpoints. Changes of body composition in persons with PsA may influence important health outcomes and should be addressed in clinical practice.

A survey on the perception of the specialty of Endocrinology and Nutrition among students preparing for the entrance exam for medical specialty training in Spain

INTRODUCTION AND AIMS

Previous studies have shown that there is decreasing interest in E&N among medical students. The aim of our study was to evaluate the perception of E&N among a sample of medical students.

MATERIAL AND METHODS

We surveyed 2252 students prior to taking the exam that allows access to specialised training in Spain.

RESULTS

Overall, 9.9% (222 participants) would probably choose E&N. The most positive aspects in includes of the specialty are its logical pathophysiological basis (54%) and that the work is dynamic and varied (27%), while the least attractive aspects are the few interventional techniques. The parts of the specialty that most attract students are hypothalamic-pituitary disease and diabetes mellitus.

CONCLUSIONS

The proportion of candidates who want to study E&N as their first choice is adequate in relation to the number of places available.

Clinical applications of body composition and functional status tools for nutrition assessment of hospitalized adults: A systematic review

BACKGROUND

No global consensus exists on diagnostic criteria for malnutrition. Muscular deficits and functional impairments are major components of available malnutrition diagnostic frameworks because these facets of nutrition status significantly impact outcomes. The purpose of this review is to explore which body composition assessment (BCA) and functional status assessment (FSA) tools are being used for nutrition assessment (NA) and monitoring the response to nutrition interventions (RNIs) in adult inpatients.

METHODS

A literature search of Embase, Medline (Ovid), Web of Science, and Cochrane Central was performed to identify studies that used BCA and/or FSA tools for NA (along with an accepted NA diagnostic framework) and/or for monitoring RNI in adult inpatients.

RESULTS

The search yielded 3667 articles; 94 were included in the review. The number of studies using BCA and/or FSA tools for NA was 47 and also 47 for monitoring RNI. Seventy-nine percent of studies used bioimpedance for BCA, and 97% that included FSA utilized handgrip strength. When compared against sets of diagnostic criteria, many of the BCA and FSA tools showed promising associations with nutrition status.

CONCLUSION

Bioimpedance methods are the most widely used bedside BCA tools, and handgrip strength is the most widely used FSA tool; however, these methods are being used with a variety of protocols, algorithms, and interpretation practices in heterogeneous populations. To create a standardized nutrition status assessment process there is a need for validation studies on bedside methods and the development of globally standardized assessment protocols in clinical inpatient settings.

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

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

Low muscle mass in COVID-19 critically-ill patients: Prognostic significance and surrogate markers for assessment

INTRODUCTION

Low muscle mass is a common condition in the critically ill population and is associated with adverse clinical outcomes. The primary aim of this study was to analyze the prognostic significance of low muscle mass using computed tomography (CT) scans in COVID-19 critically ill patients. A second objective was to determine the accuracy and agreement in low muscle mass identification using diverse markers compared to CT as the gold standard.

METHODS

This was a prospective cohort study of COVID-19 critically ill patients. Skeletal muscle area at the third lumbar vertebra was measured. Clinical outcomes (intensive care unit [ICU] and hospital length of stay [LOS], tracheostomy, days on mechanical ventilation [MV], and in-hospital mortality) were assessed. Phase angle, estimated fat-free mass index, calf circumference, and mid-upper arm circumference were measured as surrogate markers of muscle mass.

RESULTS

Eighty-six patients were included (mean age ± SD: 48.6 ± 12.9; 74% males). Patients with low muscle mass (48%) had a higher rate of tracheostomy (50 vs 20%, p = 0.01), prolonged ICU (adjusted HR 0.53, 95%CI 0.30-0.92, p = 0.024) and hospital LOS (adjusted HR 0.50, 95% CI 0.29-0.86, p = 0.014). Bedside markers of muscle mass showed poor to fair agreement and accuracy compared to CT-assessed low muscle mass.

CONCLUSION

Low muscle mass at admission was associated with prolonged length of ICU and hospital stays. Further studies are needed to establish targeted nutritional interventions to halt and correct the catabolic impact of COVID-19 in critically ill patients, based on standardized and reliable measurements of body composition.

Clinical evaluation of automated segmentation for body composition analysis on abdominal L3 CT slices in polytrauma patients

INTRODUCTION

Sarcopenia is a muscle disease that involves loss of muscle strength and physical function and is associated with adverse health effects. Even though sarcopenia has attracted increasing attention in the literature, many research findings have not yet been translated into clinical practice. In this article, we aim to validate a deep learning neural network for automated segmentation of L3 CT slices and aim to explore the potential for clinical utilization of such a tool for clinical practice.

MATERIALS AND METHODS

A deep learning neural network was trained on a multi-centre collection of 3413 abdominal cancer surgery subjects to automatically segment muscle, subcutaneous and visceral adipose tissue at the L3 lumbar vertebral level. 536 Polytrauma subjects were used as an independent test set to show generalizability. The Dice Similarity Coefficient was calculated to validate the geometric similarity. Quantitative agreement was quantified using Bland-Altman's Limits of Agreement interval and Lin's Concordance Correlation Coefficient. To determine the potential clinical usability, randomly selected segmentation images were presented to a panel of experienced clinicians to rate on a Likert scale.

RESULTS

Deep learning results gave excellent agreement versus a human expert operator for all of the body composition indices, with Concordance Correlation Coefficient for skeletal muscle index of 0.92, Skeletal muscle radiation attenuation 0.94, Visceral Adipose Tissue index 0.99 and Subcutaneous Adipose Tissue Index 0.99. Triple-blinded visual assessment of segmentation by clinicians correlated only to the Dice coefficient, but had no association to quantitative body composition metrics which were accurate irrespective of clinicians' visual rating.

CONCLUSION

A deep learning method for automatic segmentation of truncal muscle, visceral and subcutaneous adipose tissue on individual L3 CT slices has been independently validated against expert human-generated results for an enlarged polytrauma registry dataset. Time efficiency, consistency and high accuracy relative to human experts suggest that quantitative body composition analysis with deep learning should is a promising tool for clinical application in a hospital setting.

The current use of ultrasound to measure skeletal muscle and its ability to predict clinical outcomes: a systematic review

Quantification and monitoring of lean body mass is an important component of nutrition assessment to determine nutrition status and muscle loss. The negative impact of reduced muscle mass and muscle function is increasingly evident across acute and chronic disease states but is particularly pronounced in patients with cancer. Ultrasound is emerging as a promising tool to directly measure skeletal muscle mass and quality. Unlike other ionizing imaging techniques, ultrasound can be used repeatedly at the bedside and may compliment nutritional risk assessment. This review aims to describe the current use of skeletal muscle ultrasound (SMUS) to measure muscle mass and quality in patients with acute and chronic clinical conditions and its ability to predict functional capacity, severity of malnutrition, hospital admission, and survival. Databases were searched from their inception to August 2021 for full-text articles in English. Relevant articles were included if SMUS was investigated in acute or chronic clinical contexts and correlated with a defined clinical outcome measure. Data were synthesized for narrative review due to heterogeneity between studies. This review analysed 37 studies (3100 patients), which met the inclusion criteria. Most studies (n = 22) were conducted in critical care. The clinical outcomes investigated included functional status at discharge (intensive care unit-acquired weakness), nutritional status, and length of stay. SMUS was also utilized in chronic conditions such as chronic obstructive pulmonary disease, chronic heart failure, and chronic renal failure to predict hospital readmission and disease severity. Only two studies investigated the use of SMUS in patients with cancer. Of the 37 studies, 28 (76%) found that SMUS (cross-sectional area, muscle thickness, and echointensity) showed significant associations with functional capacity, length of stay, readmission, and survival. There was significant heterogeneity in terms of ultrasound technique and outcome measurement across the included studies. This review highlights that SMUS continues to gain momentum as a potential tool for skeletal muscle assessment and predicting clinically important outcomes. Further work is required to standardize the technique in nutritionally vulnerable patients, such as those with cancer, before SMUS can be widely adopted as a bedside prognostic tool.

Dietary management of adults with IBD - the emerging role of dietary therapy

Historically, dietitians played a minor part in the management of inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis. Patients were commonly referred for consequences of uncontrolled disease, such as malnutrition and bowel obstruction risk. Today, dietitians are fundamental members of the multidisciplinary IBD team, from educating on the role of diet at diagnosis and throughout the lifespan of a patient with IBD to guiding primary induction therapy. This aspect is reflected in published guidelines for IBD management, which previously placed diet as only a minor factor, but now have diet-specific publications. This Review describes a four-step approach in a dietitian's assessment and management of diet in patients with IBD: (1) identifying and correcting nutritional gaps and dietary imbalances; (2) considering diet to treat active disease with the use of exclusive enteral nutrition (EEN) or emerging diets that could replace EEN; (3) using therapeutic diets to control existing complications of IBD, such as reduced fibre to prevent bowel obstruction in stricturing disease or a fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet to manage co-existing functional gut symptoms; and (4) considering the role of diet in preventing IBD development in high-risk populations.

Guidance for assessment of the muscle mass phenotypic criterion for the Global Leadership Initiative on Malnutrition diagnosis of malnutrition

The Global Leadership Initiative on Malnutrition (GLIM) provides consensus criteria for the diagnosis of malnutrition that can be widely applied. The GLIM approach is based on the assessment of three phenotypic (weight loss, low body mass index, and low skeletal muscle mass) and two etiologic (low food intake and presence of disease with systemic inflammation) criteria, with diagnosis confirmed by any combination of one phenotypic and one etiologic criterion fulfilled. Assessment of muscle mass is less commonly performed than other phenotypic malnutrition criteria, and its interpretation may be less straightforward, particularly in settings that lack access to skilled clinical nutrition practitioners and/or to body composition methodologies. In order to promote the widespread assessment of skeletal muscle mass as an integral part of the GLIM diagnosis of malnutrition, the GLIM consortium appointed a working group to provide consensus-based guidance on assessment of skeletal muscle mass. When such methods and skills are available, quantitative assessment of muscle mass should be measured or estimated using dual-energy x-ray absorptiometry, computerized tomography, or bioelectrical impedance analysis. For settings where these resources are not available, then the use of anthropometric measures and physical examination are also endorsed. Validated ethnic- and sex-specific cutoff values for each measurement and tool are recommended when available. Measurement of skeletal muscle function is not advised as surrogate measurement of muscle mass. However, once malnutrition is diagnosed, skeletal muscle function should be investigated as a relevant component of sarcopenia and for complete nutrition assessment of persons with malnutrition.

Current Insights in Nutrition Assessment and Intervention for Malnutrition or Muscle Loss in People with Lung Cancer: A Narrative Review

Up to 70% of people with lung cancer may be affected by cancer-related malnutrition or muscle loss, depending on treatment modality and disease stage. This narrative review explores recent studies on malnutrition and muscle loss as well as nutritional and multimodal interventions to treat these conditions in the context of the changing treatment landscape in lung cancer. Various types of interventions, including individualized counseling, protein and other specific nutrient supplementation, as well as multimodal interventions to treat malnutrition and muscle loss, have been investigated. Overall, individualized dietary counseling, increasing protein intake, and supplementation with omega-3 (n-3) fatty acids appear to be beneficial for some, albeit varying, patient outcomes. Multimodal interventions, generally including a nutrition and exercise component, show promising results; however, the impact on patient outcomes is mixed. A key finding of this review is a lack of large, randomized trials to guide nutrition intervention specifically in people with lung cancer. Despite the high prevalence of malnutrition and muscle loss in people with lung cancer and the known adverse outcomes, current evidence for nutrition intervention is limited. A targeted effort is required to improve the quality of evidence for nutrition intervention in this population to provide support for clinicians to deliver effective nutrition care.

Guidance for assessment of the muscle mass phenotypic criterion for the Global Leadership Initiative on Malnutrition (GLIM) diagnosis of malnutrition

The Global Leadership Initiative on Malnutrition (GLIM) provides consensus criteria for the diagnosis of malnutrition that can be widely applied. The GLIM approach is based on the assessment of three phenotypic (weight loss, low body mass index, and low skeletal muscle mass) and two etiologic (low food intake and presence of disease with systemic inflammation) criteria, with diagnosis confirmed by any combination of one phenotypic and one etiologic criterion fulfilled. Assessment of muscle mass is less commonly performed than other phenotypic malnutrition criteria, and its interpretation may be less straightforward, particularly in settings that lack access to skilled clinical nutrition practitioners and/or to body composition methodologies. In order to promote the widespread assessment of skeletal muscle mass as an integral part of the GLIM diagnosis of malnutrition, the GLIM consortium appointed a working group to provide consensus-based guidance on assessment of skeletal muscle mass. When such methods and skills are available, quantitative assessment of muscle mass should be measured or estimated using dual-energy x-ray absorptiometry, computerized tomography, or bioelectrical impedance analysis. For settings where these resources are not available, then the use of anthropometric measures and physical examination are also endorsed. Validated ethnic- and sex-specific cutoff values for each measurement and tool are recommended when available. Measurement of skeletal muscle function is not advised as surrogate measurement of muscle mass. However, once malnutrition is diagnosed, skeletal muscle function should be investigated as a relevant component of sarcopenia and for complete nutrition assessment of persons with malnutrition.

Development and Feasibility of an Inpatient Cancer-Related Sarcopenia Pathway at a Major Cancer Centre

Cancer-related sarcopenia is a complex condition; however, no cancer-specific clinical model is available to guide clinical practice. This study aims to (1) develop an evidence-based care pathway for the management of cancer-related sarcopenia (“sarc-pathway”) and (2) pilot test the feasibility (reach, intervention fidelity, patient and clinician acceptability) of the sarc-pathway in an inpatient cancer ward. The sarc-pathway was developed using a care pathway format and informed by the current literature. Patients admitted to a 32-bed inpatient cancer ward were recruited to receive sarc-pathway care and the feasibility outcomes were assessed. Of the 317 participants admitted, 159 were recruited over 3.5-months (median age 61 years; 56.0% males). Participant consent was high (99.4% of those approached) and 30.2% were at risk of/had sarcopenia. The sarc-pathway screening, assessment and treatment components were delivered as intended; however, low completion of clinical assessment measures were observed for muscle mass (bioimpedance spectroscopy, 20.5%) and muscle function (5-times chair stand test, 50.0%). The sarc-pathway was demonstrated to be acceptable to patients and multidisciplinary clinicians. In an inpatient cancer ward, the sarc-pathway is a feasible and acceptable clinical model and method to deliver and adhere to the sarcopenia clinical parameters specified, albeit with further exploration of appropriate clinical assessment measures.

Time course of the Bioelectrical Impedance Vector Analysis and muscular ultrasound in critically ill patients

PURPOSE

Several different tools have been developed to integrate the clinical and biochemical nutritional evaluations in critical care patients. Aims of this study were to evaluate the changes in the Bioelectrical Impedance Vector Analysis (BIVA) and ultrasonographic features of the diaphragm (DTee) and rectus femoris (RFCSA) during the first week of ICU stay.

MATERIALS AND METHODS

Ninety-six adult mechanically ventilated patients enrolled within 24 h after the admission to the ICU (T1). RFCSA and diaphragm end-expiratory thickness were measured, as well as BIVA parameters. Anthropometric data and biochemical parameters were collected. The measurements were repeated on the 3rd (T3) and 7th (T7) days of ICU stay.

RESULTS

During the study period, the phase angle significantly decreased by 21%, reactance by 27%, and resistance by 11%. Both RFCSA and DTee significantly decreased, while neither were correlated to any BIVA parameter. DTee was considerably higher in survivors vs. non-survivors.

CONCLUSIONS

Body composition is significantly modified after one week of ICU stay. BIVA may be useful in the definition of hydration state, while it does not seem to track muscle mass. Different temporal trends of specific BIVA and muscle ultrasound parameters were found in patients with high or low severity of illness.

Comparison between handheld ultrasound and regional and whole-body dual energy x-ray absorptiometry (DXA) for body fat assessment

OBJECTIVES

To determine the extent of agreement between a handheld ultrasound (US) attached to an android tablet and the reference method dual energy x-ray absorptiometry (DXA) for the measurement of adiposity.

METHODS

A whole-body DXA scan and abdominal adipose tissue thickness measurements using a handheld US were obtained from 104 adults (63 females, 41 males). Body fat percent (BF%), total fat mass (kg), and trunk fat mass (kg) were obtained from DXA. Subcutaneous adipose tissue (SAT), superficial subcutaneous adipose tissue (SSAT), and deep subcutaneous adipose tissue (DSAT) thickness were obtained from US. Sex-specific total fat mass, trunk fat mass, and BF% estimates by US were compared with DXA. Spearman's correlations and Bland-Altman plots were used to assess agreement between the methods.

RESULTS

US SAT correlated strongly with total fat mass for both females (r_s = 0.74) and males (r_s = 0.87) as did trunk fat mass (females, r_s = 0.81; males, r_s = 0.83); as did SSAT and DSAT (females: r_s = 0.65 and r_s = 0.66; males: r_s = 0.63 and r_s = 0.85, respectively, all p-values < 0.0001). Bland-Altman plots demonstrated strong agreement for total and trunk fat mass for both males and females. For BF%, acceptable limits of agreement were observed for males but not for females, substantial proportional bias as indicated by a negative slope was noted for BF% using SAT (r = -0.298, p = 0.0177).

CONCLUSION

The handheld US and technique to analyze abdominal adipose tissue thickness showed strong agreement with DXA results and generated highly comparable estimates for total and trunk fat mass for both sexes.

Low phase angle is associated with 60-day mortality in critically ill patients with COVID-19

Background

Malnutrition status, body composition indicators, and bioelectrical impedance analysis (BIA) parameters have been associated with increased risk of death in several pathologies. The aim of this study was to describe the associations between phase angle (PhA) indicators obtained by BIA with length of hospital stay, days on mechanical ventilation, and 60‐day mortality in critically ill patients infected with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2).

Methods

This is a prospective cohort of mechanically ventilated patients with coronavirus disease 2019 (COVID‐19). We assessed nutrition risk and body composition with BIA within 48 h from intensive care unit admission. Logistic and linear regression models were used to analyze the association between variables and clinical outcomes. Survival analysis by PhA value was performed using Kaplan‐Meier curves.

Results

Sixty‐seven patients were included. PhA (odds ratio [OR], 0.36; P = .002), standardized PhA (SPA) (OR, 0.45; P = .001), and extracellular water/total body water ratio (OR, 3.25; P = .002) were significant predictors of 60‐day mortality. PhA <3.85° in females and <5.25° in males showed good and fair discrimination, respectively, for mortality prediction. Using cutoff values, low PhA was associated with a significantly increased risk of 60‐day mortality (hazard ratio, 3.08; 95% CI, 1.12–8.41; P = .02). No association was detected for SPA.

Conclusion

Low PhA values could be a predictor of 60‐day mortality in critically ill patients with COVID‐19. This biological marker could be incorporated as part of nutrition and mortality risk assessment in this population.

Nutrition competencies for undergraduate medical education: Results of an international interdisciplinary consensus

BACKGROUND

The gap between the nutrition education provided to medical students and the nutrition competencies and attitudes needed for physicians to provide adequate nutrition care is a global concern. There is no universally accepted benchmark on nutrition competencies for doctors. The objective of this study was to establish, by expert consensus, the objectives of undergraduate nutrition medial education, the nutrition core competencies, and strategies for curriculum development in medical nutrition education.

METHODS

We administered a Delphi survey to systematically gather the opinion of a panel of Latin American experts in nutrition. The survey questionnaire was constructed considering scientific literature by using a 5-point Likert scale. Consensus was defined as >70% agreement on the importance of an item (Likert scale 4 and 5).

RESULTS

A four-round Delphi survey was conducted for this research. In the second, third, and fourth rounds, we validated a total of 130 competencies by consensus, which were distributed into four different thematic areas: (1) basic nutrition concepts, (2) public nutrition and nutrition prevention throughout the life cycle, (3) nutrition status and disease, and (4) nutrition care process.

CONCLUSION

The curricula for general physician education in medical school must include health promotion, prevention, and treatment of diseases related to nutrition. This goal can be reached by integrating ≤130 competencies into four different fundamental areas.

The influence of coffee consumption on bioelectrical impedance parameters: a randomized, double-blind, cross-over trial

BACKGROUND

Bioelectrical impedance analysis (BIA) is a widely used method for estimating body composition. Avoiding foods/beverages containing caffeine is a frequently enforced pre-test protocol to ensure reliability of BIA measurements. However, few studies have evaluated whether this is necessary, with conflicting results. We aimed to determine whether the coffee consumption differing in caffeine content influences BIA parameters in healthy adults.

METHODS

Twenty-five healthy adults were enrolled in a randomized, double-blind cross-over trial. Three amounts of caffeine were given with 200 mL of coffee: 0 mg (11 g of decaffeinated), 200 mg (5.5 g of caffeinated plus 5.5 g of decaffeinated), and 400 mg of caffeine (11 g of caffeinated). BIA measurements were conducted at 6 different times, and coefficient variations (CV) explored.

RESULTS

No differences were observed for group × time interaction on impedance, resistance, or reactance (p > 0.05). Values of BIA parameters increased after 30-min of coffee consumption, independently of the caffeine dosage (all p < 0.001). Body fat percentage followed the same pattern and increased after 45-min (p < 0.05). Median CV for consecutive impedance, resistance, and reactance measurements were >95%CI of expected device measurement error over 70-min, without difference between groups. Urine output volume was not different between groups (decaffeinated: 440.45 ± 197.57 mL; 200 mg: 471.80 ± 171.88 mL; 400 mg: 489.30 ± 204.10 mL, p > 0.05).

CONCLUSION

Coffee consumption influenced BIA-derived results after 70-min but was not related to caffeine content, likely due to water intake.

A Deep Learning Model to Automate Skeletal Muscle Area Measurement on Computed Tomography Images

BACKGROUND

Muscle wasting (Sarcopenia) is associated with poor outcomes in cancer patients. Early identification of sarcopenia can facilitate nutritional and exercise intervention. Cross-sectional skeletal muscle (SM) area at the third lumbar vertebra (L3) slice of a computed tomography (CT) image is increasingly used to assess body composition and calculate SM index (SMI), a validated surrogate marker for sarcopenia in cancer. Manual segmentation of SM requires multiple steps, which limits use in routine clinical practice. This project aims to develop an automatic method to segment L3 muscle in CT scans.

METHODS

Attenuation correction CTs from full body PET-CT scans from patients enrolled in two prospective trials were used. The training set consisted of 66 non-small cell lung cancer (NSCLC) patients who underwent curative intent radiotherapy. An additional 42 NSCLC patients prescribed curative intent chemo-radiotherapy from a second trial were used for testing. Each patient had multiple CT scans taken at different time points prior to and post- treatment (147 CTs in the training and validation set and 116 CTs in the independent testing set). Skeletal muscle at L3 vertebra was manually segmented by two observers, according to the Alberta protocol to serve as ground truth labels. This included 40 images segmented by both observers to measure inter-observer variation. An ensemble of 2.5D fully convolutional neural networks (U-Nets) was used to perform the segmentation. The final layer of U-Net produced the binary classification of the pixels into muscle and non-muscle area. The model performance was calculated using Dice score and absolute percentage error (APE) in skeletal muscle area between manual and automated contours.

RESULTS

We trained five 2.5D U-Nets using 5-fold cross validation and used them to predict the contours in the testing set. The model achieved a mean Dice score of 0.92 and an APE of 3.1% on the independent testing set. This was similar to inter-observer variation of 0.96 and 2.9% for mean Dice and APE respectively. We further quantified the performance of sarcopenia classification using computer generated skeletal muscle area. To meet a clinical diagnosis of sarcopenia based on Alberta protocol the model achieved a sensitivity of 84% and a specificity of 95%.

CONCLUSIONS

This work demonstrates an automated method for accurate and reproducible segmentation of skeletal muscle area at L3. This is an efficient tool for large scale or routine computation of skeletal muscle area in cancer patients which may have applications on low quality CTs acquired as part of PET/CT studies for staging and surveillance of patients with cancer.

A Novel Technique for Radiographic Diagnosis of Sarcopenia that Accurately Predicts Postoperative Complications in Lower Extremity Free Flap Patients

INTRODUCTION

 Sarcopenia is linked to poor outcomes throughout the surgical literature and can be assessed on preoperative imaging to potentially aid in risk stratification. This study examined the effects of sarcopenia on surgical morbidity following lower extremity (LE) reconstruction, and also compared two methods of assessment, one of which is novel ("ellipse method").

METHODS

 A retrospective cohort study of 50 patients receiving free flap-based reconstruction of the LE was performed. Bilateral psoas density and area were quantified at L4 through tracing ("traditional method") and encircling ("ellipse method") to calculate Hounsfield unit average calculation (HUAC). Logistic regression and receiving operator curve analysis for the primary outcome of any postoperative complication was used to determine HUAC cutoffs (≤ 20.7 vs. ≤ 20.6) for sarcopenia. Risk of complications associated with sarcopenia was evaluated using Fisher's exact tests.

RESULTS

 Twelve patients (24%) met criteria for sarcopenia via the traditional method and 16 (32%) via the ellipse method. By both methods, sarcopenic patients were older and more often female and diabetic. These patients also had higher American Society of Anesthesiologists scores and lower serum prealbumin levels. The ellipse method was found to be more accurate, sensitive, and specific than the traditional method in predicting postoperative morbidity (p = 0.009). Via the ellipse method, sarcopenic patients were at higher risk for any complication (p = 0.002) and were at a higher risk for a deep vein thrombus or pulmonary embolism via the traditional method (p = 0.047).

CONCLUSION

 Sarcopenia is associated with greater pre- and postoperative morbidity in LE reconstruction. The novel ellipse method is a simplified and accurate method of assessing sarcopenia that can be easily performed in the clinical setting.

Morphometric Changes in Children With Small Bowel Crohn Disease During Induction of Therapy: A Pilot Study

OBJECTIVE

Children and adolescents with Crohn disease (CD) commonly gain weight during treatment induction, which is thought to be a marker of better health. Body composition is, however, rarely assessed at diagnosis, and changes during early treatment are not often quantified. Therefore, it is unknown if these gains are truly healthy. We sought to evaluate skeletal muscle changes during initial treatment for CD by using routine imaging.

METHODS

Single-center prospective study. Pediatric patients diagnosed with small bowel CD underwent serial magnetic resonance enterography (MRE) imaging, laboratory testing, and disease-activity assessment, at diagnosis, 1 and 6 months of treatment. MRE-based cross-sectional morphometry was used to measure psoas muscle cross sectional area (CSA). Psoas CSA z-scores were calculated using normative data.

RESULTS

We enrolled 30 children (ages 9--17 years). Twenty-eight of 30 (93%) received anti-tumor necrosis factor therapy and 4 required surgical resection. Children with below-average psoas CSA and body mass index (BMI) z-scores at diagnosis were much more likely to fail treatment or undergo surgery by 6 months compared with those with higher z-scores (55% vs 0%; P = 0.001). Children with no activity limitations at diagnosis had significantly larger muscle gains in the first month, compared with those whose activity was limited at diagnosis (P = 0.012). Most patients had higher psoas CSA z-scores by 6 months, and these increases were associated with weight and BMI z-score increases.

CONCLUSIONS

Skeletal muscle growth contributes to weight gain during treatment induction in most patients with CD. Psoas muscle CSA on diagnostic imaging may have prognostic value in children with CD.

Status of adult inpatient burn rehabilitation in Europe: Are we neglecting metabolic outcomes?

BACKGROUND

Hypermetabolism, muscle wasting and insulin resistance are challenging yet important rehabilitation targets in the management of burns. In the absence of concrete practice guidelines, however, it remains unclear how these metabolic targets are currently managed. This study aimed to describe the current practice of inpatient rehabilitation across Europe.

METHODS

An electronic survey was distributed by the European Burn Association to burn centres throughout Europe, comprising generic and profession-specific questions directed at therapists, medical doctors and dieticians. Questions concerned exercise prescription, metabolic management and treatment priorities, motivation and knowledge of burn-induced metabolic sequelae. Odds ratios were computed to analyse associations between data derived from the responses of treatment priorities and knowledge of burn-induced metabolic sequelae.

RESULTS

Fifty-nine clinicians with 12.3 ± 9 years of professional experience in burns, representing 18 out of 91 burn centres (response rate, 19.8%) across eight European countries responded. Resistance and aerobic exercises were only provided by 42% and 38% of therapists to intubated patients, 87% and 65% once out-of-bed mobility was possible and 97% and 83% once patients were able to leave their hospital room, respectively. The assessment of resting energy expenditure by indirect calorimetry, muscle wasting and insulin resistance was carried out by only 40.7%, 15.3% and 7.4% respondents, respectively, with large variability in employed frequency and methods. Not all clinicians changed their care in cases of hypermetabolism (59.3%), muscle wasting (70.4%) or insulin resistance (44.4%), and large variations in management strategies were reported. Significant interdisciplinary variation was present in treatment goal importance ratings, motivation and knowledge of burn-induced metabolic sequelae. The prevention of metabolic sequelae was regarded as the least important treatment goal, while the restoration of functional status was rated as the most important. Knowledge of burn-induced metabolic sequelae was linked to higher importance ratings of metabolic sequelae as a therapy goal (odds ratio, 4.63; 95% CI, 1.50-14.25; p < 0.01).

CONCLUSION

This survey reveals considerable non-uniformity around multiple aspects of inpatient rehabilitation across European burn care, including, most notably, a potential neglect of metabolic outcomes. The results contribute to the necessary groundwork to formulate practice guidelines for inpatient burn rehabilitation.

Assessment of muscle mass using ultrasound with minimal versus maximal pressure compared with computed tomography in critically ill adult patients

BACKGROUND

Preserved skeletal muscle mass identified using computed tomography (CT) predicts improved outcomes from critical illness; however, CT imaging have few limitations such that it involves a radiation dose and transferring patients out of the intensive care unit. This study aimed to assess in critically ill patients the relationship between muscle mass estimates obtained using minimally invasive ultrasound techniques with both minimal and maximal pressure compared with CT images at the third lumber vertebra level.

METHODS

All patients were treated in a single Australian intensive care unit. Eligible patients had paired assessments, within a 72-h window, of muscle mass by ultrasound (quadriceps muscle layer thickness in centimetres, with maximal and minimal pressure) and CT axial cross-sectional area (cm²). Data are presented as mean (standard deviation), median (interquartile range), and frequencies [n (%)].

RESULTS

Thirty-five patients [mean (standard deviation) age = 55 (16) years, median (interquartile range) body mass index = 27 (25-32) kg/m², and 26 (74%) men] contributed 41 paired measurements. Quadriceps muscle thickness measured using the maximal pressure technique was a strong independent predictor of lumbar muscle cross-sectional area. Within a multivariate mixed linear regression model and adjusting for sex, age, and body mass index, for every 1 cm increase in quadriceps muscle layer thickness, the lumbar muscle cross-sectional area increased by 35 cm² (95% confidence interval = 11-59 cm²). Similar univariate associations were observed using minimal pressure; however, as per multivariate analysis, there was no strength in this relationship [8 cm² (95% confidence interval = -5 to 22 cm²)].

CONCLUSION

Ultrasound assessment of the quadriceps muscle using maximal pressure reasonably predicts the skeletal muscle at the third lumbar vertebra level of critically ill patients. However, there is substantial uncertainty within these regression estimates, and this may reduce the current utility of this technique as a minimally invasive surrogate for CT assessment of skeletal muscle mass.

Wireless, Artefact Aware Impedance Sensor Node for Continuous Bio-Impedance Monitoring

Body bio-impedance is a unique parameter to monitor changes in body composition non-invasively. Continuous measurement of bio-impedance can track changes in body fluid content and cell mass and has widespread applications for physiological monitoring. State-of-the-art implementation of bio-impedance sensor devices is still limited for continuous use, in part, due to artefacts arising at the skin-electrode (SE) interface. Artefacts at the SE interface may arise due to various factors such as motion, applied pressure on the electrode surface, changes in ambient conditions or gradual drying of electrodes. This paper presents a novel bio-impedance sensor node that includes an artefact aware method for bio-impedance measurement. The sensor node enables autonomous and continuous measurement of bio-impedance and SE contact impedance at ten frequencies between 10 kHz to 100 kHz to detect artefacts at the SE interface. Experimental evaluation with SE contact impedance models using passive 2R1C electronic circuits and also with non-invasive in vivo measurements of SE contact impedance demonstrated high accuracy (with maximum error less than 1.5%) and precision of 0.6 Ω. The ability to detect artefacts caused by motion, vertically applied pressure and skin temperature changes was analysed in proof of concept experiments. Low power sensor node design achieved with 50mW in active mode and only 143 μW in sleep mode estimated a battery life of 90 days with a 250 mAh battery and duty-cycling impedance measurements every 60 seconds. Our method for artefact aware bio-impedance sensing is a step towards autonomous and unobtrusive continuous bio-impedance measurement for health monitoring at-home or in clinical environments.

New insights on how and where to measure muscle mass

PURPOSE OF REVIEW

This article will discuss different muscle mass assessment methods and emphasize their highlights.

RECENT FINDINGS

Several measurement techniques can be used to evaluate muscle mass, recognized as important prognostic markers for adverse functional and clinical outcomes. Choosing the best method depends on the knowledge regarding their theoretical and practical limitations and the purpose of the assessment. Image techniques are considered the gold standards, with good accuracy and precision, but not always available in clinical settings. A new biological technique, the D3-creatinine dilution, can provide not only direct information about muscle mass but also shows a strong association with physical function. With the advancement of the use of the computed tomography (CT) images to assess skeletal muscle mass, mainly in patients with cancer, the assessment of skeletal muscle radiodensity (SMD), as a marker of muscle quality, may provide additional information regarding the association between muscle composition, muscle function and prognosis. Additional muscle function assessment can improve the risk prediction in several clinical situations.

SUMMARY

The use of the best tool for the muscle mass assessment should be performed carefully among the various methodologies, according to their characteristics and clinical situation.

How does muscularity assessed by bedside methods compare to computed tomography muscle area at intensive care unit admission? A pilot prospective cross-sectional study

BACKGROUND

Low muscularity and malnutrition at intensive care unit (ICU) admission have been associated with negative clinical outcomes. There are limited data available evaluating the validity of bedside techniques to measure muscle mass in critically ill adults. We aimed to compare bedside methods for muscle mass assessment [bioimpedance spectroscopy (BIS), arm anthropometry and subjective physical assessment] against reference technology [computed tomography (CT)] at ICU admission.

METHODS

Adults who had CT scanning at the third lumbar area <72 h after ICU admission were prospectively recruited. Bedside methods were performed within 48 h of the CT scan. Pearson's correlation compared CT muscle area with BIS-derived fat-free mass (FFM) (kg) and FFM-Chamney (kg) (adjusted for overhydration), mid-upper arm circumference (cm) and mid-arm muscle circumference (cm). Depleted muscle stores were determined using published thresholds for each method. Cohen's kappa (κ) was used to evaluate the agreement between bedside and CT assessment of muscularity status (normal or low).

RESULTS

Fifty participants were enrolled. There were strong correlations between CT muscle area and FFM values and mid-arm muscle circumference (P < 0.001). Using FFM-Chamney, all six (100%) participants with low CT muscle area were detected (κ = 0.723). FFM-BIS, arm anthropometry and subjective physical assessment methods detected 28%-38% of participants with low CT muscle area.

CONCLUSIONS

BIS-derived FFM using an adjustment algorithm for overhydration was correlated with CT muscle area and had good agreement with muscularity status assessed by CT image analysis. Arm anthropometry and subjective physical assessment techniques were not able to reliably detect participants with low CT muscle area.

Clinical Oncology Society of Australia: Position statement on cancer-related malnutrition and sarcopenia

This position statement describes the recommendations of the Clinical Oncology Society of Australia (COSA) regarding management of cancer‐related malnutrition and sarcopenia. A multidisciplinary working group completed a review of the literature, focused on evidence‐based guidelines, systematic reviews and meta‐analyses, to develop recommendations for the position statement. National consultation of the position statement content was undertaken through COSA members. All people with cancer should be screened for malnutrition and sarcopenia in all health settings at diagnosis and as the clinical situation changes throughout treatment and recovery. People identified as “at risk” of malnutrition or with a high‐risk cancer diagnosis or treatment plan should have a comprehensive nutrition assessment; people identified as “at risk” of sarcopenia should have a comprehensive evaluation of muscle status using a combination of assessments for muscle mass, muscle strength and function. All people with cancer‐related malnutrition and sarcopenia should have access to the core components of treatment, including medical nutrition therapy, targeted exercise prescription and physical and psychological symptom management. Treatment for cancer‐related malnutrition and sarcopenia should be individualised, in collaboration with the multidisciplinary team (MDT), and tailored to meet needs at each stage of cancer treatment. Health services should ensure a broad range of health care professionals across the MDT have the skills and confidence to recognise malnutrition and sarcopenia to facilitate timely referrals and treatment. The position statement is expected to provide guidance at a national level to improve the multidisciplinary management of cancer‐related malnutrition and sarcopenia.

Quantifying Response to Nutrition Therapy During Critical Illness: Implications for Clinical Practice and Research? A Narrative Review

Critical illness causes substantial muscle loss that adversely impacts recovery and health-related quality of life. Treatments are therefore needed that reduce mortality and/or improve the quality of survivorship. The purpose of this Review is to describe both patient-centered and surrogate outcomes that quantify responses to nutrition therapy in critically ill patients. The use of these outcomes in randomized clinical trials will be described and the strengths and limitations of these outcomes detailed. Outcomes used to quantify the response of nutrition therapy must have a plausible mechanistic relationship to nutrition therapy and either be an accepted measure for the quality of survivorship or highly likely to lead to improvements in survivorship. This Review identified that previous trials have utilized diverse outcomes. The variety of outcomes observed is probably due to a lack of consensus as to the most appropriate surrogate outcomes to quantify response to nutrition therapy during research or clinical practice. Recent studies have used, with some success, measures of muscle mass to evaluate and monitor nutrition interventions administered to critically ill patients.

Bioimpedance spectroscopy and volumetry in the immediate/short-term monitoring of intensive complex decongestive treatment of lymphedema

AIMS

To assess (a) immediate/short-term outcomes of intensive complex decongestive treatment of lower limb lymphedema, by means of bioimpedance spectroscopy and tape measurement-based volumetry, and (b) correlation between these two methods.

PATIENTS AND METHODS

Cohort study on patients affected by unilateral primary or secondary lymphedema, stage II or III. Patients underwent complex decongestive treatment (manual and electro-sound lymphatic drainage, compression bandage, exercises, low-carb nutrition, and dietary supplements) for six days. Before (D0), three and six days after complex decongestive treatment (D3 and D6), volumetry and bioimpedance spectroscopy data of the total limb and lower leg were collected. Statistical analysis was applied to pre-post treatment outcomes and to the volumetry/bioimpedance spectroscopy correlation.

RESULTS

Forty-one patients (15 males and 26 females, mean age: 50.7 years) were included. A progressive improvement of volumetry and bioimpedance spectroscopy figures was recorded. Total limb and leg volumetry (mean value in cc) was, respectively, 11,072.9 and 3150.8 at D0, 10,493 (-5.2%, p = 0.001) and 2980.2 (-5.4%, p < 0.001) at D6. Total limb lymphatic index at D0 and D6 was 18.9 and 14.8 (-21.5%, p < 0.001). Total limb resistance at D0, D3, and D6 was 200.4, 225.7, and 237.5 (+18.5%, p < 0.001), respectively; leg resistance at D0 and D6 was 117.5 and 150 (+27.7%, p < 0.001), respectively. Total limb reactance at D0, D3, and D6 was 12.2, 15, and 16.6 (+35.5%, p < 0.001), respectively. Leg reactance at D0 and D6 was 7.7 and 11.5 (+ 49.6%, p < 0001), respectively. Correlation volumetry/bioimpedance spectroscopy data were (a) total limb volumetry/resistance rho = -0.449, p < 0.01; volumetry/reactance rho=-0.466, p < 0.01; volumetry/lymphatic index rho = 0.581, p < 0.01; (b) leg volumetry/resistance rho=-0.579, p < 0.01; volumetry/reactance rho=-0.469, p < 0.01; volumetry/lymphatic index rho = 0.466, p < 0.05.

CONCLUSIONS

Complex decongestive treatment on lymphedematous limbs was effective at short term; both volumetry and bioimpedance spectroscopy showed a statistically significant improvement. Resistance and reactance increase, with lymphatic index decrease, correlated with volumetry decrease. Bioimpedance spectroscopy proved to help to assess fluid decrease and the tissue-related parameters variations.

Three compartment bioimpedance spectroscopy in the nutritional assessment and the outcome of patients with advanced or end stage kidney disease: What have we learned so far?

Bioimpedance spectroscopy (BIS) is an easily applicable tool to assess body composition. The three compartment model BIS (3C BIS) conventionally expresses body composition as lean tissue index (LTI) (lean tissue mass [LTM]/height in meters squared) and fat tissue index (FTI) (adipose tissue mass/height in meters squared), and a virtual compartment reflecting fluid overload (FO). It has been studied extensively in relation to diagnosis and treatment guidance of fluid status disorders in patients with advanced‐stage or end‐stage renal disease. It is the aim of this article to provide a narrative review on the relevance of 3C BIS in the nutritional assessment in this population. At a population level, LTI decreases after the start of hemodialysis, whereas FTI increases. LTI below the 10th percentile is a consistent predictor of outcome whereas a low FTI is predominantly associated with outcome when combined with a low LTI. Recent research also showed the connection between low LTI, inflammation, and FO, which are cumulatively associated with an increased mortality risk. However, studies toward nutritional interventions based on BIS data are still lacking in this population. In conclusion, 3C BIS, by disentangling the components of body mass index, has contributed to our understanding of the relevance of abnormalities in different body compartments in chronic kidney disease patients, and appears to be a valuable prognostic tool, at least at a population level. Studies assessing the effect of BIS guided nutritional intervention could further support its use in the daily clinical care for renal patients.

Mortality in COPD: Comparison of Different Predictors in Patients Seeking a Pulmonary Rehabilitation Program

Resumo É clinicamente relevante identificar fatores preditores de mortalidade isolados ou multidimensionais em pacientes com Doença Pulmonar Obstrutiva Crônica (DPOC). O objetivo desse esuto foi comparar diferentes fatores na identificação de pacientes classificados em alto risco de morte e identificar o valor prognóstico de fatores isolados frente ao índice BODE. Foram avaliados pacientes quanto a fatores associado a mortalidade: função pulmonar com a medida do volume expiratório forçado (VEF1); índice de massa corpórea (IMC); índice de massa magra corporal (IMMC); Incremental Shuttle Walk Test (ISWT) com a estimativa do consumo máximo de oxigênio (VO2máx); teste de caminhada de seis minutos (TC6min); escala Medical Research Council; índice BODE e tempo sedentário. Pontos de corte previamente associados com mortalidade foram utilizados para calcular a proporção de pacientes em alto risco. Análise de curva ROC foi utilizada para testar o valor prognóstico das variáveis isoladas frente ao BODE. Foram incluídos 162 pacientes (86 homens, idade 67±8 anos). As proporções de pacientes classificados em alto risco variaram de 12,6% até 76,5% de acordo com os oito fatores analisados (P<0,05 vs todos). A área sob a curva (AUC) desses fatores testados isoladamente frente ao índice BODE indicou insatisfatória capacidade discriminativa (0,26 < AUC < 0,44). Existe uma variabilidade expressiva na proporção dos pacientes classificados como “alto risco” de acordo com cada fator preditor de mortalidade. Além disso, a avaliação prognóstica do paciente obtida com o índice BODE não pode ser substituída pela avaliação de um único fator preditor. Palavras-chave: Doença Pulmonar Obstrutiva Crônica. Mortalidade. Exercício. AbstractIt is clinically relevant to identify isolated factors or multidimensional predictors of mortality in patients with Chronic Obstructive Pulmonary Disease (COPD). To compare different factors in the identification of patients classified as high risk of death and to identify the prognostic value of isolated factors against the BODE index. Patients were evaluated considering the factors associated with mortality: pulmonary function with forced expiratory volume (FEV1); body mass index (BMI); body mass index (LMWI); Incremental Shuttle Walk Test (ISWT) with estimation of maximal oxygen consumption (VO2max); six-minute walk test (6MWT); Medical Research Council scale; BODE index and sedentary time. Cut-off points previously associated with risk of death were used to calculate the proportion of patients at high risk of death. ROC curve analysis was used to test the prognostic value of each variable against the BODE index. A total of 162 patients (86 men, age 67 ± 8 years) were included. The proportions of patients classified as high risk ranged from 12.6 to 76.5% according to all eight factors analyzed (P <0.05 vs all). The area under the curve (AUC) of each factor analyzed against the BODE index indicated insufficient discriminative capacity (0.26 < AUC < 0.44). Conclusion: There is an expressive variability of patients classified as "high risk" according to each predictor factor. Moreover, the prognostic evaluation of the patient using the BODE index cannot be replaced by the assessment of a single predictive factor. Keywords: Chronic Obstructive Pulmonary Disease, Mortality, Exercise.