Bioelectrical impedance phase angle as a prognostic indicator in advanced pancreatic cancer

Myxedema in Both Hyperthyroidism and Hypothyroidism: A Hormetic Response?

Myxedema is a potentially life-threatening condition typically observed in severe hypothyroidism. However, localized or diffuse myxedema is also observed in hyperthyroidism. The exact cause and mechanism of this paradoxical situation is not clear. We report here the analysis of body fluid distribution by bioelectrical impedance analysis (BIA) in 103 thyroid patients, subdivided according to their functional status. All BIA parameters measured in subclinical thyroid dysfunctions did not significantly differ from those observed in euthyroid controls. On the contrary, they were clearly altered in the two extreme, opposite conditions of thyroid dysfunctions, namely overt hyperthyroidism and severe hypothyroidism, indicating the occurrence of a typical hormetic condition. Surprisingly, differences in BIA parameters related to fluid body composition were even more evident in hyperthyroidism than in hypothyroidism. A hormetic response to thyroid hormone (TH)s was previously reported to explain the paradoxical, biphasic, time- and dose-dependent effects on other conditions. Our results indicate that myxedema, observed in both hypothyroid and hyperthyroid conditions, represents another example of a hormetic-type response to THs. BIA offers no additional valuable information in evaluating fluid body composition in subclinical thyroid dysfunctions, but it represents a valuable method to analyze and monitor body fluid composition and distribution in overt and severe thyroid dysfunctions.

Oral Protein Supplements Might Improve Nutritional Status and Quality of Life in Elderly Patients after Standard Pancreatic Resection

Elderly patients who undergo pancreaticoduodenectomy (PPPD) or distal pancreatectomy (DP) experience not only a reduction in protein intake but also a decrease in protease secretion, leading to impaired protein digestion and absorption. This increases the risk of malnutrition and creates a dual burden of sarcopenia. This randomized, double-blind, placebo-controlled trial examined the impact of protein supplements on the nutritional status and quality of life (QoL) of elderly patients after PPPD and DP surgeries. For six weeks, the case group (CG; n = 23) consumed protein supplements containing 18 g of protein daily, while the placebo group (PG; n = 18) consumed a placebo with the same amount of carbohydrate. In elderly patients where protein digestion and intake were compromised, the CG showed significantly higher protein intake (77.3 ± 5.3 g vs. 56.7 ± 6.0 g, p = 0.049), improved QoL, better nutritional status, and faster walking speed compared to the PG. Protein intake was positively correlated with muscle mass and phase angle. Protein supplementation may not only increase protein intake but also improve clinical outcomes such as walking speed, nutritional status, and QoL in elderly post-surgical patients at high risk of sarcopenia. Further studies are needed to determine the optimal dosage and long-term effects.

Efficacy of 1-Kestose Supplementation in Patients with Pancreatic Ductal Adenocarcinoma: A Randomized Controlled Pilot Study

Less than half of all patients diagnosed with pancreatic ductal adenocarcinoma (PDAC) respond to chemotherapy, and the prognosis of PDAC is poor, which may be mediated by the gut microbiota. We investigated the clinical improvement effects of 1-kestose, a fructooligosaccharide, on PDAC chemotherapy in this single-center, randomized, controlled pilot trial conducted at Fujita Health University Hospital, which enrolled patients with PDAC. The trial included 1-kestose administration and non-administration groups. The 1-kestose group received 9 g of 1-kestose daily for 12 weeks, and their blood markers, imaging studies, physical findings, and gut microbiota were evaluated. In the 1-kestose administration group, the cancer marker CA19-9 significantly decreased, and there was a reduction in the neutrophil-to-lymphocyte ratio (NLR). There was also suppression of the reduction of albumin levels and of an increase in C-reactive protein. Additionally, Escherichia coli, which typically increases in PDAC, significantly decreased in the 1-kestose group. Thus, 1-kestose altered the gut microbiota and improved the prognostic factors for PDAC. Large-scale, long-term trials of 1-kestose interventions for PDAC are thus warranted to improve the prognosis of PDAC.

Association between phase angle and diabetic peripheral neuropathy in Type 2 diabetes patients

BACKGROUND

Diabetic peripheral neuropathy (DPN), the very prevalent microvascular complication of type 2 diabetes mellitus (T2DM), severely threatens the quality of life of diabetic patients. Thus, prevention of DPN is extremely important for public health, and the identification of potential biomarkers may help with early prevention. Our work determined the association between phase angles (PhAs) and the risk of DPN in T2DM patients.

MATERIALS AND METHODS

This cross-sectional study recruited 697 T2DM patients from the Third Affiliated Hospital of Soochow University. All patients were divided into the non-diabetic peripheral neuropathy group and diabetic peripheral neuropathy group, and the DPN group was further divided into low, medium, and high diabetic foot ulcer risk groups according to vibration perception threshold results. Using univariate and multivariate logistic regression analyses continuously, the relationship between PhAs (arms, legs, trunk, and whole body) and the risk of DPN were evaluated. Further analysis was conducted on different subgroups of the study population.

RESULTS

After adjusting for the potential covariates, multivariate logistic regression analyses indicated that PhAs of the arms, legs, and whole body correlated inversely with the risk of DPN. However, the PhA of the trunk had no significant correlation with DPN. According to the stratified subgroup analysis, the negative association between PhA of the whole body and the risk of DPN remained significant in the sex and BMI group except for participants with BMI ≥ 28 kg/m².

CONCLUSIONS

For the first time, PhAs were acknowledged to be independently associated with DPN. Further exploration is needed to explain the findings.

Bioelectrical impedance analysis-derived phase angle (PhA) in lung cancer patients: a systematic review

BACKGROUND

Lung cancer is the second most diagnosed cancer in the world. Up to 84% of diagnosed patients have malnutrition, which can negatively affect quality of life and survival and may worsen with neoadjuvant treatment. Bioelectrical Impedance Analysis-Derived Phase Angle (PhA) in these patients could be a valid tool to assess the nutritional status in order to improve their condition.

METHODS

This review provides an update on PhA assessment in lung cancer patients over the past twenty years. We searched PubMed, Embase, Scopus, Web of Science, and Cochrane, for articles regarding the PhA obtained from Bioelectrical Impedance Analysis in lung cancer patients. The authors independently performed a literature search: sample size, patient population, study type, study dates, survival and interventions were evaluated. The final review included 11 studies from different countries.

RESULTS

Eight studies only considered patients with lung cancer, while three studies considered patients with different kind of cancer, including lung. Correlation data between PhA and age are conflicting. In patients undergoing clinical treatment and patients undergoing surgical treatment lower PhA was observed. A lower PhA is associated with a shorter survival. In three studies emerged a relationship between Karnofski Performance Status and Handgrip Strenght with PhA. From one study, univariate logistic regression analysis showed that higher PhA values represent a protective factor for sarcopenia.

CONCLUSION

Our research underlined interesting, but not conclusive, results on this topic; however more researches are needed to understand the clinical meaning of PhA.

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

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

Glycated hemoglobin (HbA1c) is independently associated with the bioelectrical impedance phase angle in junior sumo wrestlers: A pilot study

The study explores the relationship between phase angle (PhA), an indicator of cellular health, and metabolic health parameters among junior sumo wrestlers in Japan. Given the demanding lifestyle and high-energy diets of sumo wrestlers that predispose them to metabolic syndrome post-retirement, this study focuses on a younger cohort. The primary aim is to evaluate if PhA could serve as an early indicator of metabolic health issues within this unique demographic. A total of 14 sumo wrestlers aged 9-17 years were assessed to determine the relationship between PhA and various metabolic markers, including glycated hemoglobin (HbA1c), using a TANITA MC-780A-N body composition analyzer and standard blood tests. Bivariate regression analysis and Pearson's correlation revealed a negative relationship between PhA and HbA1c even after adjusting for age and weight (ß = -0.496, r2 = 0.776, r = -0.756, p = 0.004). The results indicate a significant negative relationship between PhA and HbA1c levels, suggesting that lower PhA values, which indicate poorer cellular integrity, are associated with higher HbA1c levels, signifying impaired glycemic control. These findings underscore the potential of PhA as a valuable biomarker for monitoring metabolic health in young sumo wrestlers, with implications for early intervention and management strategies.

Pretreatment fat-free mass index correlates with early death in patients with head and neck squamous cell carcinoma

BACKGROUND

A significant proportion of patients with head and neck squamous cell carcinoma (HNSCC) are malnourished at diagnosis. In this study, we investigated how pretreatment body mass index (BMI) and fat-free mass index (FFMI) correlate with early death, and whether these measurements are useful markers of prognosis for risk stratification of head and neck cancer patients.

METHODS

Patients (n = 404) with newly diagnosed, curable HNSCC and WHO performance status 0-2 were prospectively included and met with a study representative before treatment initiation, as well as up to four follow-up visits. All patients provided an estimate of body weight at 6 months prior to diagnosis. Bioelectrical impedance analysis (BIA) was performed for all patients before treatment initiation.

RESULTS

Most patients had oropharyngeal (46%), oral cavity (28%), or laryngeal cancer (12%). Forty-five (11%) patients met the standardized criteria for malnutrition according to the Global Leadership Initiative on Malnutrition (GLIM) at diagnosis. FFMI at diagnosis was lower in patients who died within 6 and 12 months after the start of treatment than in patients who survived these time points (p = 0.035 and p = 0.005, respectively).

CONCLUSIONS

In this study, pretreatment FFMI was an independent prognostic factor for death within 6 and 12 months after the start of treatment in patients with HNSCC. Pretreatment BMI was not an independent risk factor for death within 6 and 12 months after treatment termination. Thus, FFMI may be useful for risk stratification of patients with head and neck cancer.

The ability of phase angle and body composition to predict risk of death in maintenance hemodialysis patients

OBJECTIVE

The objective of this study was to investigate the ability of phase angle and body composition to identify risk factors for mortality among patients receiving maintenance hemodialysis (MHD) treatment.

METHODS

In this retrospective study, we examined the causes of death in 43 MHD patients who were treated at our hemodialysis center between January 2016 and December 2021 and compared the patients to 71 patients who survived during the same period. Body composition was measured using direct segmental multi-frequency bioelectrical impedance to obtain phase angle, fat-free mass (FFM), extracellular water/total body water (ECW/TBW), and waist circumference (WC). Laboratory data were also collected. Phase angle cut-off value-associated variables were identified using ROC analysis. The ability of body composition variables to identify risk factors for death in MHD patients was evaluated.

RESULTS

We found that cardiovascular disease was the most common cause of death among MHD patients. ROC curve analysis revealed that the optimal cut-off value for phase angle as a predictor of death risk in MHD patients was 4.50°. Additionally, lower phase angle, increased age, longer dialysis vintage, lower KT/V, and hypoproteinemia were identified as significant risk factors for death in MHD patients.

CONCLUSION

In conclusion, our findings suggest that cardiovascular disease is the leading cause of death among MHD patients and that lower phase angle, increased age, longer dialysis duration, and hypoproteinemia can be used to predict the risk of mortality in this patient population. The underlying mechanism by which lower phase angle can be used to predict the prognosis of MHD patients warrants further investigation.

An Investigation of the Role of Phase Angle in Malnutrition Risk Evaluation and Clinical Outcomes in Patients with Head and Neck or Brain Tumors Undergoing Radiotherapy

This cross-sectional study aimed to investigate the role of bioelectrical impedance analysis (BIA) and phase angle measurement in assessing malnutrition in head and neck (n = 37) and brain (n = 63) tumor patients received radiotherapy. Common nutritional screening and assessment tests were used to identify malnutrition in the patients. Each patient underwent these tests once, along with phase angle measurement. Additionally, inflammation parameters, including neutrophil lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR), and systemic inflammatory index (SII), were calculated. All study results were correlated with the phase angle cutoff point of 5.72°. The phase angle demonstrated significant correlations with subjective global assessment (SGA), mini nutritional assessment (MNA) scores, BIA parameters, nutritional index, NLR, and SII (p < 0.05). Moreover, in head and neck tumor patients, those with higher standardized phase angle values exhibited significantly better two-year overall survival (32.1% vs. 87.5%, p = 0.006). The phase angle measurement is a convenient, noninvasive, and reproducible method that can complement existing tools for assessing malnutrition risk in radiotherapy patients. The significant correlations observed between the phase angle and various nutritional, inflammation markers and prognosis highlight its potential utility. Further studies incorporating a larger patient cohort will be beneficial in establishing a standard phase angle reference value for cancer patients.

Effect of body fat mass loss on prognosis of radical resection for pancreatic ductal adenocarcinoma based on bioelectrical impedance analysis

BACKGROUND

Few reports have performed a prognostic analysis based on bioelectrical impedance analysis in patients with radical resection of pancreatic ductal adenocarcinoma (PDAC), and its usefulness in prognostic analysis remains unclear. This study aimed to evaluate body composition changes in patients undergoing radical resection for PDAC and analyze its impact on prognosis.

METHODS

The medical records of radical resection for patients with PDAC were retrospectively reviewed, and the parameters of body composition, including body weight, skeletal muscle mass, body fat mass (BFM), and extracellular water-total body water ratio, from preoperatively to 12 months postoperatively, for each surgical procedure were measured based on direct segmental multifrequency bioelectrical impedance analysis with an InBody 770 (InBody Inc., Tokyo, Japan) device. The clinicopathological and prognostic factors were analyzed.

RESULTS

Among 79 patients who underwent radical resection for PDAC, 36 (46%), 7 (8%), and 36 (46%) underwent pancreatoduodenectomy, total pancreatectomy, and distal pancreatectomy, respectively. The multivariate overall survival analysis demonstrated that BFM loss percentage at 1 month postoperatively ≧14% (p = 0.021), lymph node metastasis (p = 0.014), and non-adjuvant chemotherapy (p <  0.001) were independent poor prognostic factors. Multivariate analysis revealed that preoperative BFM < 12 kg and preoperative albumin < 3.5 g/dL were independently associated with BFM loss percentage at 1 month postoperatively ≧14% (p = 0.021 and p = 0.047, respectively).

CONCLUSIONS

Loss of BFM in the early postoperative period may have a poor prognosis in radical resection of PDAC.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

The bioelectrical impedance analysis (BIA) international database: aims, scope, and call for data

BACKGROUND

Bioelectrical impedance analysis (BIA) is a technique widely used for estimating body composition and health-related parameters. The technology is relatively simple, quick, and non-invasive, and is currently used globally in diverse settings, including private clinicians' offices, sports and health clubs, and hospitals, and across a spectrum of age, body weight, and disease states. BIA parameters can be used to estimate body composition (fat, fat-free mass, total-body water and its compartments). Moreover, raw measurements including resistance, reactance, phase angle, and impedance vector length can also be used to track health-related markers, including hydration and malnutrition, and disease-prognostic, athletic and general health status. Body composition shows profound variability in association with age, sex, race and ethnicity, geographic ancestry, lifestyle, and health status. To advance understanding of this variability, we propose to develop a large and diverse multi-country dataset of BIA raw measures and derived body components. The aim of this paper is to describe the 'BIA International Database' project and encourage researchers to join the consortium.

METHODS

The Exercise and Health Laboratory of the Faculty of Human Kinetics, University of Lisbon has agreed to host the database using an online portal. At present, the database contains 277,922 measures from individuals ranging from 11 months to 102 years, along with additional data on these participants.

CONCLUSION

The BIA International Database represents a key resource for research on body composition.

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

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

Phase angle, physical quality of life and functionality in cancer patients undergoing chemotherapy

INTRODUCTION

Nutritional deficiency, especially malnutrition, is frequent in cancer patients and is associated with changes in body composition, such as low muscle mass. Phase angle (PhA) has been used as a prognostic indicator and may be related to nutritional status, functionality, and quality of life in these patients. The objectives of this study were to assess the effect of chemotherapy treatment on PhA values, comparing the PhA variation before and after treatment, and to evaluate the PhA correlation, as a muscle mass surrogate, with the physical domain of quality of life, functionality, and nutritional risk in a sample of patients with cancer.

METHODS

A longitudinal study was conducted in patients with cancer undergoing chemotherapy for the first time. All patients aged 18 years or older, newly diagnosed, and undergoing chemotherapy for the first time were included. To analyze the difference in the PhA means according to the different classification variables, the t-test - or ANOVA - was used. The variation of the final and initial PhA was evaluated through the linear regression test.

RESULTS

A total of 175 patients were analyzed, of which 66.3% were female. The mean PhA of the initial assessment was significantly higher when compared to the final assessment of the patients PhA (p = 0.018). In both the initial and final assessments, PhA was correlated with the physical domain (r = 0.29; p < 0.001 and r = 0.19; p = 0.021) and with the functionality score (r = - 0.32; p < 0.001 and r = - 0.30; p < 0.001) and total PG-SGA (r = - 0.31; p < 0.001 and r = - 0.23; p = 0.006).

CONCLUSION

PhA can be considered a predictor of physical quality of life and functionality in cancer patients receiving chemotherapy treatment.

Independent effect of fat-to-muscle mass ratio at bioimpedance analysis on long-term survival in patients receiving surgery for pancreatic cancer

Introduction

Malnutrition and alteration of body composition are early features in pancreatic cancer and appear to be predictors of advanced stages and dismal overall survival. Whether specific patient characteristics measured at the preoperative bioimpedance analysis (BIA) could be associated with long-term outcomes following curative resection has not been yet described.

Methods

In a prospective multicenter study, all histologically proven resected pancreatic cancer patients were included in the analysis. BIA was measured for all patients on the day before surgery. Demographics, perioperative data, and postoperative outcomes were prospectively collected. Patients who experienced 90-day mortality were excluded from the analysis. Survival data were obtained through follow-up visits and phone interviews. Bioimpedance variables were analyzed according to the overall survival using the Kaplan-Meier curves and the univariate and multivariate Cox regression model.

Results

Overall, 161 pancreatic cancer patients were included. The median age was 66 (60-74) years, and 27.3% received systemic neoadjuvant treatment. There were 23 (14.3%) patients malnourished in the preoperative evaluation. Median OS was 34.0 (25.7-42.3) months. Several bioimpedance variables were associated with OS at the univariate analysis, namely the phase angle [HR 0.85, 95% CI 0.74-0.98)], standardized phase angle [HR 0.91, 95% CI 0.82-0.99)], and an increased ratio between the fat and lean mass (FM/FFM) [HR 4.27, 95% CI 1.10-16.64)]. At the multivariate analysis, the FM/FFM ratio was a confirmed independent predictor of OS following radical resection, together with a positive lymph nodal status.

Conclusion

Alteration of body composition at the preoperative bioimpedance vector analysis (BIVA) can predict dismal oncologic outcomes following pancreatic resection for cancer.

Phase angle in assessment and monitoring treatment of individuals with respiratory disease

Phase angle (PhA) represents a raw variable measured with bioelectrical impedance analysis (BIA) that is used to assess malnutrition in many diseases, including respiratory diseases, mainly chronic obstructive pulmonary disease (COPD). COPD patients with reduced PhA are older, more hypoxic and hypercapnic; patients with more severe COPD have reduced cell mass, evident skeletal muscle depletion, and worsening gas exchange. Malnourished patients with stable COPD in long-term oxygen therapy (LTOT) have more intense dyspnea at rest, greater weight loss over the past 12 months, and more exacerbations per year. Multiple regression analysis highlighted the significance of PhA° in the estimation of muscle strength: hand grip strength (HGS) and in that of respiratory muscles: maximal inspiratory pressure / max. expiratory pressure ratio (MIP/MEP). Furthermore, the relationship between PhA° and all-cause mortality in COPD patients was confirmed with the Cox regression model, Kaplan-Meier test, and log-rank tests. The role of malnutrition in idiopathic pulmonary fibrosis (IPF) is confirmed by the PhA° measurements which, regardless of body weight, is associated with the reduction in muscle mass of these patients, reduces their strength and exercise capacity, and greatly influences the prognosis. In conclusion PhA is a novel biomarker of morbidity and mortality in patients with severe respiratory diseases.

Prognostic role of bioelectrical impedance phase angle for critically ill patients: A systemic review and meta-analysis

Objective

Bioelectrical impedance-derived phase angle (PA) has exhibited good prognostic values in several non-critical illnesses. However, its predictive value for critically ill patients remains unclear. Thus, we aimed to perform a systematic review and meta-analysis to investigate the relationship between PA and survival in such a patient population.

Materials and methods

We searched for relevant studies in PubMed, Embase, and the Cochrane database up to Jan 20, 2022. Meta-analyses were performed to determine the association between the baseline PA after admission with survival. We further conducted subgroup analyses and sensitivity analyses to explore the sources of heterogeneity.

Results

We included 20 studies with 3,770 patients. Patients with low PA were associated with a significantly higher mortality risk than those with normal PA (OR 2.45, 95% CI 1.97-3.05, P < 0.00001). Compared to survivors, non-survivors had lower PA values (MD 0.82°, 95% CI 0.66-0.98; P < 0.00001). Similar results were also found when pooling studies reported regression analyses of PA as continuous (OR = 0.64; 95% CI 0.52-0.79, P < 0.00001) or categorical variable (OR = 2.42; 95% CI 1.76-3.34; P < 0.00001). These results were further confirmed in subgroup analyses and sensitivity analyses.

Conclusion

Our results indicated that PA may be an important prognostic factor of survival in critically ill patients and can nicely complement the deficiencies of other severity scoring systems in the ICU setting.

[Malnutrition management of hospitalized patients with diabetes/hyperglycemia and cancer cachexia]

Introduction

Diabetes is a frequent comorbidity in cancer patients, since they share common risk factors. In cancer, the concurrence of cachexia represents a poor prognostic factor, which is aggravated by poor nutritional status. Clinically, cancer cachexia manifests as a significant reduction in body weight, accompanied by changes in body composition and alterations in the balance of the biological system, and causes progressive dysfunction. This article describes the results of the expert consensus and the responses of the panelists on the nutritional management in routine clinical practice of patients with diabetes/hyperglycemia hospitalized (non-critically ill) with cancer cachexia.

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.

Phase angle as an index of physiological status: validating bioelectrical assessments of hydration and cell mass in health and disease

Bioelectrical impedance (BI) is a practical method to assess body composition in health and disease. This method relies on the passive conduction of an applied, safe, low-level alternating current through water and electrolytes in the body. Using a phase-sensitive device, BI yields measurements of impedance (Z) and its components, resistance (R) and reactance (Xc), that are related geometrically as phase angle (PhA). In vitro studies provide empirical evidence relating BI measurements to physiological variables. Cooking raw food samples results in greater decreases in PhA, predominantly Xc, with smaller reductions R indicating destruction of cell membrane integrity with simultaneous movement of fluid from intracellular to extracellular space. Infusion of saline into a cell-free model shows a proportional decrease in R with increases in volume. Saline infusion in a composite model of cells disproportionately decreases Xc and PhA, compared to R, demonstrating greater relative expansion of extracellular water (ECW) with a lesser relative increase in total fluid volume. Surgical patients treated with fluid infusion and diuresis demonstrate changes in Xc predominantly indicating relative changes in ECW with lesser variations in R indicating fluctuations in total fluid volume. Proteomics studies disclose strong independent associations of PhA with protein markers of fluid overload and protein proliferation. Interpretations of PhA measurements for body cell mass should be examined in the context of hydration status.

A Low Body Fat Mass Ratio Predicts Poor Prognosis in Patients with Advanced Non-Small Cell Lung Cancer

PURPOSE

The aim of this study was to investigate the effect of the body fat mass ratio on survival and prognosis in advanced non-small-cell lung cancer patients.

METHODS

The study includes 200 patients who were diagnosed with advanced non-small-cell lung cancer between 2014 and 2018 and whose body fat mass percentage and body mass index (BMI) were determined using the Tanita Body Composition Analyzer during admission.

RESULTS

All patients had advanced incurable non-small-cell lung cancer (30% had locally advanced disease, 70% were stage IV). In the univariate and multivariate analyses, age, gender, histopathological type, smoking history, comorbidities, weight loss in the last six months and body mass index had no statistically significant effect on survival (p > 0.05). However, the performance status (p = 0.008), metastatic status (p = 0.003) and body fat mass ratio (p = 0.01) were found to have a significant effect on overall survival (OS): the median OS was 16.4 mo, in patients with the BFM ratio ≤ 22% and 29.2 mo, in those with > 22% (p = 0.01).

CONCLUSION

In this study, it was found that the body fat mass ratio was an important prognostic factor in patients with advanced non-small-cell lung cancer.

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

Simple Summary

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

Abstract

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

Impact of sarcopenia on prediction of progression-free survival and overall survival of patients with pancreatic ductal adenocarcinoma receiving first-line gemcitabine and nab-paclitaxel chemotherapy

BACKGROUND AND AIMS

Sarcopenia is an important prognostic factor for cancer patients. Here, we assessed the effects of sarcopenia on progression-free survival (PFS) and overall survival (OS) of patients with pancreatic ductal adenocarcinoma (PDAC) who underwent treatment with first-line gemcitabine and nab-paclitaxel (GEM and nab-PTX).

METHODS

The study enrolled patients with unresectable PDAC who underwent chemotherapy between April 2016 and May 2020. The skeletal muscle index (SMI) at the third lumbar spine level (L3) was calculated from computed tomography (CT) images. Propensity score analysis was used to compare PFS and OS in the sarcopenia and non-sarcopenia groups. Univariate and multivariate analyses were performed to determine variables significantly associated with prognosis.

RESULTS

Of the 176 patients who received first-line GEM and nab-PTX, 84 were selected and divided into two groups of 42 (the sarcopenia and the non-sarcopenia groups) by propensity score matching. The median PFS of the sarcopenia and the non-sarcopenia groups was 5.0 and 8.0 months, respectively (p = 0.004). The median OS was 10.3 and 18.1 months, respectively (p = 0.001). Multivariate analyses revealed that sarcopenia was an independent prognostic factor for PFS and OS (p = 0.004, p = 0.001, respectively). The rates of major grade 3 or 4 AEs were significantly higher in the sarcopenia group (p = 0.008).

CONCLUSIONS

Sarcopenia is an independent indicator of a poor prognosis in patients with PDAC treated with first-line GEM and nab-PTX.

Nutritional Screening and Anthropometry in Patients Admitted From the Emergency Department

Background

Due to the high prevalence of malnutrition among hospitalized patients, screening and assessment of nutritional status should be routinely performed upon hospital admission. The main objective of this observational study was to evaluate the prevalence of and the risk for malnutrition, as identified by using three nutritional screening tests, and to observe whether some anthropometric and functional parameters used for nutritional evaluation were related to these test scores.

Methods

This single-center observational study included 207 patients admitted from the emergency department for hospitalization in either the internal medicine or surgery units of our institution from September 2017 to December 2018. The prevalence of malnutrition among this patient sample was evaluated by using the Nutritional Risk Screening (NRS-2002), the Subjective Global Assessment (SGA) and the Global Leadership Initiative on Malnutrition (GLIM) criteria. Body mass index (BMI), bioimpedance analysis (BIA), handgrip strength (HGS) and calf circumference (CC) assessments were also performed.

Results

According to the NRS-2002, 93% of the patients were at no risk or at low nutritional risk (NRS score < 3), and 7% were at a high nutritional risk (NRS score ≥ 3). On the other hand, according to the SGA, 46.3% of the patients were well-nourished (SGA-a), 49.8% were moderately malnourished (SGA-b), and 3.9% were severely malnourished (SGA-c). Finally, according to the GLIM criteria, 18% patients were malnourished. Body weight, body mass index (BMI), phase angle (PhA), CC and HGS were significantly lower in the patients with NRS scores ≥ 3, SGA-c and in patients with stage 1 and stage 2 malnutrition, according to the GLIM criteria.

Conclusion

The NRS-2002, the SGA and the GLIM criteria appear to be valuable tools for the screening and assessment of nutritional status. In particular, the lowest NRS-2002, SGA and GLIM scores were associated with the lowest PhA and CC. Nevertheless, a weekly re-evaluation of patients with better screening and assessment scores is recommended to facilitate early detection of changes in nutritional status.

Handgrip Strength, Overhydration and Nutritional Status as a Predictors of Gastrointestinal Toxicity in Cervical Cancer Patients. A Prospective Study

Background: Antineoplastic treatments produce adverse events (AE) such as gastrointestinal toxicity. These AE can reduce nutritional intake and promote weight and muscle mass loss. Objective: To determine if body composition, nutritional status, or muscle function predicts gastrointestinal toxicity during chemotherapy in cervical cancer (CC) patients. Methods: Women with CC were studied. Nutritional status was evaluated according to PG-SGA, and body composition was measured with bioimpedance. Toxicity was graded according to the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE). Results: A total of 207 women, 81 with toxicity and 126 without toxicity groups, were studied. Patients in the toxicity group had less handgrip strength (17.7 ± 5.0 vs. 20.3 ± 5.0 p = 0.0004); phase angle (5.2 ± 1.1 vs. 5.9 ± 1.0, p = 0.0065); higher prevalence of sarcopenia (35.9% vs. 20.6%, p = 0.016); overhydration (25.9% vs. 6.3% p < 0.001); and PG-SGA C (14.1% vs. 4.0%, p < 0.001) when compared to patients without toxicity. Handgrip strength (HR: 0.93, 95% CI 0.88-0.98, p = 0.028), overhydration (HR: 2.82, 95% CI 1.22-6.51, p = 0.015) and been severely malnourished according to PG-PGA (HR: 3.6, 95%CI 1.46-9.2, p < 0.001) were associated with the risk to present gastrointestinal toxicity. Conclusion: handgrip strength, overhydration, and severe malnutrition are independent risk factors to the presence of gastrointestinal toxicity in CC patients.

Impact of healthy aging on active bacterial assemblages throughout the gastrointestinal tract

The adaption of gut microbiota (GM) throughout human life is a key factor in maintaining health. Interventions to restore a healthy GM composition may have the potential to improve health and disease outcomes in the elderly. We performed a comprehensive characterization of changes in the luminal and mucosa-associated microbiota composition in elderly compared with younger healthy individuals. Samples from saliva and feces, and biopsies from the upper and lower gastrointestinal tract (UGIT, LGIT), were collected from 59 asymptomatic individuals grouped by age: 40-55, 56-70, and 71-85 years). All underwent anthropometric, geriatric, and nutritional assessment. RNA was extracted and reverse-transcribed into complementary DNA; the V1-V2 regions of 16S ribosomal RNA genes were amplified and sequenced. Abundances of the taxa in all taxonomic ranks in each sample type were used to construct sample-similarity matrices by the Bray-Curtis algorithm. Significant differences between defined groups were assessed by analysis of similarity. The bacterial community showed strong interindividual variations and a clear distinction between samples from UGIT, LGIT, and feces. While in saliva some taxa were affected by aging, this number was considerably greater in UGIT and was subsequently higher in LGIT. Unexpectedly, aging scarcely influenced the bacterial community of feces over the age range of 40-85 years. The development of interventions to preserve and restore human health with increased age by establishing a healthy gut microbiome should not rely solely on data from fecal analysis, as the intestinal mucosa is affected by more significant changes, which differ from those observed in fecal analyses.

Predictors of Mortality in Patients with Advanced Cancer-A Systematic Review and Meta-Analysis

To timely initiate advance care planning in patients with advanced cancer, physicians should identify patients with limited life expectancy. We aimed to identify predictors of mortality. To identify the relevant literature, we searched Embase, MEDLINE, Cochrane Central, Web of Science, and PubMed databases between January 2000-April 2020. Identified studies were assessed on risk-of-bias with a modified QUIPS tool. The main outcomes were predictors and prediction models of mortality within a period of 3-24 months. We included predictors that were studied in ≥2 cancer types in a meta-analysis using a fixed or random-effects model and summarized the discriminative ability of models. We included 68 studies (ranging from 42 to 66,112 patients), of which 24 were low risk-of-bias, and 39 were included in the meta-analysis. Using a fixed-effects model, the predictors of mortality were: the surprise question, performance status, cognitive impairment, (sub)cutaneous metastases, body mass index, comorbidity, serum albumin, and hemoglobin. Using a random-effects model, predictors were: disease stage IV (hazard ratio [HR] 7.58; 95% confidence interval [CI] 4.00-14.36), lung cancer (HR 2.51; 95% CI 1.24-5.06), ECOG performance status 1+ (HR 2.03; 95% CI 1.44-2.86) and 2+ (HR 4.06; 95% CI 2.36-6.98), age (HR 1.20; 95% CI 1.05-1.38), male sex (HR 1.24; 95% CI 1.14-1.36), and Charlson comorbidity score 3+ (HR 1.60; 95% CI 1.11-2.32). Thirteen studies reported on prediction models consisting of different sets of predictors with mostly moderate discriminative ability. To conclude, we identified reasonably accurate non-tumor specific predictors of mortality. Those predictors could guide in developing a more accurate prediction model and in selecting patients for advance care planning.

Extracellular water to total body water ratio may mediate the association between phase angle and mortality in patients with cancer cachexia: A single-center, retrospective study

BACKGROUND & AIMS

Recently, prognostic factors for cancer cachexia patients have been reported. We hypothesized that phase angle (PhA), which is measured by bioelectrical impedance analysis (BIA), might be a promising marker for assessing the nutritional status and prognosis of cancer patients. This study aimed to evaluate the predictive utility of PhA, which is mediated by several BIA factors and other anthropometric parameters, such as calf circumference, for the prognosis of cancer cachexia patients.

METHODS

Consecutive patients (114, both outpatients and inpatients) with an unselected stage of cancer cachexia were recruited between July 2018 and December 2019 in Fujita Health University Hospital for this retrospective cohort study. Their mean age was 74.0 years (standard deviation, 8.5); among the total, 70 were men and 44 women. A time-dependent Cox proportional-hazards regression analysis (adjusted for age and sex) was performed to assess the following: 1) the association between potential mediators and mortality; 2) the association between five PhAs and statistically significant mediators from 1); and 3) the association between the five PhAs and mortality. Finally, Kaplan-Meier survival curves were constructed and compared between the two groups based on the patients' median baseline ratio of extracellular water (ECW) to total body water (TBW) using a log-rank test.

RESULTS

The ECW/TBW ratio (hazard ratio [HR] per 1-interquartile range [IQR] increase: 2.87; 95% confidence interval [CI]: 1.46, 5.46; p < 0.001) and skeletal muscle mass index (HR per 1-IQR increase: 0.67; 95% CI: 0.51, 0.89; p = 0.001) were associated with mortality. All five PhAs were associated with the ECW/TBW ratio (p < 0.001). Before adjustment for the ECW/TBW ratio, all five PhAs were associated with mortality (p < 0.001); only the association of the PhAs of the left arm and the trunk retained the statistical significance after adjusting for confounders (p < 0.05). The median survival times in the low (370 days; 95% CI: 168, not calculated) and high ECW/TBW groups (101 days; 95% CI: 61, 219) differed significantly (p < 0.001).

CONCLUSIONS

The association between PhA and mortality in cancer cachexia patients was largely mediated by the ECW/TBW ratio. We believe that adjusting PhA for the ECW/TBW ratio may improve the prognostication of cancer patients with cachexia, ultimately improving their palliative care.

Nonthyroidal illness syndrome (NTIS) in severe COVID-19 patients: role of T3 on the Na/K pump gene expression and on hydroelectrolytic equilibrium

Background

Nonthyroidal Illness Syndrome (NTIS) can be detected in many critical illnesses. Recently, we demonstrated that this condition is frequently observed in COVID-19 patients too and it is correlated with the severity the disease. However, the exact mechanism through which thyroid hormones influence the course of COVID-19, as well as that of many other critical illnesses, is not clear yet and treatment with T4, T3 or a combination of both is still controversial. Aim of this study was to analyze body composition in COVID-19 patients in search of possible correlation with the thyroid function.

Methods and findings

We report here our experience performed in 74 critically ill COVID-19 patients hospitalized in the intensive care unit (ICU) of our University Hospital in Rome. In these patients, we evaluated the thyroid hormone function and body composition by Bioelectrical Impedance Analysis (BIA) during the acute phase of the disease at admission in the ICU. To examine the effects of thyroid function on BIA parameters we analyzed also 96 outpatients, affected by thyroid diseases in different functional conditions. We demonstrated that COVID-19 patients with low FT3 serum values exhibited increased values of the Total Body Water/Free Fat Mass (TBW/FFM) ratio. Patients with the lowest FT3 serum values had also the highest level of TBW/FFM ratio. This ratio is an indicator of the fraction of FFM as water and represents one of the best-known body-composition constants in mammals. We found an inverse correlation between FT3 serum values and this constant. Reduced FT3 serum values in COVID-19 patients were correlated with the increase in the total body water (TBW), the extracellular water (ECW) and the sodium/potassium exchangeable ratio (Na_e:K_e), and with the reduction of the intracellular water (ICW). No specific correlation was observed in thyroid patients at different functional conditions between any BIA parameters and FT3 serum values, except for the patient with myxedema, that showed a picture similar to that seen in COVID-19 patients with NTIS. Since the Na⁺/K⁺ pump is a well-known T3 target, we measured the mRNA expression levels of the two genes coding for the two major isoforms of this pump. We demonstrated that COVID-19 patients with NTIS had lower levels of mRNA of both genes in the peripheral blood mononuclear cells (PBMC)s obtained from our patients during the acute phase of the disease. In addition, we retrieved data from transcriptome analysis, performed on human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CM)s treated with T3 and we demonstrated that in these cells T3 is able to stimulate the expression of these two genes in a dose-dependent manner.

Conclusions

In conclusion, we demonstrated that measurement of BIA parameters is a useful method to analyze water and salt retention in COVID-19 patients hospitalized in ICU and, in particular, in those that develop NTIS. Our results indicate that NTIS has peculiar similarities with myxedema seen in severe hypothyroid patients, albeit it occurs more rapidly. The Na⁺/K⁺ pump is a possible target of T3 action, involved in the pathogenesis of the anasarcatic condition observed in our COVID-19 patients with NTIS. Finally, measurement of BIA parameters may represent good endpoints to evaluate the benefit of future clinical interventional trials, based on the administration of T3 in patients with NTIS.

The Relationship between Nutritional Status and Body Composition with Clinical Parameters, Tumor Stage, CA19-9, CEA Levels in Patients with Pancreatic and Periampullary Tumors

Recent studies have obtained inadequate data on the association between nutritional status, body composition, clinical parameters and tumor stage in patients withpancreatic and periampullary tumors. The purpose of this study was to assess the relationship between nutritional status (NS), body composition (BC) and selected clinical parameters in patients with pancreatic and periampullary cancer, as well as describe the differences between resection and non-resection groups. This is a prospective study of 76 patients with pancreatic and periampullary tumors. We evaluated NS, BMI, body mass loss (BML) and albumin, total protein, CRP, CEA, CA19-9, lipase, amylase, tumor stage, and BC using bioelectrical impedance (BIA). All subjects were divided into resection (n = 59) and non-resection (n = 17) groups. The non-resection group had a worse NS, as well as increased amylase and WBC, compared to the resection. The selected parameters of BC corresponded to BML albumin, TP, NS, age, BMI, Karnofsky, RBC, HCT and HGB. No associations were found between BC with tumor size, CRP, CA19-9, and CEA. We recorded the relationship between metastasis and NRS, as well as tumor size with SGA. The percentage of BML was positively correlated with age and CRP but negatively correlated with RBC, HGB, HCT and anthropometric measurements. We found many statistical correlations with NS and selected parameters, as well as differences between the resection and non-resection group. The detection of early prognostic factors of nutritional impairments would improve the quality of life and reduce the rate of postoperative complications.

Safety, Feasibility, and Effects of Short-Term Calorie Reduction during Induction Chemotherapy in Patients with Diffuse Large B-Cell Lymphoma: A Pilot Study

Short-term calorie reduction (SCR) requires individuals to reduce their calorie intake to less than 50% of normal requirements and has shown good tolerance and potential benefits in prior studies addressing gynecological cancer patients. More studies are needed to further confirm its safety, feasibility, and effects in patients with different cancers, including hematological malignancies. This pilot cohort study with a matched-pair comparison group was registered at ClinicalTrails.gov [201810112RIND]. Adult patients diagnosed with advanced-stage diffuse large-B cell lymphoma were recruited (SCR group) and matched with one comparison patient (comparison group), each in a manner blinded to their outcomes. The SCR group undertook at least two cycles of 48 h water fast along with their chemotherapy R-CHOP. Descriptive analysis and generalized estimating equations were used to analyze the data. Six participants completed multiple cycles of SCR and were compared to their six counterparts in the comparison group. The results showed that SCR is safe and feasible in terms of a high compliance rate and stable nutritional status. The SCR was associated with benefits in post-chemotherapy hematological parameters (i.e., erythrocyte [p < 0.001] and lymphocyte counts [p < 0.001]). More randomized controlled trials are needed to validate the effects of SCR on different types of cancer populations.

Phase Angle From Bioelectrical Impedance for the Assessment of Sarcopenia in Cirrhosis With or Without Ascites

BACKGROUND AND AIMS

Skeletal muscle index (SMI) from computed tomography (CT) reliably assesses sarcopenia, however, it is expensive and involves serial radiation exposure. Phase angle (PhA) from bioimpedance analysis (BIA) is a noninvasive, low cost, bedside nutritional tool used to monitor changes to nutritional interventions. We aimed to compare the performance of PhA with SMI to assess sarcopenia in cirrhosis.

METHODS

Ambispective cohort study. Consecutive patients with cirrhosis and available images from abdominal CT scan were included. Monofrequency BIA was performed within 2 weeks CT. Spearman's correlation, ROC curve, and survival analysis with Kaplan-Meier, Cox and competing-risk regression were performed.

RESULTS

136 patients were included with a mean age of 54.5 years (60% female). Most had decompensated disease (66%) with ascites in 47%, and a mean MELD of 14 ± 6. We found positive correlations between SMI and PhA (r = 0.58 , P < .001), irrespective of the presence of ascites. The AUROC of PhA-sarcopenia in all patients was 0.702; (0.748 in males,0.677 in females). The best cutoffs of PhA for diagnosing sarcopenia were ≤5.6° in males and ≤5.4° in females. SMI and PhA were significantly associated with survival in Kaplan-Meier curves. In multivariable analyses, SMI was outperformed by age and MELD, whereas PhA remained independently associated with mortality. Considering transplantation as a competing risk, regression analysis showed both SMI and PhA to be independent predictors of mortality (sHR:0.95 [0.90-0.99] and sHR:0.61 [0.42-0.88]).

CONCLUSION

PhA moderately correlates with SMI for the identification of sarcopenia in patients with cirrhosis. However, its prognostic accuracy is comparable to that of SMI, and it is not influenced by ascites.

Phase angle and Mediterranean diet in patients with acne: Two easy tools for assessing the clinical severity of disease

BACKGROUND

Acne is a chronic, inflammatory and debilitating skin disorder. Dietary factors and nutritional status are among the exacerbating factors of acne. Phase angle (PhA), a direct measure of Bioelectrical Impedance Analysis (BIA), represents an indicator of the chronic inflammatory state. The Mediterranean diet (MD) is a healthy dietary pattern that can exert anti-inflammatory effects in several inflammatory diseases. We aimed to investigate the difference in PhA and adherence to the MD and their associations with the severity of acne in a sample of naïve treatment patients with acne compared to control group.

MATERIALS

In this cross-sectional, case-control, observational study, we enrolled 51 patients with acne and 51 control individuals. Body composition was evaluated by a BIA phase-sensitive system (50 kHz BIA 101 RJL, Akern Bioresearch, Florence, Italy, Akern). For adherence to the MD, we have used the PREvención con DIeta MEDiterránea (PREDIMED) questionnaire. The clinical severity of acne was assessed by using the global acne grading system (GAGS), a quantitative scoring system to assess acne severity.

RESULTS

Patients with acne had a worse body composition, in particular smaller PhA (p = 0.003), and a lower adherence to the MD (p < 0.001) than the control group, in spite of no differences in gender, age and BMI between the two groups. Stratifying patients with acne according to GAGS categories, both PhA (p = 0.006) and PREDIMED score (p = 0.007) decreased significantly in severe acne than mild/moderate acne. The GAGS score was negative correlations with PhA (r = - 0.478, p < 0.001) and PREDIMED score (r = - 0.504, p < 0.001). The results of the multivariate analysis showed PhA and PREDIMED score were the major determinants of GAGS score (p < 0.001). The receiver operator characteristic (ROC) analysis reporting a value of PhA of ≤ 6.1° and a PREDIMED score of ≤ 9 identified patients with acne with the highest clinical severity of the disease.

CONCLUSIONS

Novel correlations were reported between PhA and the degree of adherence to the MD with acne severity. Of interest, PhA and PREDIMED scores might represent possible markers of the severity of acne in a clinical setting. This study highlights how a cooperation between dermatologist and nutritionists might provide a combination key in the complex management of acne patients.

Effects of Yoga on Phase Angle and Quality of Life in Patients with Breast Cancer: A Randomized, Single-Blind, Controlled Trial

INTRODUCTION

Phase angle (PA), a parameter that is obtained from body composition analysis, is an indicator of cellular health status. A lower PA in cancer patients can lead to a decrease in functional status and quality of life (QoL) and increased mortality. Studies have shown that physical activity increases PA. In this study, we aimed to examine the effects of Hatha yoga on PA, body composition, and QoL in patients with breast cancer.

METHODS

Thirty-one patients were randomized into the yoga (group 1, n = 15) and the control group (group 2, n = 16). Hatha yoga was practiced twice a week for 10 weeks in the intervention group. The PA of the patients was assessed using a body analysis instrument, and QoL was evaluated with an EORTC QLQ questionnaire both before treatment and at week 10.

RESULTS

Group 1 had significant improvements in the posttreatment EORTC QLQ functional and global scores (p < 0.05). In group 2, a significant improvement was observed in the EORTC QLQ symptom subscale (p = 0.035). PA values did not show any improvements in both groups (p > 0.05). Comparison of the 2 groups revealed no differences.

CONCLUSION

Yoga may have beneficial effects on QoL in patients with breast cancer but does not have a significant effect on PA. There is a need for further studies to make a definitive statement.

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

BACKGROUND

Patients undergoing surgery for cancer are at particular risk of post-operative complications. The pre-operative period is an opportunity to identify and mitigate risk factors and improve outcome. Bioelectrical impedance analysis (BIA) may offer an additional means of identifying patients at risk of post-operative morbidity.

AIMS

The aim of this systematic review was to assess the use of measures and estimates of body composition determined by BIA as markers of peri-operative risk in adult patients undergoing elective surgery for cancer.

METHODS

This review was performed in accordance with the PRISMA guidelines. The electronic databases of MEDLINE, EMBASE, CINAHL, CENTRAL and the Web of Science were searched from inception. Studies of adult participants having elective surgery for cancer were included if participants underwent BIA in the peri-operative period and were assessed for post-operative complications.

RESULTS

2578 studies were identified, of which 12 were eligible for inclusion. In total the studies report data from 1508 subjects. Five studies examined phase angle or standardized phase angle, six examined derived measures and one examined both. Eight of the 12 demonstrated an association between phase angle and/or body composition and an increased risk of post-operative complications.

CONCLUSIONS

Bioelectrical impedance analysis in the peri-operative period may be useful in predicting the risk of complications following elective cancer surgery. Phase angle more consistently demonstrates an association than derived estimates. Further high quality studies are needed and should report the raw impedance values, standardized phase angle and the equations used to derive body composition.

Clinical Significance of TNFRSF1A36T/C Polymorphism in Cachectic Patients with Chronic Heart Failure

Introduction: One of the main factors contributing to the development of nutritional deficits in chronic heart failure (CHF) patients is the systemic inflammatory process. Progressing inflammatory response leads to exacerbation of the disease and could develop into cardiac cachexia (CC), characterized by involuntary weight loss followed by muscle wasting. The aim of this study was to assess the relationship between rs767455 (36 T/C) of the TNFRSF1A and the occurrence of nutritional disorders in CHF patients with cachexia. Materials and Methods: We enrolled 142 CHF individuals who underwent cardiac and nutritional screening in order to assess cardiac performance and nutritional status. The relationship between TNFRSF1A rs767455 genotypes and patients' features was investigated. Results: A greater distribution of the TT genotype among cachectic patients in contrast to non-cachectic individuals was found (TT frequencies of 62.9% and 37.1%, respectively; p = 0.013). We noted a significantly lower albumin concentration (p = 0.039) and higher C-reactive protein (CRP) levels (p = 0.019) in patients with the TT genotype. Regarding cardiac parameters, CHF individuals bearing the TT genotype demonstrated a significant reduction in ejection fraction (EF) (p = 0.033) in contrast to other genotype carriers; moreover, they had a significantly higher concentration of N-terminal prohormone of brain natriuretic peptide (NT-proBNP) in the blood (p = 0.018). We also noted a lower frequency of TT genotype carriers among individuals qualified as grades I or II of the New York Heart Association (NYHA) (p = 0.006). The multivariable analysis selected the TT genotype as an unfavorable factor related to a higher chance of cachexia in CHF patients (Odds ratio (OR) = 2.56; p = 0.036). Conclusions: The rs767455TT genotype of TNFRSF1A can be considered as an unfavorable factor related to a higher risk of cachexia in CHF patients.

The associations between nutritional and functional status during recovery from Guillain-Barré syndrome: a retrospective study

Patients with Guillain-Barré syndrome (GBS) are at high risk for inadequate nutrition throughout their illness, yet the wider impact of malnutrition in this population remains unknown. Thus, the purpose of our study was to investigate the associations between nutritional status and functional status at admission to inpatient rehabilitation for GBS and to determine whether the admission phase angle, a biological marker of cellular health, is a prognostic indicator of functional improvement at the end of rehabilitation. The study included 27 participants recovering from GBS who screened positive for nutritional risk upon admission to rehabilitation. According to the Global Leadership Initiative on Malnutrition criteria, the majority of participants were classified as malnourished. A decreased phase angle was found in 93% (mean 3.7°, SD 1.3°). Lower phase angle was moderately associated with lower motor Functional Independence Measure (mFIM) at admission (r = 0.53, P = 0.005), suggesting that phase angle may be an indicator of functional status. By the end of rehabilitation, all participants improved functional independence and muscle strength, and the majority improved walking abilities. However, the correlation between admission phase angle and mFIM efficiency was not statistically significant (P = 0.3867). We conclude that malnutrition is significantly associated with low functional independence and muscle strength at admission. The inability of admission phase angle to predict functional improvement is probably due to the complex interactions between recovery from GBS and interventions provided during a comprehensive multidisciplinary rehabilitation for GBS, and also relatively small sample size.

Potential bioelectrical impedance analysis (BIA) parameters in prediction muscle strength in women with anorexia nervosa

OBJECTIVES

The role of physical activity in anorexia nervosa (AN) treatment has been investigated. Muscle strength (MS) reflects physical condition and can predict AN patients' response to this novel treatment approach. This study was intended to find bioelectrical impedance analysis (BIA) parameters that predict AN patients' MS.

METHODS

The study included 42 AN patients and 42 healthy ones in the control group. BIA parameters that predict MS were assessed by dividing AN patients into groups by their hand grip strength test score (higher/lower than 22.5 kg).

RESULTS

The highest accuracy for distinguishing AN subjects from the control group was achieved by cell membrane capacitance (AUC = 0.916), impedance at 200 kHz and 5 kHz ratio (AUC = 0.924), phase angle (PA) 5 kHz (AUC = 0.906) and PA 50 kHz (AUC = 0.919). The low MS group had significantly lower values of PA 50 kHz (mean: 4.03 ± 0.80° vs. 4.58 ± 0.65°; p = 0.032) and fat-free mass index (mean: 12.22 ± 1.41 kg/m² vs. 13.14 ± 0.94 kg/m²; p = 0.026). In the univariate model, PA 50 kHz ≥4.037° was associated with the lowest chance of muscle weakness (OR = 0.230; p = 0.005). In the multivariate analysis, PA 50 kHz was the only significant factor of MS (OR = 0.01; p = 0.027).

CONCLUSIONS

PA 50 kHz is the best BIA parameter to predict MS in AN patients. It could be useful for assessment before physical activity treatment application.

Bioelectrical impedance analysis for predicting postoperative complications and survival after liver resection for hepatocellular carcinoma

Background

Bioelectrical impedance analysis provides information on body composition and nutritional status. However, it's unclear whether the preoperative edema index or phase angle predicts postoperative complication or mortality in patients with hepatocellular carcinoma (HCC). Thus, we investigated whether preoperative bioelectrical impedance analysis could predict postoperative complications and survival in patients with HCC.

Methods

Seventy-nine patients who underwent hepatectomy for hepatocellular carcinoma were prospectively enrolled and bioelectrical impedance analysis was performed before surgery. Postoperative ascites or acute kidney injury and patients' survival were monitored after surgery.

Results

Among 79 patients, 35 (44.3%) developed ascites or acute kidney injury after hepatectomy. In multivariate analysis, a high preoperative edema index (extracellular water/total body water) (>0.384) (odds ratio 3.96; 95% confidence interval: 1.03-15.17; P=0.045) and higher fluid infusion during surgery (odds ratio 1.36; 95% confidence interval: 1.04-1.79; P=0.026) were identified as significant risk factors for ascites or acute kidney injury after hepatectomy. Subgroup analyses showed that the edema index was a significant predictor of ascites or acute kidney injury in patients with cirrhosis. Tumor size was the only significant predictive factor for short-term survival after hepatectomy.

Conclusions

The preoperative edema index using bioelectrical impedance analysis can be used as a predictor of post-hepatectomy complication, especially in patients with liver cirrhosis.

Preoperative standardized phase angle at bioimpedance vector analysis predicts the outbreak of antimicrobial-resistant infections after major abdominal oncologic surgery: A prospective trial

OBJECTIVES

Infectious morbidity is the most common and costly among all surgery-related complications, and infections by multidrug-resistant microorganisms (MDR) are associated with poor outcomes. Derangements of body composition is a recognized risk factor for infections. The aim of this study was to investigate the potential association between specific traits of body composition and the risk of having MDR-related infections.

METHODS

This was a prospective study with patients scheduled for major abdominal surgery for gastrointestinal cancer. Bioimpedance vector analysis (BIVA), a reliable tool for body composition assessment, was performed the day before the operation. Postoperative complications were collected focusing on resistance patterns and site of infection. Patterns of resistance were compared with BIVA parameters.

RESULTS

Data from 182 patients suffering from pancreatic (n = 76, 41.7%), rectal (n = 38, 20.9%), gastric (n = 31, 17%), or hepatic (n = 37, 20.3%) malignancy were collected. Overall complications occurred in 108 patients (59%), and in 45 patients (28%) bacterial infections were proven at culture. Of these, 15 (8%) were multidrug-sensitive (MDS), 38 MDR, and 2 extended drug-resistant (XDR) infections. The standardized phase angle measured (SPA) at BIVA was significantly lower in the MDR/XDR infections (-0.02 ± 1.20) than for no infection/MDS (0.56 ± 1.53; P = 0.029). A multivariate analysis showed that SPA was the only independent variable for MDR/XDR infections with an odds ratio of 3.057 (95% confidence interval, 1.354-6903; P = 0.007). The predictive ability of SPA revealed an area under the receiver operating characteristic curve of 0.662, with an optimal threshold of -0.3.

CONCLUSIONS

In surgical cancer patients, preoperative value of SPA lower than -0.3 is associated with the outbreak of MDR bacterial infections.

Phase Angle and Frailty Are Important Prognostic Factors in Critically Ill Medical Patients: A Prospective Cohort Study

OBJECTIVES

To investigate whether phase angle (PhA) measured by bioelectrical impedance analysis (BIA) and frailty are associated with the outcomes of critical illnesses.

DESIGN

A single-center prospective cohort study.

SETTING

Medical intensive care unit (ICU) in Seoul National University Hospital, Seoul, Republic of Korea.

PARTICIPANTS

97 patients who were admitted to the medical ICU.

MEASUREMENTS

On admission, PhA was measured by BIA, and frailty was assessed by the Korean Modified Barthel Index (KMBI) scoring system. Patients were classified according to PhA and KMBI scores, and their impact on the outcomes of critical illnesses was evaluated.

RESULTS

The patients' mean age was 62.4 ± 16.4 years, and 56 of the patients (57.7%) were men. Having a high PhA above 3.5 at the time of ICU admission was associated with lower in-hospital mortality (adjusted OR 0.42, p = .042), and a shorter duration of ICU stay (5.6 days vs. 9.8 days, p = .016) compared to those with a low PhA. Other indices measured by BIA were not significantly associated with outcomes of critical illnesses. Frailty (KMBI > 60) was associated with more mechanical ventilation days (2.3 days vs. 7.1 days; p = .018).

CONCLUSION

Both PhA and frailty are important prognostic factors predicting the outcomes of critical illnesses. Low PhA scores were associated with increased mortality and a longer duration of ICU stay, and frailty was associated with more mechanical ventilation days.

Bioelectrical impedance vector analysis evaluates cellularity and hydration in cirrhotic patients

BACKGROUND

Malnutrition in cirrhotic patients is correlated with mortality and a better response to liver transplantation. However, recovery of the nutritional status in these patients is a challenge due to the difficulty in establishing a reliable nutritional diagnosis. The bioelectrical impedance vector analysis (BIVA) method appears as a feasible tool in clinical practice to define the physiological state of cirrhotic patients by assessing hydration and body cellularity.

AIM

To evaluate body composition in cirrhotic patients using BIVA.

METHODS

This retrospective cross-sectional study was carried out by following cirrhotic outpatients at a hospital in Porto Alegre, Brazil. A tetrapolar bioelectrical impedance analysis device was used to evaluate cellularity and hydration and to perform the BIVA. The BIVA graphic was elaborated by software and for statistical analysis a significance level of 5% (P ≤ 0.05) was considered.

RESULTS

One hundred and ninety patients, 61.1% males, with a mean age of 56.6 ± 11.0 years, were evaluated. Of these, 56.3% had Child-Turcotte-Pugh (CTP) A score, and the prevalent etiology was hepatitis C virus (47.4%). The patients were classified according to cellularity and hydration by the quadrants and ellipses of the BIVA method, quadrant 1 (47.9%); quadrant 2 (18.9%); quadrant 3 (14.2%); and quadrant 4 (18.9%). Those classified in quadrant 1 and 2 had a higher phase angle compared to those in quadrants 3 and 4 (P < 0.001). Quadrant 2 patients had a lower average age than the other groups. The association with CTP score showed that patients in quadrant 2 had a higher proportion of CTP A, and those in quadrant 4 had a higher proportion of CTP C (P < 0.052).

CONCLUSION

The BIVA method allows identification of the cellularity and hydration status of cirrhotic patients, and its association with clinical factors determines the disease severity, age and prognostic index.

Relationship between Phase Angle and Objective and Subjective Indicators of Nutritional Status in Cancer Patients: A Systematic Review

To investigate the relationship between phase angle (PA) and objective and subjective indicators of nutritional status in cancer patients, as well as to identify cutoff points for PA, to detect malnutrition in these patients. The study was a systematic review, carried out following the guidelines of the Preferred Reporting Items for Systematic Reviews and meta-analyses (PRISMA). Literature search was performed for two authors, in indexed databases, including the National Library of Medicine, Bethesda, MD (PubMed), Latin American and Caribbean Literature in Health Sciences (LILACS), and Scopus (Elsevier). We used the checklist from the Joanna Briggs Institute for assessing the risk of bias. The review was registered with the Systematic Review Registration (PROSPERO), number CRD42020134324. In total, nine papers were eligible. PA was correlated with several objective and subjective indicators of nutritional status in most cases. Cutoff point values for the PA, capable of detecting malnutrition, varied from 4.73° to 6°, despite the modest diagnostic accuracy. We assume that PA may be considered an indicator of nutritional status, when complementing additional data and assisting health practitioners in evaluating individuals with malignant neoplasms. However, a single cutoff point with fair and concomitant sensitivity and specificity was not identified.

Phase angle is associated with length of hospital stay, readmissions, mortality, and falls in patients hospitalized in internal-medicine wards: A retrospective cohort study

OBJECTIVES

The aim of this study was to investigate the predictive value of bioimpedance phase angle (PA) on selected clinical outcomes in patients hospitalized in internal-medicine wards.

METHODS

This was a retrospective observational study of 168 patients admitted to the internalmedicine service (52.9% women, 47.1% men), with a mean (± SD) age of 73.9 ± 15.9 y. Anthropometric examination, laboratory tests, and bioelectrical impedance analysis were performed. Bioimpedance-derived PA was the study's parameter. Length of hospital stay, prospective all-cause hospital readmission, mortality, and falls were the clinical endpoints.

RESULTS

Across the four PA quartile groups, age was incrementally higher (P ≤ 0.001). Multivariate linear regression models showed that PA quartile 1 was significantly associated with length of hospital stay (β, SE) in both crude and adjusted models-respectively, β (SE) = 6.199 (1.625), P ≤ 0.001, and β = 2.193 (1.355), P = 0.033. Over a 9-mo follow-up period, the hazard ratios for readmission, in-hospital falls, and mortality were associated with the lowest phase angle (PA quartile 1 versus quartiles 2-4)-respectively, 2.07 (95% confidence interval [CI], 1.28-3.35), 2.36 (95% CI, 1.05-5.33), and 2.85 (95% CI, 1.01-7.39). Associations between narrow PA and outcomes continued to be significant after adjustments for various confounders.

CONCLUSIONS

In internal-medicine wards, bioimpedance-derived PA emerged as a predictor of length of hospital stay, hospital readmission, falls, and mortality. The present findings suggest that in the hospital setting, PA assessment could be useful in identifying patients at higher risk who need specific nutritional support.

Obesity Affects the Association of Bioelectrical Impedance Phase Angle With Mortality in People Living With HIV

Bioelectrical impedance analysis phase angle (BIA-PA) is a valid indicator of mortality risk in people living with HIV; however, it is not known whether BIA-PA is valid for people living with HIV who are overweight or obese. We assessed whether BIA-PA differentially predicted mortality by body mass index category in participants receiving clinical care at a single site between 2000 and 2012. Change in BIA-PA from the highest versus last available phase angle was assessed using multivariate logistic regression models. Eight hundred ninety participants were included in the final analyses, with 102 deaths recorded during the study period. Decline in BIA-PA was associated with mortality in underweight and normal weight participants but not in overweight or obese participants. Additional investigation is warranted to determine the appropriate clinical BIA-PA equations and parameters to identify overweight and obese patients with increased mortality risk.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Independent Association of Phase Angle with Fasting Blood Glucose and Hemoglobin A1c in Korean Type 2 Diabetes Patients

The relationship between phase angle (PhA) of bioelectrical impedance analysis (BIA) and glycemic parameters in diabetes mellitus (DM) patients has not been well studied. To evaluate the prognostic value of the PhA from BIA as a glycemic marker, we investigated the relationship of PhA with various variables such as age, body mass index (BMI), and glycemic parameters in Korean patients with type 2 DM (T2DM). We evaluated the anthropometric data, body composition, glycemic parameters, and PhA of 321 T2DM patients aged 30–83 years. The patients were classified by sex into men (n = 133) and women (n = 188). General linear models identified the independent effects of PhA after covarying for age, sex and BMI. The PhA, body cell mass (BCM), extracellular mass (ECM), lean body mass, intracellular water (ICW), extracellular water (ECW), total body water (TBW), fasting blood glucose, and hemoglobin A1c (HbA1c) of T2DM Korean patients were significantly higher in men than in women. However, fat mass, ECM/BCM, ECW/ICW, ECW/TBW, and serum insulin were significantly higher in women than in men. Statistically significant independent associations were observed between PhA and age, BCM, ECM, ECM/BCM, ICW, ECW, ECW/ICW, and ECW/TBW for both sexes. There was no significant association between PhA and BMI the patients. Glycemic parameters, such as HbA1c and fasting blood glucose were independently associated with PhA. These results suggest that PhA could be an indicator for assessing ability to control fasting blood glucose in T2DM patients in Korea.