Association of Paraspinal Muscle Measurements on Chest Computed Tomography With Clinical Outcomes in Patients With Severe Coronavirus Disease 2019

Unveiling the detrimental vicious cycle linking skeletal muscle and COVID-19: A systematic review and meta-analysis

OBJECTIVE

Skeletal muscle catabolism supports multiple organs and systems during severe trauma and infection, but its role in COVID-19 remains unclear. This study investigates the interactions between skeletal muscle and COVID-19.

METHODS

The PubMed, EMbase, and The Cochrane Library databases were systematically searched from January 2020 to August 2023 for cohort studies focusing on the impact of skeletal muscle on COVID-19 prevalence and outcomes, and longitudinal studies examining skeletal muscle changes caused by COVID-19. Skeletal muscle quantity (SMQN) and quality (SMQL) were assessed separately. The random-effect model was predominantly utilized for statistical analysis.

RESULTS

Seventy studies with moderate to high quality were included. Low SMQN/SMQL was associated with an increased risk of COVID-19 infection (OR = 1.62, p < 0.001). Both the low SMQN and SMQL predicted COVID-19-related mortality (OR = 1.53, p = 0.016; OR = 2.18, p = 0.001, respectively). Mortality risk decreased with increasing SMQN (OR = 0.979, p = 0.009) and SMQL (OR = 0.972, p = 0.034). Low SMQN and SMQL were also linked to the need for intensive care unit/mechanical ventilation, increased COVID-19 severity, and longer hospital stays. Significant skeletal muscle wasting, characterized by reduced volume and strength, was observed during COVID-19 infection and the pandemic.

CONCLUSIONS

This study reveals a detrimental vicious circle between skeletal muscle and COVID-19. Effective management of skeletal muscle could be beneficial for treating COVID-19 infections and addressing the broader pandemic. These findings have important implications for the management of future virus pandemics.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023395476.

Prognostic utility of paraspinal muscle index in elderly patients with community-acquired pneumonia

OBJECTIVE

This study investigated the associations between paraspinal muscle measurements on chest computed tomography and clinical outcomes of elderly patients with community-acquired pneumonia (CAP).

METHODS

This single-center, retrospective, observational study analyzed elderly patients (≥65 years) with CAP hospitalized through an emergency department between March 2020 and December 2022. We collected their baseline characteristics and laboratory data at the time of admission. The paraspinal muscle index and attenuation were calculated at the level of the 12th thoracic vertebra using chest computed tomography taken within 48 hours before or after admission. Univariable and multivariable logistic regression analyses were conducted to evaluate the association between paraspinal muscle measurements and 28-day mortality. Receiver operating characteristic (ROC) curve and area under the curve (AUC) analyses were used to evaluate the prognostic predictive power.

RESULTS

Of the 338 enrolled patients, 60 (17.8%) died within 28 days after admission. A high paraspinal muscle index was associated with low 28-day mortality in elderly patients with CAP (adjusted odds ratio, 0.994; 95% confidence interval, 0.992-0.997). The area under the ROC curve for the muscle index was 0.75, which outperformed the pneumonia severity index and the CURB-65 (confusion, urea, respiratory rate, blood pressure, age ≥65 years) metric, both of which showed an AUC of 0.64 in predicting mortality.

CONCLUSION

A high paraspinal muscle index was associated with low 28-day mortality in patients aged 65 years or older with CAP.

Association of excess visceral fat and severe illness in hospitalized COVID-19 patients in Japan: a retrospective cohort study

BACKGROUND/OBJECTIVES

Obesity, defined by body mass index (BMI), is a well-known risk factor for the severity of coronavirus disease 2019 (COVID-19). Adipose tissue distribution has also been implicated as an important factor in the body's response to infection, and excess visceral fat (VF), which is prevalent in Japanese, may contribute significantly to the severity. Therefore, this study aimed to evaluate the association of obesity and VF with COVID-19 severe illness in Japan.

SUBJECTS/METHODS

This retrospective cohort study involved 550 COVID-19 patients admitted to a tertiary care hospital with BMI and body composition data, including VF. The primary endpoint was severe illness, including death, due to COVID-19 during hospitalization. Logistic regression analysis was applied to examine the quartiles of BMI and VF on severe illness after adjusting for covariates such as age, sex, subcutaneous fat, paraspinal muscle radiodensity, and comorbidities affecting VF (COPD, cancer within 5 years, immunosuppressive agent use).

RESULTS

The median age was 56.0 years; 71.8% were males. During hospitalization, 82 (14.9%) experienced COVID-19 severe illness. In the multivariate logistic regression analysis, Q4 of BMI was not significantly associated with severe illness compared to Q1 of BMI (OR 1.03; 95% CI 0.37-2.86; p = 0.95). Conversely, Q3 and Q4 of VF showed a higher risk for severe illness compared to Q1 of VF (OR 2.68; 95% CI 1.01-7.11; p = 0.04, OR 3.66; 95% CI 1.30-10.26; p = 0.01, respectively). Stratified analysis by BMI and adjusted for covariates showed the positive association of VF with severe illness only in the BMI < 25 kg/m2 group.

CONCLUSIONS

High BMI was not an independent risk factor for COVID-19 severe illness in hospitalized patients in Japan, whereas excess VF significantly influenced severe illness, especially in patients with a BMI < 25 kg/m2.

Integrated assessment of computed tomography density in pectoralis and erector spinae muscles as a prognostic biomarker for coronavirus disease 2019

BACKGROUND ＆ AIMS: Muscle quantification using chest computed tomography (CT) is a useful prognostic biomarker for coronavirus disease 2019 (COVID-19). However, no studies have evaluated the clinical course through comprehensive assessment of the pectoralis and erector spinae muscles. Therefore, we compared the impact of the areas and densities of these muscles on COVID-19 infection outcome.

METHODS

This multicenter retrospective cohort study was conducted by the COVID-19 Task Force. A total of 1410 patients with COVID-19 were included, and data on the area and density of the pectoralis and erector spinae muscles on chest CT were collected. The impact of each muscle parameter on the clinical outcome of COVID-19 was stratified according to sex. The primary outcome was the percentage of patients with severe disease, including those requiring oxygen supplementation and those who died. Additionally, 167 patients were followed up for changes in muscle parameters at three months and for the clinical characteristics in case of reduced CT density.

RESULTS

For both muscles, low density rather than muscle area was associated with COVID-19 severity. Regardless of sex, lower erector spinae muscle density was associated with more severe disease than pectoralis muscle density. The muscles were divided into two groups using the receiver operating characteristic curve of CT density, and the population was classified into four (Group A: high CT density for both muscles, Group B: low CT density for pectoralis and high for erector spinae muscle. Group C: high CT density for pectoralis and low for erector spinae muscle, Group D: low CT density for both muscles). In univariate analysis, Group D patients exhibited worse outcomes than Group A (OR: 2.96, 95% CI: 2.03-4.34 in men; OR: 3.02, 95% CI: 2.66-10.4 in women). Multivariate analysis revealed that men in Group D had a significantly more severe prognosis than those in Group A (OR: 1.82, 95% CI: 1.16-2.87). Moreover, Group D patients tended to have the highest incidence of other complications due to secondary infections and acute kidney injury during the clinical course. Longitudinal analysis of both muscle densities over three months revealed that patients with decreased muscle density over time were more likely to have severe cases than those who did not.

CONCLUSIONS

Muscle density, rather than muscle area, predicts the clinical outcomes of COVID-19. Integrated assessment of pectoralis and erector spinae muscle densities demonstrated higher accuracy in predicting the clinical course of COVID-19 than individual assessments.

Establishment and application of the BRP prognosis model for idiopathic pulmonary fibrosis

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is the most common idiopathic interstitial lung disease. Clinical models to accurately evaluate the prognosis of IPF are currently lacking. This study aimed to construct an easy-to-use and robust prediction model for transplant-free survival (TFS) of IPF based on clinical and radiological information.

METHODS

A multicenter prognostic study was conducted involving 166 IPF patients who were followed up for 3 years. The end point of follow-up was death or lung transplantation. Clinical information, lung function tests, and chest computed tomography (CT) scans were collected. Body composition quantification on CT was performed using 3D Slicer software. Risk factors in blood routine examination-radiology-pulmonary function (BRP) were identified by Cox regression and utilized to construct the "BRP Prognosis Model". The performance of the BRP model and the gender-age-physiology variables (GAP) model was compared using time-ROC curves, calibration curves, and decision curve analysis (DCA). Furthermore, histopathology fibrosis scores in clinical specimens were compared between the different risk stratifications identified by the BRP model. The correlations among body composition, lung function, serum inflammatory factors, and profibrotic factors were analyzed.

RESULTS

Neutrophil percentage > 68.3%, pericardial adipose tissue (PAT) > 94.91 cm3, pectoralis muscle radiodensity (PMD) ≤ 36.24 HU, diffusing capacity of the lung for carbon monoxide/alveolar ventilation (DLCO/VA) ≤ 56.03%, and maximum vital capacity (VCmax) < 90.5% were identified as independent risk factors for poor TFS among patients with IPF. We constructed a BRP model, which showed superior accuracy, discrimination, and clinical practicability to the GAP model. Median TFS differed significantly among patients at different risk levels identified by the BRP model (low risk: TFS > 3 years; intermediate risk: TFS = 2-3 years; high risk: TFS ≈ 1 year). Patients with a high-risk stratification according to the BRP model had a higher fibrosis score on histopathology. Additionally, serum proinflammatory markers were positively correlated with visceral fat volume and infiltration.

CONCLUSIONS

In this study, the BRP prognostic model of IPF was successfully constructed and validated. Compared with the commonly used GAP model, the BRP model had better performance and generalization with easily obtainable indicators. The BRP model is suitable for clinical promotion.

Erector spinae muscle-based nomogram for predicting in-hospital mortality among older patients with severe community-acquired pneumonia

BACKGROUND

No multivariable model incorporating erector spinae muscle (ESM) has been developed to predict clinical outcomes in older patients with severe community-acquired pneumonia (SCAP). This study aimed to construct a nomogram based on ESM to predict in-hospital mortality in patients with SCAP.

METHODS

Patients aged ≥ 65 years with SCAP were enrolled in this prospective observational study. Least absolute selection and shrinkage operator and multivariable logistic regression analyses were used to identify risk factors for in-hospital mortality. A nomogram prediction model was constructed. The predictive performance was evaluated using the concordance index (C-index), calibration curve, net reclassification improvement (NRI), integrated discrimination improvement (IDI), and decision curve analysis.

RESULTS

A total of 490 patients were included, and the in-hospital mortality rate was 36.1%. The nomogram included the following independent risk factors: mean arterial pressure, peripheral capillary oxygen saturation, Glasgow Coma Scale score (GCS), lactate, lactate dehydrogenase, blood urea nitrogen levels, and ESM cross-sectional area. Incorporating ESM into the base model with other risk factors significantly improved the C-index from 0.803 (95% confidence interval [CI], 0.761-0.845) to 0.836 (95% CI, 0.798-0.873), and these improvements were confirmed by category-free NRI and IDI. The ESM-based nomogram demonstrated a high level of discrimination, good calibration, and overall net benefits for predicting in-hospital mortality compared with the combination of confusion, urea, respiratory rate, blood pressure, and age ≥ 65 years (CURB-65), Pneumonia Severity Index (PSI), Acute Physiology and Chronic Health Evaluation II (APACHEII), and Sequential Organ Failure Assessment (SOFA).

CONCLUSIONS

The proposed ESM-based nomogram for predicting in-hospital mortality among older patients with SCAP may help physicians to promptly identify patients prone to adverse outcomes.

TRIAL REGISTRATION

This study was registered at www.chictr.org.cn (registration number Chi CTR-2300070377).

Assessment of body composition in adults hospitalized with acute COVID-19: a scoping review

Introduction

Body composition (BC) assessment can supply accurate information for in-hospital nutritional evaluation. The aim of this study was to explore in the literature how the studies assessed BC, for what purpose, and investigate the role of BC findings in COVID-19 hospitalized patients' outcomes.

Methods

A scoping review was conducted according to the methodology available on the Joanna Briggs Institute website. We used the PCC acronym for the systematic search (population: adults with COVID-19, concept: assessment of BC, context: hospital setting) and performed it on PubMed, Scopus, and the Web of Science on 16 September 2022. Eligibility criteria consisted of the utilization of BC assessment tools in COVID-19 patients. Studies in which BC was solely measured with anthropometry (perimeters and skinfolds) were excluded. No language restriction was applied.

Results

Fifty-five studies were eligible for the review. Out of the 55 studies, 36 used computed tomography (CT), 13 used bioelectrical impedance (BIA), and 6 used ultrasound (US). No studies with D3-creatinine, 24  h urine excretion, dual-energy X-ray absorptiometry, or magnetic resonance were retrieved. BC was mainly assessed to test associations with adverse outcomes such as disease severity and mortality.

Discussion

Studies assessing BC in hospitalized patients with COVID-19 used mainly CT and BIA and associated the parameters with severity and mortality. There is little evidence of BC being assessed by other methods, as well as studies on BC changes during hospitalization.

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

BACKGROUND

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

RESEARCH QUESTION

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

STUDY DESIGN AND METHODS

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

RESULTS

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

INTERPRETATION

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

Prevalence and clinical implications of abnormal body composition phenotypes in patients with COVID-19: a systematic review

BACKGROUND

The impact of body composition (BC) abnormalities on coronavirus disease 2019 (COVID-19) outcomes remains to be determined.

OBJECTIVE

We summarized the evidence on BC abnormalities and their relationship with adverse clinical outcomes in patients with COVID-19.

METHODS

A systematic search was conducted up until September 26, 2022 for observational studies using BC techniques to quantify skeletal muscle mass (or related compartments), muscle radiodensity or echo intensity, adipose tissue (AT, or related compartments), and phase angle (PhA) in adults with COVID-19. Methodological quality of studies was assessed using the Newcastle-Ottawa Scale. A synthesis without meta-analysis was conducted to summarize the prevalence of BC abnormalities and their significant associations with clinical outcomes.

RESULTS

We included 62 studies (69.4% low risk of bias) with 12 to 1,138 participants, except three with up to 490,301 participants. Using computed tomography and different cut-offs, prevalence ranged approximately from 22-90% for low muscle mass, 12-85% for low muscle radiodensity, 16-70% for high visceral AT. Using bioelectrical impedance analysis (BIA), prevalence of high fat mass was 51% and low PhA was 22-88%. Mortality was inversely related to PhA (3/4 studies) and positively related to intramuscular AT (4/5 studies), muscle echo intensity (2/2 studies), and BIA-estimated fat mass (2/2 studies). Intensive care unit admission was positively related to visceral AT (6/7 studies) and total AT (2/3 studies). Disease severity and hospitalization outcomes were positively related to intramuscular AT (2/2 studies). Inconsistent associations were found for the rest of BC measures and hospitalization outcomes.

CONCLUSIONS

Abnormalities in BC were prevalent in patients with COVID-19. Although conflicting associations were observed among certain BC abnormalities and clinical outcomes, higher muscle echo intensity (reflective of myosteatosis) and lower PhA were more consistently associated with greater mortality risk. Likewise, high IMAT and VAT were associated with mortality and ICU admission, respectively.

Sarcopenia and COVID-19 Outcomes

Coronavirus disease 2019 (COVID-19) spread rapidly and became a severe global public health threat. Older adults have a high risk of COVID-19 and its associated mortality. Sarcopenia has emerged as a predictor of poor outcomes in COVID-19 patients, including lengthy hospital stays, mortality, intensive care unit admission, need for invasive mechanical ventilation, and poor rehabilitation outcomes. Chronic inflammation, immune dysfunction, respiratory muscle dysfunction, and swallowing dysfunction may underlie the association between sarcopenia and the poor outcomes of COVID-19 patients. Interleukin 6 receptor blockers (tocilizumab or sarilumab) are recommended for treating patients with severe COVID-19, and their therapeutic effects on sarcopenia are of great interest. This review aimed to analyze the current reports on the association between sarcopenia and COVID-19 and provide an update on the contribution of sarcopenia to the severity and adverse outcomes of COVID-19 and its underlying mechanisms. We also aimed to explore the different screening tools for sarcopenia concurrent with COVID-19, and advocate for early diagnosis and treatment of sarcopenia. Given that the fight against the COVID-19 pandemic may be long-term, further research into understanding the effects of sarcopenia in patients infected with the Omicron variant is necessary.

Prognostic Role of the Pectoralis Musculature in Patients with COVID-19. A Multicenter Study

RATIONALE AND OBJECTIVES

To evaluate the impact of low skeletal muscle mass in patients with COVID-19 on relevant outcomes like 30-day mortality, need for intubation and need for intensive care unit admission.

MATERIALS AND METHODS

For this study, data from six centers were acquired. The acquired sample comprises 1138 patients. There were 547 women (48.1%) and 591 men (51.9%) with a mean age of 54.5 ± 18.8 years; median age, 55 years; range, 18-84 years). In every case, thoracic CT without intravenous application of contrast medium was performed. The following parameters of the pectoralis muscles were estimated: muscle area as a sum of the bilateral areas of the pectoralis major and minor muscles, muscle density, muscle index (PMI) (pectoralis muscle area divided by the patient's body height square) as a ratio pectoralis major and minor muscles divided by the patient's body height², and muscle gauge as PMI x muscle density.

RESULTS

Overall, 220 patients (19.33%) were admitted to the intensive care unit. In 171 patients (15.03%), mechanical lung ventilation was performed. Finally, 154 patients (13.53%) died within the observation time of 30-day. All investigated parameters of pectoralis muscle were lower in the patients with unfavorable courses of Covid-19. All pectoralis muscle parameters were associated with 30-day mortality in multivariate analyses adjusted for age and sex: pectoralis muscle area, HR = 0.93 CI 95% (0.91-0.95) p < 0.001; pectoralis muscle density, HR = 0.94 CI 95% (0.93-0.96) p < 0.001; pectoralis muscle index, HR = 0.79 CI 95% (0.75-0.85) p < 0.001, pectoralis muscle gauge, HR = 0.995 CI 95% (0.99-0.996) p < 0.001.

CONCLUSION

in COVID-19, survivors have larger areas and higher index, gauge and density of the pectoralis muscles in comparison to nonsurvivors. However, the analyzed muscle parameters cannot be used for prediction of disease courses.

Acute skeletal muscle loss in SARS-CoV-2 infection contributes to poor clinical outcomes in COVID-19 patients

BACKGROUND

Chronic disease causes skeletal muscle loss that contributes to morbidity and mortality. There are limited data on the impact of dynamic muscle loss on clinical outcomes in COVID-19. We hypothesized that acute COVID-19-related muscle loss (acute sarcopenia) is associated with adverse outcomes.

METHODS

A retrospective analysis of a prospective clinical registry of COVID-19 patients was performed in consecutive hospitalized patients with acute COVID-19 (n = 95) and compared with non-COVID-19 controls (n = 19) with two temporally unique CT scans. Pectoralis muscle (PM), erector spinae muscle (ESM) and 30 day standardized per cent change in cross sectional muscle area were quantified. Primary outcomes included mortality and need for intensive care unit (ICU) admission. Multivariate linear and logistic regression were performed. Cox proportional hazard ratios were generated for ICU admission or mortality for the per cent muscle loss standardized to 30 days.

RESULTS

The COVID-19 CT scan cohort (n = 95) had an average age of 63.3 ± 14.3 years, comorbidities including COPD (28.4%) and diabetes mellitus (42.1%), and was predominantly Caucasian (64.9%). The proportion of those admitted to the ICU was 54.7%, with 10.5% requiring tracheostomy and overall mortality 16.8%. Median duration between CT scans was 32 days (IQR: 16-63 days). Significant reductions in median per cent loss was noted for PM (-2.64% loss [IQR: -0.28, -5.47] in COVID-19 vs. -0.06 loss [IQR: -0.01, -0.28] in non-COVID-19 CT controls, P < 0.001) and ESM (-1.86% loss [IQR: -0.28, -5.47] in COVID-19 vs. -0.06 loss [IQR: -0.02, -0.11]) in non-COVID-19 CT controls, P < 0.001). Multivariate linear regression analysis of per cent loss in PM was significantly associated with mortality (-10.8% loss [95% CI: -21.5 to -0.19]) and ICU admission (-11.1% loss [95% CI: -19.4 to -2.67]), and not significant for ESM. Cox proportional hazard ratios demonstrated greater association with ICU admission (adj HR 2.01 [95% CI: 1.14-3.55]) and mortality (adj HR 5.30 [95% CI: 1.19-23.6]) for those with significant per cent loss in PM, and greater association with ICU admission (adj HR 8.22 [95% CI: 1.11-61.04]) but not mortality (adj HR 2.20 [95% CI: 0.70-6.97]) for those with significant per cent loss in ESM.

CONCLUSIONS

In a well-characterized cohort of 95 hospitalized patients with acute COVID-19 and two temporally distinct CT scans, acute sarcopenia, determined by standardized reductions in PM and ESM, was associated with worse clinical outcomes. These data lay the foundation for evaluating dynamic muscle loss as a predictor of clinical outcomes and targeting acute sarcopenia to improve clinical outcomes for COVID-19.

Duration of SARS-CoV-2 RNA positivity from various specimens and clinical characteristics in patients with COVID-19: a systematic review and meta-analysis

BACKGROUND

The duration of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA positivity will be important to prevent the spread of coronavirus disease 2019 (COVID-19). A systematic review and meta-analysis were conducted following PRISMA to determine the duration from several parts of the body and clinical characteristics affecting it.

MAIN TEXT

PubMed, Web of Science, Scopus, and CENTRAL were searched for original studies reporting the duration from COVID-19 onset to the disappearance of viral RNA. Of the 1682 studies identified, 100 met the selection criteria and 13,431 patients were included in this study. The duration of SARS-CoV-2 RNA positivity was 18.29 [95% confidence interval: 17.00-19.89] days in the upper respiratory tract samples, 23.79 [20.43-27.16] days in the sputum, 14.60 [12.16-17.05] days in the blood, and 22.38 [18.40-26.35] days in the stool. Sensitivity analysis revealed that the duration was positively correlated with age, comorbidities, severity, and usage of glucocorticoid. Subgroup analysis indicated that the presence or absence of complications had the greatest impact on the difference in DSRP.

CONCLUSIONS

The duration of SARS-CoV-2 RNA positivity was 18.29 days in the upper respiratory tract samples. The duration in the sputum and the stool was longer, while that in the blood was shorter. The duration in the upper respiratory tract samples was longer in older, with any comorbidities, severer, and treated with glucocorticoid. These results provide the basic data for the duration of SARS-CoV-2 RNA positivity, and in the future, the effect of vaccination against SARS-CoV-2 and the SARS-CoV-2 variants on the duration of RNA positivity should be assessed.

Effects of 3 months of multi-nutrient supplementation on the immune system and muscle and respiratory function of older adults in aged care (The Pomerium Study): protocol for a randomised controlled trial

INTRODUCTION

Immunosenescence leads to increased morbidity and mortality associated with viral infections and weaker vaccine responses. This has been well documented for seasonal influenza and the current pandemic with SARS-CoV-2 (COVID-19), which disproportionately impact older adults, particularly those in residential aged care facilities. Inadequate nutrient intakes associated with impaired immunity, respiratory and muscle function are likely to augment the effects of immunosenescence. In this study, we test whether the impact of inadequate nutrition can be reversed using multi-nutrient supplementation, consequently enhancing vaccine responses, reducing the risk of viral infections and improving respiratory and muscle function.

METHODS AND ANALYSIS

The Pomerium Study is a 3-month, single-blind, randomised, controlled trial testing the effects of two daily servings of an oral multi-nutrient supplement (330 kcal, 20 g protein, 1.5 g calcium 3-hydroxy-3-methylbutyrate monohydrate (CaHMB), 449 mg calcium, 500 IU vitamin D₃ and 25 vitamins and minerals) on the immune system and muscle and respiratory function of older adults in aged care in Melbourne, Australia. 160 older adults (≥75 years old) will be recruited from aged care facilities and randomised to treatment (multi-nutrient supplement) or control (usual care). The primary outcome is a change in T-cell subsets CD8 + and CD28null counts at months 1 and 3. Secondary outcomes measured at baseline and month 3 are multiple markers of immunosenescence (also at 1 month), body composition (bioimpedance), handgrip strength (dynamometer), physical function (short physical performance battery), respiratory function (spirometry) and quality of life (EQ-5D-5L). Incidence and complications of COVID-19 and/or viral infections (ie, hospitalisation, complications or death) will be recorded throughout the trial, including 3 months after supplementation is ceased.

ETHICS AND DISSEMINATION

This study was approved by Melbourne Health Human Research Ethics Committee (Ref No. HREC/73985/MH-2021, ERM Ref No. RMH73985, Melbourne Health Site Ref No. 2021.115). Written informed consent will be obtained from participants. Results will be published in peer-reviewed journals and made available to key aged care stakeholders, including providers, residents, and government bodies.

TRIAL REGISTRATION NUMBER

ACTRN12621000420842.

The effectiveness of the sarcopenia index in predicting septic shock and death in elderly patients with community-acquired pneumonia

Background

Community-acquired pneumonia (CAP) causes high morbidity and mortality in all age groups worldwide. Lower muscle radiodensity was associated with worse clinical outcomes (including shock) and higher in-hospital mortality. Prompt detection of sarcopenia in older adults with CAP is important. The measurement of muscle mass often involves specialized and expensive techniques. A relatively simple and inexpensive method such as the sarcopenia index (SI) to measure muscle mass would be helpful. Therefore, we performed a retrospective cohort study to assess the association between SI and septic shock risk and mortality in older patients with CAP.

Study design

In this retrospective cohort study, information on hospitalized CAP patients, including general information and septic shock, were obtained from the medical record database of the Southwest Medical University Zigong Affiliated Hospital, China. Data on patient survival and mortality (all-cause) were acquired from government authorities and telephonic follow-up. Serum creatinine (Cr) and cystatin-C (CysC) levels on admission were included in the database. The SI was determined as the serum Cr/CysC ratio × 100 and the participants were assigned to low and high SI groups. The association between SI and septic shock was evaluated by logistic regression, and that between SI and mortality by Cox regression analysis.

Results

In total, 769 older adults (≥ 60 years) with CAP were included, of which 480(62.4%) were male and 289(37.6%)were female. We found that the total prevalence of septic shock in older adults with CAP was 16.0%. In the female group, septic shock was more prevalent in the low SI group than in the high SI group (low SI vs. high SI, 22.22% vs. 11.52%, p = 0.024). Following adjustment for confounders, there was a significant association between high SI and a lower risk of septic shock in female patients (OR = 0.38, 95%CI: 0.16–0.94; p < 0.05). The total death toll of older adults with CAP was 332(43.2%). Irrespective of sex, there was a higher risk of mortality in the low SI group (total group: low SI vs. high SI, 63.02% vs. 36.57%, p < 0.001; male group: low SI vs. high SI, 63.03% vs. 39.34%, p < 0.001; female group: low SI vs. high SI, 73.61% vs. 28.57%, p < 0.001) and, after adjustment for confounding factors and irrespective of sex, high SI was a protective factor for mortality in older adults with CAP (total group: HR = 0.64, 95%CI: 0.48–0.84; p < 0.05; male: HR = 0.69, 95%CI: 0.49–0.97; p < 0.05; female: HR = 0.39, 95%CI: 0.24–0.62; p < 0.05).

Conclusion

While the SI effectively predicts mortality in older adults with CAP, it was only found to be associated with septic shock in older females.

Cross-sectional area of erector spinae muscles is associated with activities of daily living at discharge in middle- to older-aged patients with coronavirus disease 2019

Objectives

Measurement of skeletal muscle wasting using computed tomography (CT) is widely known to be useful in predicting prognosis. Although some reports have been found in patients with coronavirus disease 2019 (COVID-19), few reports have focused on the ability to perform activities of daily living (ADLs). This study retrospectively investigated the relationship between the erector spinae muscle area measured from CT images and ADL at the time of hospital discharge in patients with COVID-19.

Methods

Among patients aged 40 years or older, 271 patients (median age, 65 years; 180/271 male patients) who had CT cross-sectional images of the 12th thoracic vertebral level on admission were included. The Katz index was used to assess ADLs, and patients who were not completely independent were defined as dependent. Multivariable logistic and Poisson regression analyses were applied to examine the relationship between the cross-sectional area of the erector spinae muscles and the onset of ADL dependence at discharge.

Results

A total of 75 (27.7%) patients became dependent on ADL at the time of hospital discharge. Decreased erector spinae muscle area was significantly related to dependent ADL at discharge (adjusted odds ratio: 0.886, 95% confidence interval: 0.805–0.975). In addition, the erector spinae muscle area was significantly related to the number of ADL items for which independence was not achieved (adjusted incidence rate ratio: 0.959, P < 0.001).

Conclusions

The cross-sectional area of the erector spinae muscles from the thoracic CT image was associated with the ability to perform basic ADL at hospital discharge.

Skeletal muscle depletion predicts death in severe community-acquired pneumonia patients entering ICU

BACKGROUND

Sarcopenia, or skeletal muscle depletion, was common in the elderly and often led to a poor prognosis of diseases. The area of the psoas muscle in abdominal computed tomography (CT) is the most common used for diagnosing sarcopenia. However, patients with pneumonia routinely only undergo chest CT.

OBJECTIVES

This study aimed to determine whether paraspinal muscle area (PMA) obtained by chest CT can predict death for community-acquired pneumonia (SCAP) patients entering intensive care unit (ICU).

METHODS

This study enrolled 208 SCAP patients admitted to ICU after undergoing chest CT. PMA, paraspinal muscle radiodensity (PMD), and lean paraspinal muscle area (LPMA) were calculated on chest CT images. The main outcome was mortality during hospitalization. Logistic regression, receiver operating characteristic (ROC) curve, and Kaplan-Meier curves were used to evaluate forecasting effectiveness.

RESULTS

The primary outcome occurred in 76 (36.53%) patients. In multivariate logistic regression, PMA, lactic dehydrogenase (LDH), invasive mechanical ventilation (IMV), red blood cell (RBC) and age≥ 65 years were independent risk factors predicting death during hospitalization (adjusted Odds Ratio [OR]: 0.886, 1.002, 3.178, 0.612 and 2.003, respectively). The area under curve (AUC) of PMA to predict death was 0.720 (P< 0.001). During hospitalization, the median survival time of high-PMA (51.00 days) and low-PMA groups (20.00 days) was statistically significant (P< 0.001).

CONCLUSION

Lower PMA was associated with an increased risk of death for SCAP patients admitted to the ICU. In other words, PMA may help early identify adverse prognosis of SCAP patients admitted to ICU.