Bioelectric impedance analysis for body composition measurement and other potential clinical applications in critical illness

Fluid accumulation syndrome in sepsis and septic shock: pathophysiology, relevance and treatment-a comprehensive review

In this review, we aimed to comprehensively summarize current literature on pathophysiology, relevance, diagnosis and treatment of fluid accumulation in patients with sepsis/septic shock. Fluid accumulation syndrome (FAS) is defined as fluid accumulation (any degree, expressed as percentage from baseline body weight) with new onset organ-failure. Over the years, many studies have described the negative impact of FAS on clinically relevant outcomes. While the relationship between FAS and ICU outcomes is well described, uncertainty exists regarding its diagnosis, monitoring and treatment. A stepwise approach is suggested to prevent and treat FAS in patients with septic shock, including minimizing fluid intake (e.g., by limiting intravenous fluid administration and employing de-escalation whenever possible), limiting sodium and chloride administration, and maximizing fluid output (e.g., with diuretics, or renal replacement therapy). Current literature implies the need for a multi-tier, multi-modal approach to de-resuscitation, combining a restrictive fluid management regime with a standardized early active de-resuscitation, maintenance fluid reduction (avoiding fluid creep) and potentially using physical measures such as compression stockings.Trial registration: Not applicable.

Bioimpedance analysis for identifying new indicators of exercise-induced muscle damage

A noninvasive, immediate, and convenient method for assessing muscle tissue status during exercise-induced muscle damage (EIMD) has not been established. This study was designed to assess and determine parameters suitable for measuring EIMD after eccentric exercise, using multi-frequency bioimpedance analysis (BIA). Thirty-five young male participants performed dumbbell exercises with their left arm, and their BIA parameters were measured at various time points up to 168 h post exercise using a multi-frequency BIA device. At all-time points, intra and extracellular water content was greater in the left arm than in the right arm, whereas the impedance, reactance, resistance, and phase angle were lower in the left arm than in the right arm. Established EIMD indices, such as maximal isometric voluntary contraction, were measured and used in correlational analyses. Only reactance was correlated with biomarkers, indicating muscle damage (r =  - 0.56 to - 0.49). Furthermore, reactance was found to correlate well with indirect indicators of EIMD, suggesting that it may be a suitable marker for evaluating EIMD. However, the relationship with the limited evaluation indices employed in this study is constrained. Future studies should investigate the correlation between reactance and direct damage indicators, such as structural damage, observed in biopsies.

Analysis of hemodynamics and impedance using bioelectrical impedance analysis in hypovolemic shock-induced swine model

To treat hypovolemic shock, fluid infusion or blood transfusion is essential to address insufficient volume. Much controversy surrounds resuscitation in hypovolemic shock. We aimed to identify the ideal fluid combination for treating hypovolemic shock-induced swine model, analyzing bioelectrical impedance and hemodynamics. Fifteen female three-way crossbred pigs were divided into three different groups. The three resuscitation fluids were (1) balanced crystalloid, (2) balanced crystalloid + 5% dextrose water, and (3) balanced crystalloid + 20% albumin. The experiment was divided into three phases and conducted sequentially: (1) controlled hemorrhage (1 L bleeding, 60 min), (2) resuscitation phase 1 (1 L fluid infusion, 60 min), and (3) resuscitation phase 2 (1 L fluid infusion, 60 min). Bioelectrical impedance analysis was implemented with a segmental multifrequency bioelectrical impedance analyzer. A total of 61 impedance measurements were assessed for each pig at six different frequencies in five segments of the pig. Pulse rate (PR), mean arterial pressure (MAP), stroke volume (SV), and stroke volume variation (SVV) were measured using a minimally invasive hemodynamic monitoring device. The three-dimensional graph showed a curved pattern when infused with 1 L of balanced crystalloid + 1 L of 5% dextrose water and 1.6 L of balanced crystalloid + 400 ml of 20% albumin. The 1M impedance increased in all groups during the controlled hemorrhage, and continuously decreased from fluid infusion to the end of the experiment. Only balanced crystalloid + 20% albumin significantly restored MAP and SV to the same level as the start of the experiment after the end of fluid infusion. There were no significant differences in MAP and SV from the time of recovery to the initial value of 1M impedance to the end of fluid infusion in all groups. The change and the recovery of hemodynamic indices such as MAP and SV coincide with the change and the recovery of 1M impedance. Using balanced crystalloid mixed with 20% albumin in hypovolemic shock-induced swine model may be helpful in securing hemodynamic stability, compared with balanced crystalloid single administration.

Long-Term Rehabilitation Therapy Is Effective for Physical Function in a Patient With Amyloid Light Chain Amyloidosis Complicated by Nephrotic Syndrome: A Case Report and Literature Review

We report on the rehabilitation of a patient with amyloid light chain (AL) amyloidosis complicated by nephrotic syndrome. Various symptoms produced by AL amyloidosis, including nephrotic syndrome, complicate rehabilitation therapy. In this case report, long-term physical therapy was initiated prior to autologous peripheral blood stem cell transplantation owing to the risk of further decline in physical function due to decreased mobility and physical activity. Patients were instructed on how to perform home exercise therapy. Furthermore, compliance was monitored using a checklist and regular face-to-face feedback. There was no increase in skeletal muscle mass, but improvements in grip strength, lower extremity muscle strength, and phase angle were observed after 24 weeks of physical therapy. Despite the absence of partial remission (urinary protein level of 3.5 g/gCre or higher), nephrotic syndrome demonstrated a trend toward improvement. Since the effectiveness of physical therapy in such patients has not yet been fully established, this report suggests that long-term rehabilitation therapy for physical function in patients with nephrotic syndrome complicated by persistent proteinuria may be effective.

[Clinical experience in patients with intestinal failure: a cohort study in a third referral hospital]

Introduction

Introduction: intestinal failure (IF) is an organic failure classified into three types (I-III); it conditions inability to absorb nutrients and water, so parenteral nutrition (PN) is required. Objective: to evaluate the characteristics of hospitalized patients with IF, and their association with clinical and nutritional outcomes. Methods: historical cohort of hospitalized adults with IF and PN. Variables of the nutritional care process (screening, anthropometric, biochemical, clinical, nutritional), mortality and hospital stay were recorded. Results: six hundred and ninety-seven patients aged 56 (41-68) years, 327 women (46.8 %), with body mass index (BMI) 22.4 (18.3-25.9), were included. Diagnosis: 577 patients with IF-I, 96 patients with IF-II, and 24 patients with IF-III. The most frequent causes were malignant neoplasms, IF-I (26.7 %) and surgical complications in IF-II (21.9 %) and IF-III (37.5 %). The most common pathophysiology in all types of IF was motility disorders (40.6 % in IF-I; 43.8 % in IF-II; 33.8 % in IF-III). The majority of patients had high nutritional risk (92.4 %) and refeeding syndrome (65.6 % high and very high). In acute IF (FI-I) compared to prolonged IF (If-II/IF-III) there is a higher BMI (p = 0.039), visceral fat (p = 0.041) and over-hydration (p = 0.014), but they have a smaller phase angle (p = 0.004), with a lower adequacy percentage than what is prescribed in relation to their energy expenditure (p < 0.001). Conclusions: during the nutritional care process there are differences between the types of IF, which are relevant to optimize their multidisciplinary management and avoid related complications.

Difference Between Estimated GFR Based on Cystatin C Versus Creatinine and Incident Atrial Fibrillation: A Cohort Study of the UK Biobank

RATIONALE & OBJECTIVE

The difference between cystatin C-based and creatinine-based estimated glomerular filtration rate (eGFRdiff) has been suggested to reflect factors distinct from kidney function that are associated with cardiovascular risk. However, the association between eGFRdiff and atrial fibrillation (AF) risk has not been extensively evaluated.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

Using data from the UK Biobank, this study included 363,494 participants with measured serum creatinine and cystatin C levels and without a prior diagnosis of AF or a history of related procedures.

EXPOSURE

Estimated GFRdiff, calculated as cystatin C-based eGFR minus creatinine-based eGFR. Estimated GFRdiff was also categorized as negative (<-15mL/min/1.73m2), midrange (-15 to 15mL/min/1.73m2), or positive (≥15mL/min/1.73m2).

OUTCOME

Incident AF.

ANALYTICAL APPROACH

Subdistribution hazard models were fit, treating death that occurred before development of AF as a competing event.

RESULTS

During the median follow-up period of 11.7 years, incident AF occurred in 18,994 (5.2%) participants. In the multivariable-adjusted model, participants with a negative eGFRdiff had a higher risk of incident AF (subdistribution HR [SHR], 1.25 [95% CI, 1.20-1.30]), whereas participants with a positive eGFRdiff had a lower risk of AF (SHR, 0.81 [95% CI, 0.77-0.87]) compared with those with a midrange eGFRdiff. When eGFRdiff was treated as a continuous variable in the adjusted model, every 10mL/min/1.73m2 higher eGFRdiff was associated with a 0.90-fold decrease in the risk of incident AF.

LIMITATIONS

A single measurement of baseline serum creatinine and cystatin C levels.

CONCLUSIONS

The difference between cystatin C- and creatinine-based eGFRs was associated with the risk of AF development. A higher eGFRdiff was associated with a lower risk of AF. These findings may have implications for the management of patients at risk of incident AF.

PLAIN-LANGUAGE SUMMARY

The difference between cystatin C-based estimated glomerular filtration rate (eGFR) and creatinine-based eGFR has recently gained attention as a potential indicator of cardiovascular outcomes influenced by factors other than kidney function. This study investigated the association between the differences in 2 eGFRs (cystatin C-based eGFR minus creatinine-based eGFR) and incident atrial fibrillation (AF) among>340,000 participants from the UK Biobank Study. Compared with those with a near zero eGFR difference, participants with a negative eGFR difference had a higher risk of AF, while those with a positive eGFR difference had a lower risk. These findings suggest that measuring eGFR differences may help identify individuals at a higher risk of developing AF.

Navigating the Intersection: Sarcopenia and Sarcopenic Obesity in Inflammatory Bowel Disease

Inflammatory bowel diseases (IBDs) are intricate systemic conditions that can extend beyond the gastrointestinal tract through both direct and indirect mechanisms. Sarcopenia, characterized by a reduction in muscle mass and strength, often emerges as a consequence of the clinical course of IBDs. Indeed, sarcopenia exhibits a high prevalence in Crohn's disease (52%) and ulcerative colitis (37%). While computed tomography and magnetic resonance imaging remain gold-standard methods for assessing muscle mass, ultrasound is gaining traction as a reliable, cost-effective, and widely available diagnostic method. Muscle strength serves as a key indicator of muscle function, with grip strength test emerging nowadays as the most reliable assessment method. In IBDs, sarcopenia may arise from factors such as inflammation, malnutrition, and gut dysbiosis, leading to the formulation of the 'gut-muscle axis' hypothesis. This condition determines an increased need for surgery with poorer post-surgical outcomes and a reduced response to biological treatments. Sarcopenia and its consequences lead to reduced quality of life (QoL), in addition to the already impaired QoL. Of emerging concern is sarcopenic obesity in IBDs, a challenging condition whose pathogenesis and management are still poorly understood. Resistance exercise and nutritional interventions, particularly those aimed at augmenting protein intake, have demonstrated efficacy in addressing sarcopenia in IBDs. Furthermore, anti-TNF biological therapies showed interesting outcomes in managing this condition. This review seeks to furnish a comprehensive overview of sarcopenia in IBDs, elucidating diagnostic methodologies, pathophysiological mechanisms, and clinical implications and management. Attention will also be paid to sarcopenic obesity, exploring the pathophysiology and possible treatment modalities of this condition.

Multidimensional Assessment of Sarcopenia and Sarcopenic Obesity in Geriatric Patients: Creatinine/Cystatin C Ratio Performs Better than Sarcopenia Index

The serum creatinine/cystatin C ratio (CCR) and the sarcopenia index (SI) are novel indicators for sarcopenia, but their accuracy may depend on various confounders. To assess CCR and SI diagnostic accuracy, we studied the clinical and biophysical parameters associated with sarcopenia or sarcopenic obesity. A total of 79 elderly patients (65-99 yrs, 33 females) underwent clinical, anthropometric, body composition, geriatric performance, and blood chemistry evaluation. The CCR and SI accuracy were assessed to identify sarcopenia. Sarcopenia was confirmed in 40.5%, and sarcopenic obesity in 8.9% of the subjects. Sarcopenic patients showed an increased Charlson comorbidity index, cardiovascular disease (CVD) rates and frailty, and decreased physical performance than non-sarcopenic subjects. Patients with sarcopenic obesity had increased body fat and inflammatory markers compared to obese subjects without sarcopenia. Sarcopenia was associated with a decreased CCR and SI. However, when the logistic regression models were adjusted for possible confounders (i.e., age, gender, Charlson comorbidity index, presence of CVD, and frailty score), a significant OR was confirmed for the CCR (OR 0.021, 95% CI 0.00055-0.83) but not for the SI. The AUC for the CCR for sarcopenia discrimination was 0.72. A higher performance was observed in patients without chronic kidney diseases (CKD, AUC 0.83). CCR, more than the SI, is a useful, non-invasive, and cost-effective tool to predict sarcopenia, irrespective of the potential confounders, particularly in subjects without CKD.

Impact of androgenic anabolic steroid use on cardiovascular and mental health in Danish recreational athletes: protocol for a nationwide cross-sectional cohort study as a part of the Fitness Doping in Denmark (FIDO-DK) study

INTRODUCTION

The use of androgenic anabolic steroids (AASs) among recreational athletes is steadily increasing. However, knowledge regarding the potentially harmful effects of AAS primarily originates from case reports and small observational studies. This large-scale study aims to investigate the impact of AAS use on vascular plaque formation, preclinical coronary disease, cardiac function, circulating cardiovascular risk markers, quality of life (QoL) and mental health in a broad population of illicit AAS users.

METHODS AND ANALYSES

A nationwide cross-sectional cohort study including a diverse population of men and women aged ≥18 years, with current or previous illicit AAS use for at least 3 months. Conducted at Odense University Hospital, Denmark, the study comprises two parts. In part A (the pilot study), 120 recreational athletes with an AAS history will be compared with a sex-matched and age-matched control population of 60 recreational athletes with no previous AAS use. Cardiovascular outcomes include examination of non-calcified coronary plaque volume and calcium score using coronary CT angiography, myocardial structure and function via echocardiography, and assessing carotid and femoral artery plaques using ultrasonography. Retinal microvascular status is evaluated through fundus photography. Cardiovascular risk markers are measured in blood. Mental health outcomes include health-related QoL, interpersonal difficulties, body image concerns, aggression dimensions, anxiety symptoms, depressive severity and cognitive function assessed through validated questionnaires. The findings of our comprehensive study will be used to compose a less intensive investigatory cohort study of cardiovascular and mental health (part B) involving a larger group of recreational athletes with a history of illicit AAS use.

ETHICS AND DISSEMINATION

The study received approval from the Regional Committee on Health Research Ethics for Southern Denmark (S-20210078) and the Danish Data Protection Agency (21/28259). All participants will provide signed informed consent. Research outcomes will be disseminated through peer-reviewed journals and scientific conferences.

TRIAL REGISTRATION NUMBER

NCT05178537.

Determination of resistance at zero and infinite frequencies in bioimpedance spectroscopy for assessment of body composition in babies

Objective. Bioimpedance spectroscopy (BIS) is a popular technique for the assessment of body composition in children and adults but has not found extensive use in babies and infants. This due primarily to technical difficulties of measurement in these groups. Although improvements in data modelling have, in part, mitigated this issue, the problem continues to yield unacceptably high rates of poor quality data. This study investigated an alternative data modelling procedure obviating issues associated with BIS measurements in babies and infants.Approach.BIS data are conventionally analysed according to the Cole model describing the impedance response of body tissues to an appliedACcurrent. This approach is susceptible to errors due to capacitive leakage errors of measurement at high frequency. The alternative is to model BIS data based on the resistance-frequency spectrum rather than the reactance-resistance Cole model thereby avoiding capacitive error impacts upon reactance measurements.Main results.The resistance-frequency approach allowed analysis of 100% of data files obtained from BIS measurements in 72 babies compared to 87% successful analyses with the Cole model. Resistance-frequency modelling error (percentage standard error of the estimate) was half that of the Cole method. Estimated resistances at zero and infinite frequency were used to predict body composition. Resistance-based prediction of fat-free mass (FFM) exhibited a 30% improvement in the two-standard deviation limits of agreement with reference FFM measured by air displacement plethysmography when compared to Cole model-based predictions.Significance.This study has demonstrated improvement in the analysis of BIS data based on the resistance frequency response rather than conventional Cole modelling. This approach is recommended for use where BIS data are compromised by high frequency capacitive leakage errors such as those obtained in babies and infants.

Integrated Sensors for Soft Medical Robotics

Minimally invasive procedures assisted by soft robots for surgery, diagnostics, and drug delivery have unprecedented benefits over traditional solutions from both patient and surgeon perspectives. However, the translation of such technology into commercialization remains challenging. The lack of perception abilities is one of the obstructive factors paramount for a safe, accurate and efficient robot-assisted intervention. Integrating different types of miniature sensors onto robotic end-effectors is a promising trend to compensate for the perceptual deficiencies in soft robots. For example, haptic feedback with force sensors helps surgeons to control the interaction force at the tool-tissue interface, impedance sensing of tissue electrical properties can be used for tumor detection. The last decade has witnessed significant progress in the development of multimodal sensors built on the advancement in engineering, material science and scalable micromachining technologies. This review article provides a snapshot on common types of integrated sensors for soft medical robots. It covers various sensing mechanisms, examples for practical and clinical applications, standard manufacturing processes, as well as insights on emerging engineering routes for the fabrication of novel and high-performing sensing devices.

Total and segmental phase angle in a cohort of hospitalised patients with COVID-19: mortality prediction and changes throughout hospitalisation

Body composition and phase angle (PhA) have been used to predict mortality in multiple diseases. However, little has been studied regarding segmental measurements, which could potentially help assess subtle changes in specific tissue segments. This study aimed to identify the total PhA cut-off point associated with mortality risk and changes in body composition within a week of hospitalisation in non-critical hospitalised patients with COVID-19. A cohort study was conducted where patients underwent to a complete nutritional assessment upon admission and after seven days, and followed up until hospital discharge or death. A receiver operating characteristic curve was constructed to determine the PhA cut-off point, and the Kaplan–Meier estimator was used to determine survival analysis. Segmental and complete body compositions on admission and after 7 d were compared. We included 110 patients (60 men) with a mean age of 50·5 ± 15·0 years and a median BMI of 28·5 (IQR, 25·6–33·5) kg/m2. The median length of hospital stay was 6 (IQR, 4–9) d, and the mortality rate was 13·6 %. The PhA cut-off point obtained was 4°, with significant differences in the survival rate (P < 0·001) and mortality (HR = 5·81, 95 % CI: 1·80, 18·67, P = 0·003). Segmental and whole-body compositions were negatively affected within one week of hospitalisation, with changes in the approach by the graphical method in both sexes. Nutritional status deteriorates within a week of hospitalisation. PhA < 4° is strongly associated with increased mortality in non-critical hospitalised patients with COVID-19.

Adult obesity diagnostic tool: A narrative review

Obesity is a complex chronic metabolic disorder characterized by abnormalities in lipid metabolism. Obesity is not only associated with various chronic diseases but also has negative effects on physiological functions such as the cardiovascular, endocrine and immune systems. As a global health problem, the incidence and prevalence of obesity have increased significantly in recent years. Therefore, understanding assessment methods and measurement indicators for obesity is critical for early screening and effective disease control. Current methods for measuring obesity in adult include density calculation, anthropometric measurements, bioelectrical impedance analysis, dual-energy X-ray absorptiometry, computerized imaging, etc. Measurement indicators mainly include weight, hip circumference, waist circumference, neck circumference, skinfold thickness, etc. This paper provides a comprehensive review of the literature to date, summarizes and analyzes various assessment methods and measurement indicators for adult obesity, and provides insights and guidance for the innovation of obesity assessment indicators.

Smartfeeding: A Dynamic Strategy to Increase Nutritional Efficiency in Critically Ill Patients-Positioning Document of the Metabolism and Nutrition Working Group and the Early Mobilization Working Group of the Catalan Society of Intensive and Critical Care Medicine (SOCMiC)

Adequate medical nutrition therapy for critically ill patients has an impact on their prognoses. However, it requires an individualized approach that takes into account the activity (phases of metabolic stress) and particularity of these patients. We propose a comprehensive strategy considering the patients' nutritional status and the set of modifiable circumstances in these patients, in order to optimize/support nutritional efficiency: (1) A detailed anamnesis and an adequate initial nutritional assessment must be performed in order to implement medical nutrition therapy that is in line with the needs and characteristics of each patient. Furthermore, risks associated with refeeding syndrome, nutritrauma or gastrointestinal dysfunction must be considered and prevented. (2) A safe transition between nutrition therapy routes and between health care units will greatly contribute to recovery. The main objective is to preserve lean mass in critically ill patients, considering metabolic factors, adequate protein intake and muscle stimulation. (3) Continuous monitoring is required for the successful implementation of any health strategy. We lack precise tools for calculating nutritional efficiency in critically ill patients, therefore thorough monitoring of the process is essential. (4) The medical nutrition approach in critically ill patients is multidisciplinary and requires the participation of the entire team involved. A comprehensive strategy such as this can make a significant difference in the functional recovery of critically ill patients, but leaders must be identified to promote training, evaluation, analysis and feedback as essential components of its implementation, and to coordinate this process with the recognition of hospital management.

Clinical practice guidelines for nutritional assessment and monitoring of adult ICU patients in China

The Chinese Society of Critical Care Medicine (CSCCM) has developed clinical practice guidelines for nutrition assessment and monitoring for patients in adult intensive care units (ICUs) in China. This guideline focuses on nutrition evaluation and metabolic monitoring to achieve optimal and personalized nutrition therapy for critically ill patients. This guideline was developed by experts in critical care medicine and evidence-based medicine methodology and was developed after a thorough review of the system and a summary of relevant trials or studies published from 2000 to July 2023. A total of 18 recommendations were formed and consensus was reached through discussions and reviews by expert groups in critical care medicine, parenteral and enteral nutrition, and surgery. The recommendations are based on currently available evidence and cover several key fields, including screening and assessment, evaluation and assessment of enteral feeding intolerance, metabolic and nutritional measurement and monitoring during nutrition therapy, and organ function evaluation related to nutrition supply. Each question was analyzed according to the Population, Intervention, Comparison, and Outcome (PICO) principle. In addition, interpretations were provided for four questions that did not reach a consensus but may have potential clinical and research value. The plan is to update this nutrition assessment and monitoring guideline using the international guideline update method within 3-5 years.

Muscle Dysfunction and Functional Status in COVID-19 Patients during Illness and after Hospital Discharge

BACKGROUND

COVID-19 pneumonia is associated with SIRS and hypercatabolism. The aim of this study was to determine muscle loss during the acute phase of COVID-19 pneumonia and evaluate long-term sequelae in discharged patients.

METHODS

A total of 16 patients with COVID-19 pneumonia and respiratory insufficiency were included in the study. Selected parameters (weight, BMI, LBM = lean body mass, albumin, CRP, NLR = neutrophil-to-lymphocyte ratio, ultrasound measured thickness of rectus femoris muscle = US RF and rectus femoris + vastus intermedius = US RF + VI, handgrip strength, quality of life = EQ-5D questionnaire, and activities of daily living = Barthel's ADLs) were recorded on admission, discharge, and 1, 3, and 6 months after discharge.

RESULTS

The most significant changes were between hospital admission and discharge: US RF and RF + VI (-1.28 ± 1.97 mm, p = 0.046; -1.76 ± 2.94 mm, p = 0.05), EQ-5D score (14.6 ± 19.2, p = 0.02), and ADLs (17.1 ± 22.6; p = 0.02). There was a significant positive correlation between US RF + VI and handgrip strength (p = 0.014) and a negative correlation between weight and Barthel index (p = 0.012). There was an association between muscle function with an EQ-5D score and ADLs during outpatient check-ups, most noticeably between handgrip strength, US RF+VI, and ADLs (p = 0.08; p = 0.1, respectively). Conclusions: In patients with COVID-19 pneumonia, there is a significant reduction of health-related quality of life, impaired even 6 months after hospital discharge, influenced mainly by muscle loss. During the hospital stay, there was a significant muscle mass reduction. Ultrasound measurement of thigh muscle thickness may be a useful method to monitor muscle loss.

Bioimpedance-assessed muscle wasting and its relation to nutritional intake during the first week of ICU: a pre-planned secondary analysis of Nutriti Study

BACKGROUND

Muscle mass evaluation in ICU is crucial since its loss is related with long term complications, including physical impairment. However, quantifying muscle wasting with available bedside tools (ultrasound and bioimpedance analysis) must be more primarily understood. Bioimpedance analysis (BIA) provides estimates of muscle mass and phase angle (PA). The primary aim of this study was to evaluate muscle mass changes with bioimpedance analysis during the first 7 days after ICU admission. Secondary aims searched for correlations between muscular loss and caloric and protein debt.

METHODS

Patients with an expected ICU-stay ≥ 72 h and the need for artificial nutritional support were evaluated for study inclusion. BIA evaluation of muscle mass and phase angle were performed at ICU admission and after 7 days. Considering the difference between ideal caloric and protein targets, with adequate nutritional macronutrients delivered, we calculated the caloric and protein debt. We analyzed the potential correlation between caloric and protein debt and changes in muscle mass and phase angle.

RESULTS

72 patients from September 1st to October 30th, 2019 and from August 1st to October 30th, 2021 were included in the final statistical analysis. Median age was 68 [59-77] years, mainly men (72%) admitted due to respiratory failure (25%), and requiring invasive mechanical ventilation for 7 [4-10] days. Median ICU stay was 8 [6-12] days. Bioimpedance data at ICU admission and after 7 days showed that MM and PA resulted significantly reduced after 7 days of critically illness, 34.3 kg vs 30.6 kg (p < 0.0001) and 4.90° vs 4.35° (p = 0.0004) respectively. Mean muscle loss was 3.84 ± 6.7 kg, accounting for 8.4% [1-14] MM reduction. Correlation between caloric debt (r = 0.14, p = 0.13) and protein debt (r = 0.18, p = 0.13) with change in MM was absent. Similarly, no correlation was found between caloric debt (r = -0.057, p = 0.631) and protein debt (r = -0.095, p = 0.424) with changes in PA.

CONCLUSIONS

bioimpedance analysis demonstrated that muscle mass and phase angle were significantly lower after 7 days in ICU. The total amount of calories and proteins does not correlate with changes in muscle mass and phase angle.

Gender-Related Effectiveness of Personalized Post-COVID-19 Rehabilitation

Background: Post-COVID-19 syndrome (PCS) may affect a substantial proportion of patients who have had COVID-19. The rehabilitation program might improve the physical capacity, functioning of the cardiopulmonary system, and mental conditions of these patients. This study aimed to investigate the effectiveness of personalized rehabilitation in patients with PCS according to gender. Methods: Adults who underwent a 6-week personalized PCS rehabilitation program were enrolled in a prospective post-COVID-19 Rehabilitation (PCR-SIRIO 8) study. The initial visit and the final visit included the hand-grip strength test, the bioimpedance analysis of body composition, and the following scales: modified Borg's scale, Modified Fatigue Impact Scale (MFIS), Functioning in Chronic Illness Scale (FCIS), modified Medical Research Council (mMRC) dyspnea scale, and tests: 30 s chair stand test (30 CST), Six-Minute Walk Test (6MWT), Short Physical Performance Battery test (SPPB)e. Results: A total of 90 patients (54% female) underwent the rehabilitation program. Rehabilitation was associated with an increase in skeletal muscle mass (24.11 kg vs. 24.37 kg, p = 0.001) and phase angle (4.89° vs. 5.01°, p = 0.001) and with a reduction in abdominal fat tissue volume (3.03 L vs. 2.85 L, p = 0.01), waist circumference (0.96 m vs. 0.95 m, p = 0.001), and hydration level (83.54% vs. 82.72%, p = 0.001). A decrease in fat tissue volume and an increase in skeletal muscle mass were observed only in females, while an increase in grip strength was noticed selectively in males. Patients' fatigue (modified Borg's scale, MFIS), physical capacity (30 CST, 6MWT), balance (SPPB), dyspnea (mMRC), and functioning (FICS) were significantly improved after the rehabilitation regardless of gender. Conclusions: Personalized rehabilitation improved the body composition, muscle strength, and functioning of patients diagnosed with PCS. The beneficial effect of rehabilitation on body composition, hydration, and phase angle was observed regardless of gender.

Skeletal muscle atrophy in clinical and preclinical models of chronic kidney disease: A systematic review and meta-analysis

Patients with chronic kidney disease (CKD) are often regarded as experiencing wasting of muscle mass and declining muscle strength and function, collectively termed sarcopenia. The extent of skeletal muscle wasting in clinical and preclinical CKD populations is unclear. We evaluated skeletal muscle atrophy in preclinical and clinical models of CKD, with multiple sub-analyses for muscle mass assessment methods, CKD severity, sex and across the different preclinical models of CKD. We performed a systematic literature review of clinical and preclinical studies that measured muscle mass/size using the following databases: Ovid Medline, Embase and Scopus. A random effects meta-analysis was utilized to determine standard mean difference (SMD; Hedges' g) between healthy and CKD. Heterogeneity was evaluated using the I2 statistic. Preclinical study quality was assessed via the Systematic Review Centre for Laboratory Animal Experimentation and clinical studies quality was assessed via the Newcastle-Ottawa Scale. This study was registered in PROSPERO (CRD42020180737) prior to initiation of the search. A total of 111 studies were included in this analysis using the following subgroups: 106 studies in the primary CKD analysis, 18 studies that accounted for diabetes and 7 kidney transplant studies. Significant atrophy was demonstrated in 78% of the preclinical studies and 49% of the clinical studies. The random effects model demonstrated a medium overall SMD (SMD = 0.58, 95% CI = 0.52-0.64) when combining clinical and preclinical studies, a medium SMD for the clinical population (SMD = 0.48, 95% CI = 0.42-0.55; all stages) and a large SMD for preclinical CKD (SMD = 0.95, 95% CI = 0.76-1.14). Further sub-analyses were performed based upon assessment methods, disease status and animal model. Muscle atrophy was reported in 49% of the clinical studies, paired with small mean differences. Preclinical studies reported significant atrophy in 78% of studies, with large mean differences. Across multiple clinical sub-analyses such as severity of CKD, dialysis modality and diabetes, a medium mean difference was found. Sub-analyses in both clinical and preclinical studies found a large mean difference for males and medium for females suggesting sex-specific implications. Muscle atrophy differences varied based upon assessment method for clinical and preclinical studies. Limitations in study design prevented conclusions to be made about the extent of muscle loss with disease progression, or the impact of dialysis. Future work would benefit from the use of standardized measurement methods and consistent clinical staging to improve our understanding of atrophy changes in CKD progression, and analysis of biological sex differences.

Association between fat-free mass and survival in critically ill patients with COVID-19: A prospective cohort study

BACKGROUND

Most critically ill patients with COVID-19 experience malnutrition and weight loss associated with negative clinical outcomes. Our primary aim was to assess body composition during acute and late phase of illness in these patients in relation to clinical outcome and secondary to tailored nutrition support.

METHODS

This prospective cohort study included adult critically ill patients with COVID-19. Body composition (fat-free mass [FFM] [exposure of interest], fat mass [FM], skeletal muscle mass [SMM], and phase angle [PA]) was determined with multifrequency bioelectrical impedance analyses in the acute and late phase. Nutrition support data were collected simultaneously. Clinical outcome was defined as intensive care unit (ICU) survival (primary outcome) and 30-90 days thereafter, duration of mechanical ventilation, and length of ICU stay and length of hospital stay (LOS). Nonparametric tests and regression analyses were performed.

RESULTS

We included 70 patients (73% male, median age 60 years). Upon admission, median BMI was 30 kg/m2 , 54% had obesity (BMI > 30 kg/m2 ). Median weight change during ICU stay was -3 kg: +3 kg FM and -6 kg FFM (-4 kg SMM). Body composition changed significantly (P < 0.001). Regarding clinical outcome, only low PA was associated with prolonged LOS (odds ratio = 0.83, 95% CI = 0.72-0.96; P = 0.015). Patients with optimal protein intake (>80%) during acute phase maintained significantly more FFM (2.7 kg, P = 0.047) in the late phase compared with patients who received <80%.

CONCLUSION

FFM decreased significantly during acute and late phase of illness, but we observed no association with ICU survival. Only low PA was associated with prolonged LOS. FFM wasting likely occurred because of disease severity and immobility.

Fluid Status Assessment in Critically Ill Patients with COVID-19: A Retrospective Cohort Study

Fluid status (FS) is a diagnostic challenge in critically ill patients with COVID-19. Here, we compared parameters related to FS derived from cumulative fluid balance (CFB), bioelectrical impedance analysis (BIA) and venous congestion assessed by ultrasound (VExUS) to predict mortality. We retrospectively reviewed the medical records of individuals with severe pneumonia due to COVID-19 between July and November 2021 in a single center. Comorbidities, demographic, clinical and laboratory data as well as results from CFB, BIA and VExUS measurements were collected on admission and weekly afterwards for two consecutive evaluations. Seventy-nine patients were included, of which eighteen (14.2%) died. Abnormalities of FS were only identified by BIA. Extracellular water/total body water ratio (ECW/TBW) > 0.394 (overhydrated) by BIA was a good predictor of mortality (AUC = 0.78, 95% CI: 0.067-0.89). Mortality risk was higher in overhydrated patients (OR: 6.2, 95% CI: 1.2-32.6, p = 0.02) and in persistently overhydrated patients (OR: 9.57, 95% CI: 1.18-77.5, p = 0.03) even after adjustment to age, serum albumin and acute kidney injury (AKI) in stages 2-3. Time to death was shorter in overhydrated patients (HR: 2.82, 95% CI: 1.05-7.5, log-rank test p = 0.03). Abnormalities in FS associated with mortality were only identified by BIA in critically ill patients with COVID-19.

Peak Week Carbohydrate Manipulation Practices in Physique Athletes: A Narrative Review

BACKGROUND

Physique athletes are ranked by a panel of judges against the judging criteria of the corresponding division. To enhance on-stage presentation and performance, competitors in certain categories (i.e. bodybuilding and classic physique) achieve extreme muscle size and definition aided by implementing acute "peaking protocols" in the days before competition. Such practices can involve manipulating nutrition and training variables to increase intramuscular glycogen and water while minimising the thickness of the subcutaneous layer. Carbohydrate manipulation is a prevalent strategy utilised to plausibly induce muscle glycogen supercompensation and subsequently increase muscle size. The relationship between carbohydrate intake and muscle glycogen saturation was first examined in endurance event performance and similar strategies have been adopted by physique athletes despite the distinct physiological dissimilarities and aims between the sports.

OBJECTIVES

The aim of this narrative review is to (1) critically examine and appraise the existing scientific literature relating to carbohydrate manipulation practices in physique athletes prior to competition; (2) identify research gaps and provide direction for future studies; and (3) provide broad practical applications based on the findings and physiological reasoning for coaches and competitors.

FINDINGS

The findings of this review indicate that carbohydrate manipulation practices are prevalent amongst physique athletes despite a paucity of experimental evidence demonstrating the efficacy of such strategies on physique performance. Competitors have also been observed to manipulate water and electrolytes in conjunction with carbohydrate predicated on speculative physiological mechanisms which may be detrimental for performance.

CONCLUSIONS

Further experimental evidence which closely replicates the nutritional and training practices of physique athletes during peak week is required to make conclusions on the efficacy of carbohydrate manipulation strategies. Quasi-experimental designs may be a feasible alternative to randomised controlled trials to examine such strategies due to the difficulty in recruiting the population of interest. Finally, we recommend that coaches and competitors manipulate as few variables as possible, and experiment with different magnitudes of carbohydrate loads in advance of competition if implementing a peaking strategy.

Comparison of Bioelectrical Impedance Analysis (BIA)-Derived Parameters in Healthy Volunteers and Critically Ill Patients

OBJECTIVE

To compare bioelectrical impedance analysis (BIA)-derived parameters in healthy volunteers and critically ill patients and to assess its prognostic value in an ICU patient cohort.

DESIGN

Retrospective, observational data analysis.

SETTING

Single centre, tertiary-level ICU (Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg Hospital).

PATIENTS

101 patients and 101 healthy subjects, participants of International Fluid Academy Days.

MEASUREMENTS AND MAIN RESULTS

Compared to healthy volunteers, both male and female ICU patients had significantly higher values for total body water (TBW), extracellular water (ECW), extracellular fluid (ECF), plasma, and interstitial fluid volumes. The phase angle was significantly lower and the malnutrition index was significantly higher in ICU patients, regardless of gender. Non-survivors in the ICU had significantly higher extracellular water content (ECW, 50.7 ± 5.1 vs. 48.9 ± 4.3%, p = 0.047) and accordingly significantly lower intracellular water (ICW, 49.2 ± 5.1 vs. 51.1 ± 4.3%, p = 0.047). The malnutrition index was also significantly higher in non-survivors compared to survivors (0.94 ± 0.17 vs. 0.87 ± 0.16, p = 0.048), as was the capillary leak index (ECW/ICW).

CONCLUSIONS

Compared to healthy volunteers, this study observed a higher malnutrition index and TBW in ICU patients with an accumulation of fluids in the extracellular compartment. ICU non-survivors showed similar results, indicating that ICU patients and a fortiori non-survivors are generally overhydrated, with increased TBW and ECW, and more undernourished, as indicated by a higher malnutrition index.

Individualised energy and protein targets achieved during intensive care admission are associated with lower mortality in mechanically ventilated COVID-19 patients: The COFEED-19 study

BACKGROUND & AIMS

Malnutrition is prevalent among COVID-19 patients admitted to the intensive care unit (ICU) and it is associated with poor survival. Customized nutrition plays a vital role in enhancing outcomes for this patient population. This study explores the association between energy and protein intake and 90-day mortality in invasively mechanically ventilated COVID-19 patients, utilizing fat-free mass (FFM) and actual body weight (ABW) for nutritional requirements. Furthermore, the study investigates the occurrence of gastrointestinal (GI) intolerance in critically ill COVID-19 patients in relation to their nutritional intake and survival.

METHODS

A retrospective study was undertaken at a university-affiliated teaching hospital, focusing on COVID-19 patients on invasive mechanical ventilation admitted to the ICU between March 2020 and December 2021. The study collected demographic and clinical data, along with cumulative energy and protein goals, and recorded cumulative intake on days 4, 7, and throughout the ICU stay. Univariate and multivariable Cox regression analyses were conducted to evaluate associations between energy and protein deficits and the 90-day all-cause mortality.

RESULTS

The study included 85 patients, of whom 67 (78 %) survived 90 days after ICU admission. There were no significant differences in body composition between survivors and non-survivors. Reaching ≥70 % of the energy goal based on both ABW and FFM during the ICU stay was associated with decreased 90-day mortality (HR 0.22, 95 % CI 0.08-0.60 and HR 0.28, 95 % CI 0.09-0.85, respectively). Similarly, achieving ≥80 % of the protein target based on FFM was associated with decreased 90-day mortality (HR 0.26, 95 % CI 0.07-0.94), whereas no significant association was found for reaching protein targets based on ABW (HR 0.03, 95 % CI 0.00-3.40). Patients who reached both their energy and protein goal based on FFM during ICU admission showed a lower risk of all-cause 90-day mortality compared to those who received <70 % of the energy goal and <80 % of protein based on FFM after adjusting for age (aHR 0.12, 95 % CI 0.03-0.50). No differences in GI intolerance related symptoms between COVID-19 survivors and non-survivors were observed.

CONCLUSIONS

This study underscores the significance of providing adequate nutritional therapy to COVID-19 ICU patients who require IMV. Meeting over 80 % of the protein goals based on BIA-derived FFM was associated with lower mortality rates, which emphasizes the need for further investigation into the role of FFM in establishing nutritional targets.

Impact of Immuno-Nutrition on the Nutritional Status, Inflammatory Response and Clinical Outcome of Clinic-Admitted Mild-Intensity-COVID-19 Patients: A Pilot, Perspective-Concluding Study

The SARS-CoV-2 pandemic has impacted our lives since early 2020. Both malnutrition and an overweight status significantly correlate with worse patient outcomes and mortality. Immuno-nutrition (IN) has shown promising results in the inflammatory bowel disease (IBD) clinical course and the extubation time and mortality of patients admitted to intensive care units (ICUs). Thus, we wanted to assess the impact of a standardized IN oral formula on COVID-19 patients admitted to our mild-intensity clinic in late 2021. We prospectively enrolled patients admitted to the Internal Medicine COVID-19 Unit of San Benedetto General Hospital. All patients had biochemical, anthropometric, HRCT chest scan, and nutritional assessments at the time of admission and, after oral immuno-nutrition formula administration, at 15 days of the interval follow up. We enrolled 52 consecutive patients (mean age of 60.9 ± 5.4 years, 17 F, and BMI of 23.5 Kg/m2). The main comorbidities were diabetes (20%, type 2: 90%), hyperuricemia (15%), hypertension (38%), chronic ischemic heart disease (12%), COPD (13%), anxiety (10%), and depression (8%). Upon informed consent, 14 patients (mean age of 67.9 ± 5.4 years, 7 F, and BMI of 26.7 Kg/m2) were accepted to be administered IN. A moderate to severe overweight status was present in 59% of the patients; MNA test (4.4 ± 0.7) and phase angle (PA) values, suggestive of malnutrition, were present in 13% of the patients. After 15 days of admission, we recorded three deaths (mean age of 68.9 ± 4.1 years, 3 F, and BMI of 27.5 Kg/m2). An overweight status significantly correlated with the exitus occurrence (r = 0.65). One death was reported among the IN-treated patients. IN administration was followed by a significant decrease in inflammatory markers with a tendency to be higher than those of non-treated patients. IN prevented the worsening of BMI and PA vs. non-treated patients. In this overweight COVID-19 population, immuno-nutrition prevented malnutrition development with a significant decrease in inflammatory markers.

Body composition and muscle strength at the end of ICU stay are associated with 1-year mortality, a prospective multicenter observational study

BACKGROUND & AIMS

After a prolonged intensive care unit (ICU) stay patients experience increased mortality and morbidity. The primary aim of this study was to assess the prognostic value of nutritional status, body mass composition and muscle strength, as assessed by body mass index (BMI), bioelectrical impedance analysis (BIA), handgrip (HG) test, and that of the biological features to predict one-year survival at the end of a prolonged ICU stay.

METHODS

This was a multicenter prospective observational study. Survivor patients older than 18 years with ICU length of stay >72 h were eligible for inclusion. BIA and HG were performed at the end of the ICU stay. Malnutrition was defined by BMI and fat-free mass index (FFMI). The primary endpoint was one-year mortality. Multivariable logistic regression was performed to determine parameters associated with mortality.

RESULTS

572 patients were included with a median age of 63 years [53.5; 71.1], BMI of 26.6 kg/m2 [22.8; 31.3], SAPS II score of 43 [31; 58], and ICU length of stay of 9 days [6; 15]. Malnutrition was observed in 142 (24.9%) patients. During the 1-year follow-up after discharge, 96 (18.5%) patients died. After adjustment, a low HG test score (aOR = 1.44 [1.11; 1.89], p = 0.01) was associated with 1-year mortality. Patients with low HG score, malnutrition, and Albuminemia <30 g/L had a one-year death rate of 41.4%. Conversely, patients with none of these parameters had a 1-year death rate of 4.1%.

CONCLUSION

BIA to assess FFMI, HG and albuminemia at the end of ICU stay could be used to predict 1-year mortality. Their ability to identify patients eligible for a structured recovery program could be studied.

Angiopoietin-2 is associated with capillary leak and predicts complications after cardiac surgery

BACKGROUND

Patients undergoing cardiac surgery are prone to numerous complications. Increased vascular permeability may be associated with morbidity and mortality due to hemodynamic instability, fluid overload, and edema formation. We hypothesized that markers of endothelial injury and inflammation are associated with capillary leak, ultimately increasing the risk of postoperative complications.

METHODS

In this prospective, observational, multidisciplinary cohort study at our tertiary academic medical center, we recruited 405 cardiac surgery patients. Patients were assessed daily using body impedance electrical analysis, ultrasound, sublingual intravital microscopy, and analysis of serum biomarkers. Multivariable models, as well as machine learning, were used to study the association of angiopoietin-2 with extracellular water as well as common complications after cardiac surgery.

RESULTS

The majority of patients underwent coronary artery bypass grafting, valvular, or aortic surgeries. Across the groups, extracellular water increased postoperatively (20 ± 6 preoperatively to 29 ± 7L on postoperative day 2; P < 0.001). Concomitantly, the levels of the biomarker angiopoietin-2 rose, showing a strong correlation based on the time points of measurements (r = 0.959, P = 0.041). Inflammatory (IL-6, IL-8, CRP) and endothelial biomarkers (VE-Cadherin, syndecan-1, ICAM-1) suggestive of capillary leak were increased. After controlling for common risk factors of edema formation, we found that an increase of 1 ng/mL in angiopoietin-2 was associated with a 0.24L increase in extracellular water (P < 0.001). Angiopoietin-2 showed increased odds for the development of acute kidney injury (OR 1.095 [95% CI 1.032, 1.169]; P = 0.004) and was furthermore associated with delayed extubation, longer time in the ICU, and a higher chance of prolonged dependence on vasoactive medication. Machine learning predicted postoperative complications when capillary leak was added to standard risk factors.

CONCLUSIONS

Capillary leak and subsequent edema formation are relevant problems after cardiac surgery. Levels of angiopoietin-2 in combination with extracellular water show promising potential to predict postoperative complications after cardiac surgery.

TRIAL REGISTRATION NUMBER

German Clinical Trials Registry (DRKS No. 00017057), Date of registration 05/04/2019, www.drks.de.

Personalized nutrition therapy in critical care: 10 expert recommendations

Personalization of ICU nutrition is essential to future of critical care. Recommendations from American/European guidelines and practice suggestions incorporating recent literature are presented. Low-dose enteral nutrition (EN) or parenteral nutrition (PN) can be started within 48 h of admission. While EN is preferred route of delivery, new data highlight PN can be given safely without increased risk; thus, when early EN is not feasible, provision of isocaloric PN is effective and results in similar outcomes. Indirect calorimetry (IC) measurement of energy expenditure (EE) is recommended by both European/American guidelines after stabilization post-ICU admission. Below-measured EE (~ 70%) targets should be used during early phase and increased to match EE later in stay. Low-dose protein delivery can be used early (~ D1-2) (< 0.8 g/kg/d) and progressed to ≥ 1.2 g/kg/d as patients stabilize, with consideration of avoiding higher protein in unstable patients and in acute kidney injury not on CRRT. Intermittent-feeding schedules hold promise for further research. Clinicians must be aware of delivered energy/protein and what percentage of targets delivered nutrition represents. Computerized nutrition monitoring systems/platforms have become widely available. In patients at risk of micronutrient/vitamin losses (i.e., CRRT), evaluation of micronutrient levels should be considered post-ICU days 5-7 with repletion of deficiencies where indicated. In future, we hope use of muscle monitors such as ultrasound, CT scan, and/or BIA will be utilized to assess nutrition risk and monitor response to nutrition. Use of specialized anabolic nutrients such as HMB, creatine, and leucine to improve strength/muscle mass is promising in other populations and deserves future study. In post-ICU setting, continued use of IC measurement and other muscle measures should be considered to guide nutrition. Research on using rehabilitation interventions such as cardiopulmonary exercise testing (CPET) to guide post-ICU exercise/rehabilitation prescription and using anabolic agents such as testosterone/oxandrolone to promote post-ICU recovery is needed.

Branched-chain amino acids plus vitamin D supplementation promote increased muscle strength following lumbar surgery for lumbar spinal stenosis: a randomized trial

BACKGROUND CONTEXT

Adequate nutrition is essential to address the surgical stress response and mitigate loss of muscle mass, strength, and functionality in older adults with lumbar spinal stenosis (LSS). However, it is unknown whether amino acids and/or vitamin D are beneficial in older adults following lumbar surgery for LSS.

PURPOSE

To evaluate whether branched-chain amino acids (BCAA) plus vitamin D supplementation could attenuate the loss of muscle mass and strength, accelerate the return of functional mobility, and improve clinical outcomes following lumbar surgery for LSS.

STUDY DESIGN/SETTING

A single-center, single-blind randomized controlled trial.

PATIENT SAMPLE

Eighty patients who received lumbar surgery for LSS.

OUTCOME MEASURES

The primary outcome was the Zurich claudication questionnaire (ZCQ), and secondary outcomes included knee muscle strength, muscle mass measured by bioelectrical impedance analysis, gait speed and a timed up-and-go test (TUG) at 12 weeks postoperatively. Follow-up assessment was performed for the ZCQ at 52 weeks postoperatively.

METHODS

Patients ingested the supplementation (BCAA group: BCAA plus vitamin D, Nonamino acid group: nonamino acid) twice daily for 3 weeks from the day after surgery, and received two hours of postoperative inpatient rehabilitation 5 times a week.

RESULTS

No significant differences were observed in the mean changes on the ZCQ between the two groups at 12 weeks and 52 weeks. At 2 weeks postoperatively, the nonamino acid group showed significant deterioration compared with the BCAA group for strengths of knee extensor and knee flexor (p < .01). At 12 weeks, the BCAA group showed significant improvements in knee extensor strength and knee flexor strength compared with the nonamino acid group (p <.01). There were no significant differences in mean changes of muscle mass, maximum gait speed, and TUG at 12 weeks between two groups.

CONCLUSIONS

BCAA plus vitamin D supplementation did not improve LSS-related clinical outcomes after lumbar surgery for LSS, even though muscle strength increased. Future studies should focus on long-term outcomes for muscle mass and physical function, including development of sarcopenia and frailty.

Association between phase angle and the nutritional status in pediatric populations: a systematic review

Background and aims

Malnutrition is prevalent in pediatric populations with any disease, and it is also related to changes in body composition. In addition, recent studies have documented relationships between these changes and phase angle (PhA), an important parameter of functional nutritional assessment. PhA could be a new marker of nutritional status. Many studies have generated information about the association between PhA and malnutrition in various pathologies, although the vast majority of this information is from adult populations. In this systematic review, we answered the following question: What is the association between PhA and the nutritional status in pediatric populations?

Methods

We performed a systematic search of the Medline/PubMed and Latin American and Caribbean Health Sciences Literature databases (LILACS) databases for studies published up to October 2022. The inclusion criteria were pediatric subjects, which reported the relationship between PhA and the nutritional status with any objective nutritional indicator, and PhA was measured by electric impedance and reported at 50 kHz. We synthesized data from the studies that reported cutoff analysis of PhA with receiver operating characteristic (ROC) curves, mean PhA values presented by nutritional status strata, and correlations between PhA and nutritional status indicators. We assessed the risk of bias by using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and the Quality Assessment for Diagnostic Accuracy Studies.

Results

Of the 126 studies we identified, 15 met the inclusion criteria. The included studies reported the association between PhA and objective indicators of nutritional status, including weight-for-age z-score (WAZ) <-1 standard deviation (SD) for malnutrition, height-for-age z-score (HAZ) for malnutrition-stunting, body mass index (BMI) for the starvation state, body mass index z-score (BMIz) and BMI for malnutrition, mid-upper arm circumference (MUAC) <11 cm for severe acute malnutrition (SAM), and fat-free mass index z-score (FFMIz) <-2 z-score for moderate malnutrition, among others. The report of these associations between PhA and nutritional status was based on cutoff points generated with ROC curve analysis or comparison of mean PhA values, which were reported stratified by the presence or absence of malnutrition, and correlations between PhA and anthropometric indicators for the evaluation of the nutritional status in the pediatric population. It was difficult to compare the studies due to the heterogeneity of the bioelectrical impedance analysis models used, how PhA was reported (standardized, percentiles, or degrees), and the anthropometric indicators used to diagnose malnutrition.

Conclusion

The early identification of malnutrition is relevant to establish the correct nutritional treatment; PhA appears to be a sensitive indicator of nutritional status and is easy to obtain. Although the results of this review are inadequate to establish PhA cutoff points associated with malnutrition in pediatric populations, in most of the studies, there was an association between PhA and objective indicators of nutritional status.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022362413, identifier: PROSPERO 2022 CRD42022362413.

Handgrip Strength Test and Bioelectrical Impedance Analysis in SARS-CoV-2 Patients Admitted to Sub-Intensive Unit

Hospitalized patients with respiratory failure due to SARS-CoV-2 pneumonia are at increased risk of malnutrition and related mortality. The predictive value of the Mini-Nutritional Assessment short form (MNA-sf^®), hand-grip strength (HGS), and bioelectrical impedance analysis (BIA) was determined with respect to in-hospital mortality or endotracheal intubation. The study included 101 patients admitted to a sub-intensive care unit from November 2021 to April 2022. The discriminative capacity of MNA-sf, HGS, and body composition parameters (skeletal mass index and phase angle) was assessed computing the area under the receiver operating characteristic curves (AUC). Analyses were stratified by age groups (<70/70+ years). The MNA-sf alone or in combination with HGS or BIA was not able to reliably predict our outcome. In younger participants, HGS showed a sensitivity of 0.87 and a specificity of 0.54 (AUC: 0.77). In older participants, phase angle (AUC: 0.72) was the best predictor and MNA-sf in combination with HGS had an AUC of 0.66. In our sample, MNA- sf alone, or in combination with HGS and BIA was not useful to predict our outcome in patients with COVID-19 pneumonia. Phase angle and HGS may be useful tools to predict worse outcomes in older and younger patients, respectively.

Current insights in ICU nutrition: tailored nutrition

PURPOSE OF REVIEW

To summarize recent research on critical care nutrition focusing on the optimal composition, timing, and monitoring of enteral feeding strategies for (post)-ICU patients. We provide new insights on energy and protein recommendations, feeding intolerance, and describe nutritional practices for coronavirus disease 2019 ICU patients.

RECENT FINDINGS

The use of indirect calorimetry to establish individual energy requirements for ICU patients is considered the gold standard. The limited research on optimal feeding targets in the early phase of critical illness suggests avoiding overfeeding. Protein provision based upon the absolute lean body mass is rational. Therefore, body composition measurements should be considered. Body impedance analysis and muscle ultrasound seem reliable, affordable, and accessible methods to assess body composition at the bedside. There is inadequate evidence to change our practice of continuous enteral feeding into intermittent feeding. Finally, severe acute respiratory syndrome coronavirus 2 patients are prone to underfeeding due to hypermetabolism and should be closely monitored.

SUMMARY

Nutritional therapy should be adapted to the patient's characteristics, diagnosis, and state of metabolism during ICU stay and convalescence. A personalized nutrition plan may prevent harmful over- or underfeeding and attenuate muscle loss. Despite novel insights, more research is warranted into tailored nutrition strategies during critical illness and convalescence.

Molecular, Metabolic, and Nutritional Changes after Metabolic Surgery in Obese Diabetic Patients (MoMen): A Protocol for a Multicenter Prospective Cohort Study

Metabolic surgery is an essential option in the treatment of obese patients with type 2 diabetes (T2D). Despite its known advantages, this surgery still needs to be introduced in Malaysia. In this prospective study, the pathophysiological mechanisms at the molecular level will be studied and the metabolomics pathways of diabetes remission will be explored. The present study aims to evaluate the changes in the anthropometric measurements, body composition, phase angle, diet intake, biochemistry parameters, adipokines, microRNA, and metabolomics, both pre- and post-surgery, among obese diabetic patients in Malaysia. This is a multicenter prospective cohort study that will involve obese patients (n = 102) with a body mass index (BMI) of ≥25 kg/m2 (Asian BMI categories: WHO/IASO/IOTF, 2000) who will undergo metabolic surgery. They will be categorized into three groups: non-diabetes, prediabetes, and diabetes. Their body composition will be measured using a bioimpedance analyzer (BIA). The phase angle (PhA) data will be analyzed. Venous blood will be collected from each patient for glycated hemoglobin (HbA1c), lipids, liver, renal profile, hormones, adipokines, and molecular and metabolomics analyses. The serum microRNA will be measured. A gene expression study of the adipose tissue of different groups will be conducted to compare the groups. The relationship between the 1HNMR-metabolic fingerprint and the patients’ lifestyles and dietary practices will be determined. The factors responsible for the excellent remission of T2D will be explored in this study.

Effect of Immuno-Nutrition on Malnutrition, Inflammatory Response and Clinical Course of Semi-Critically Ill COVID-19 Patients: A Pilot Perspective Study

BACKGROUND

The SARS-COV 2 pandemic has hit on our lives since early 2020. During different contagion waves, both malnutrition and overweight significantly correlated with patient mortality. Immune-nutrition (IN) has shown promising results in the clinical course of pediatric inflammatory bowel disease (IBD) and in both the rate of extubation and mortality of patients admitted to an intensive care unit (ICU). Thus, we wanted to assess the effects of IN on a clinical course of patients admitted to a semi-intensive COVID-19 Unit during the fourth wave of contagion that occurred at the end of 2021.

METHODS

we prospectively enrolled patients admitted to the semi-intensive COVID-19 Unit of San Benedetto General hospital. All patients had a biochemical, anthropometric, high-resolution tomography chest scan (HRCT) and complete nutritional assessments at the time of admission, after oral administration of immune-nutrition (IN) formula, and at 15 days interval follow-up.

RESULTS

we enrolled 34 consecutive patients (age 70.3 ± 5.4 years, 6 F, BMI 27.0 ± 0.5 kg/m²). Main comorbidities were diabetes (20%, type 2 90 %), hyperuricemia (15%), hypertension (38%), chronic ischemic heart disease (8 %), COPD (8%), anxiety syndrome (5%), and depression (5%). 58% of patients were affected as moderately-to-severely overweight; mini nutritional assessment (MNA) score (4.8 ± 0.7) and phase angle (PA) values (3.8 ± 0.5) suggestive of malnutrition were present in 15% of patients, mainly with a history of cancer. After 15 days upon admission, we recorded 3 deaths (mean age 75.7 ± 5.1 years, BMI 26.3 ± 0.7 kg/m²) and 4 patients were admitted to the ICU. Following IN formula administration, inflammatory markers significantly decreased (p < 0.05) while BMI and PA did not worsen. These latter findings were not observed in a historical control group that did not receive IN. Only one patient needed protein-rich formula administration.

CONCLUSIONS

in this overweight COVID-19 population immune-nutrition prevented malnutrition development with a significant decrease of inflammatory markers.

Update on Lean Body Mass Diagnostic Assessment in Critical Illness

Acute critical illnesses can alter vital functions with profound biological, biochemical, metabolic, and functional modifications. Despite etiology, patient's nutritional status is pivotal to guide metabolic support. The assessment of nutritional status remains complex and not completely elucidated. Loss of lean body mass is a clear marker of malnutrition; however, the question of how to investigate it still remains unanswered. Several tools have been implemented to measure lean body mass, including a computed tomography scan, ultrasound, and bioelectrical impedance analysis, although such methods unfortunately require validation. A lack of uniform bedside measurement tools could impact the nutrition outcome. Metabolic assessment, nutritional status, and nutritional risk have a pivotal role in critical care. Therefore, knowledge about the methods used to assess lean body mass in critical illnesses is increasingly required. The aim of the present review is to update the scientific evidence regarding lean body mass diagnostic assessment in critical illness to provide the diagnostic key points for metabolic and nutritional support.

Relationship Between Appetite-Related Peptides and Frailty in Older Adults

BACKGROUND

Frailty, is a geriatric syndrome that reduces the resistance to stress situations caused by activities of daily living and increases morbidity and mortality. We hypothesized that a decrease in orexigenic peptides or an increase in anorexigenic peptides might be associated with frailty. We aimed to investigate the relationship between frailty and six appetite-related peptides: ghrelin, neuropeptide Y (NPY), agouti-related peptide (AgRP), cocaine-amphetamine-associated peptide (CART), peptide YY, and alpha MSH (α-MSH).

METHODS

This cross-sectional study was conducted on 85 older adults who visited the outpatient clinic. All patients underwent comprehensive geriatric assessment. Frailty status was assessed using the Fried frailty index. Plasma levels of six appetite-related peptides were studied.

RESULTS

The mean age was 73.7 ± 5.4 years, 27 (31.8%) of the patients were male, and 32 of the patients (37.6%) were frail. While plasma levels of ghrelin, NPY and AgRP were significantly lower in frail patients, CART and α-MSH levels were higher compared to non-frail patients (p < .05 for all). Peptide YY was found to be higher in the frail group, however, the difference did not reach statistical significance (p = .052). In multivariate logistic regression analysis, the ghrelin, AgRP, CART, and α-MSH levels were independent predictors of frailty. Moreover, a weak correlation was found between all peptides(except NPY) and handgrip strength and Lawton-Brody score.

CONCLUSION

Ghrelin, AgRP, CART, and α-MSH levels were found to be independent predictors of frailty. Our results suggest that appetite-related peptides might be playing roles in the pathogenesis of frailty. Further larger prospective studies are needed to test this hypothesis.

Relationship Between Skeletal Muscle Quality and Hospital-Acquired Disability in Patients With Sepsis Admitted to the ICU: A Pilot Study

Early risk assessment of functional decline in patients with sepsis is clinically challenging. Recently, there is increasing interest in the nonvolitional evaluation of skeletal muscle quality.

OBJECTIVES

The aim of this study was to assess the relationship between skeletal muscle quality and functional decline after intensive care.

DESIGN SETTING AND PARTICIPANTS

This pilot study was a single-center prospective observational study conducted from March 2021 to February 2022. We included consecutive patients with sepsis who were admitted to our ICU.

MAIN OUTCOMES AND MEASURES

The primary outcome was hospital-acquired disability (HAD), which is defined as a decrease in the Barthel index score of at least 5 points from pre-hospital to hospital discharge. Muscle quality was assessed by: 1) muscle echogenicity with ultrasound and 2) phase angle (PhA) with bioelectrical impedance analysis, both of which were measured on ICU days less than 3, 3-5, 5-7, 7-10, and 10-14. We compared longitudinal changes in muscle echogenicity and PhA between the HAD and non-HAD groups using two-way repeated measures analysis of variance with mixed models.

RESULTS

Among the 22 patients, 7 (31.8%) had HAD. Muscle echogenicity was higher in the HAD group than in the non-HAD group (p < 0.001); however, no interaction effects were found between the two groups (p = 0.189). PhA showed a main effect on each evaluation day in patients (p = 0.040) and a significant interaction effect between the groups, including an early decreased pattern in the HAD group (p = 0.036).

CONCLUSIONS AND RELEVANCE

Higher muscle echogenicity and a decreased PhA pattern are related to HAD. Noninvasive assessment of muscle quality using ultrasound and bioelectrical impedance analysis may be useful in predicting the functional prognosis of patients with sepsis.

Bioelectrical Impedance Spectroscopy for Monitoring Mammalian Cells and Tissues under Different Frequency Domains: A Review

Bioelectrical impedance analysis and bioelectrical impedance spectroscopy (BIA/BIS) of tissues reveal important information on molecular composition and physical structure that is useful in diagnostics and prognostics. The heterogeneity in structural elements of cells, tissues, organs, and the whole human body, the variability in molecular composition arising from the dynamics of biochemical reactions, and the contributions of inherently electroresponsive components, such as ions, proteins, and polarized membranes, have rendered bioimpedance challenging to interpret but also a powerful evaluation and monitoring technique in biomedicine. BIA/BIS has thus become the basis for a wide range of diagnostic and monitoring systems such as plethysmography and tomography. The use of BIA/BIS arises from (i) being a noninvasive and safe measurement modality, (ii) its ease of miniaturization, and (iii) multiple technological formats for its biomedical implementation. Considering the dependency of the absolute and relative values of impedance on frequency, and the uniqueness of the origins of the α-, β-, δ-, and γ-dispersions, this targeted review discusses biological events and underlying principles that are employed to analyze the impedance data based on the frequency range. The emergence of BIA/BIS in wearable devices and its relevance to the Internet of Medical Things (IoMT) are introduced and discussed.

Revised Protein Sparing Diet in Obesity and Type 2 Diabetes Mellitus

Effective nutrition therapy is a pressing issue in obesity and type 2 diabetes mellitus (T2DM) management. As such, this research aimed to determine the performance of a revised dietary strategy built on the protein-sparing diet in obesity and type 2 diabetes mellitus with regard to obtaining a rapid and stable improvement in glucometabolic control, body weight, body composition, and energy metabolism when applying the strategy in just twenty-one days. The revised protein-sparing diet differs from the traditional protein-sparing modified fast (PSMF) because it does not include foods. The daily calorie intake of this diet is exclusively derived from Isolate whey protein in addition to a formulation of Isolate whey protein enriched with essential amino acids in free form, with the addition of lipids such as extra virgin olive oil and coconut oil as a source of medium chain fatty acids, where the latter is taken for only the first four days of the diet, together with the use, for the same duration, of extended-release metformin, as the only antihyperglycemic allowed. Anthropometric measurements, bioimpedance analysis, indirect calorimetry, and blood chemistry assessments were conducted at the beginning of the study, time 0 (T0), and at the end, time 1 (T1), i.e., on the 21st day. The main outcomes of the revised protein-sparing diet after only twenty-one days were a reduction in body weight with the predominant loss of visceral atherogenic abdominal fat and, therefore, a possible contextual reduction in ectopic fat deposits together with a simultaneous reduction in insulin resistance and normalization of insulin levels, maintenance of free fat mass and basal metabolism, restoration of metabolic flexibility, and improvement of the glucometabolic and lipidic parameters. These results demonstrate the promising potential of the revised protein-sparing diet as an "etiologic tool" in the integrated nutritional treatment of metabolic diseases such as obesity and type 2 diabetes mellitus.

Feasibility study using longitudinal bioelectrical impedance analysis to evaluate body water status during fluid resuscitation in a swine sepsis model

Fluid resuscitation is crucial in the initial management of sepsis; however, little is known about the serial changes and overall distribution of fluids administered into the body. To identify the feasibility of longitudinal bioelectrical impedance analysis during fluid treatment, a preclinical porcine model of Escherichia coli-induced sepsis was used. After sepsis induction, pigs were treated with fluid and vasopressors and monitored for up to 12 h after bacterial infusion or until death. Bipolar electrodes for bioelectrical impedance analysis were attached to the left extremities and measurements were performed every 10 min. Among the 12 subjects, 7 pigs expired during the experiment, and the median survival was 9.5 h. As sepsis progressed with an increase in cumulative fluid balance, R₀ [∝ 1/extracellular water (ECW)] decreased, while R_i [∝ 1/intracellular water (ICW)] and ratio of extracellular water to total body water (ECW/TBW) increased. The phase angle constantly decreased throughout the monitoring period, and all non-survivors died when the phase angle decreased by more than 10%. Among the variables, ΔR₀ and Δphase angle showed moderate negative correlations, and ΔECW/TBW showed a moderate positive correlation with the hourly fluid balance. Compared to survivors, a greater increase in ΔECW/TBW and a decrease in phase angle were observed in non-survivors over time, with an increase in cumulative fluid balance. Differences in ΔECW/TBW and phase angle emerged at 240 min when the difference in cumulative fluid balance between the two groups (survivors vs non-survivors) exceeded 1000 mL. In conclusion, continuous measurements of bioelectrical impedance analysis in a porcine sepsis model are feasible and may reflect changes in the body water profile during fluid resuscitation.

The levels of TGFβ1, VEGF, PDGF-BB, and PF4 in platelet-rich plasma of professional soccer players: a cross-sectional pilot study

Background

Regenerative therapy using platelet-rich plasma (PRP), a rich source of growth factors, has become popular in orthopedic sports medicine. Elite athletes prefer PRP therapy for their injured muscles and tendons primarily to avoid the possible risks of surgical treatment. However, the clinical effectiveness of PRP therapy in elite athletes compared to that in non-athletes remains unknown. Therefore, to investigate the effectiveness of PRP therapy in professional athletes (pro-athletes), we focused on the quality of PRP preparations and compared the levels of bioactive molecules between pro-athletes and non-athletes.

Methods

PRP was prepared from healthy, non-smoking male professional soccer players (pro-athletes) (n = 22) and non-athletes (VEGF: n = 34, others: n = 38). The levels of TGFβ1, PDGF-BB, VEGF, and PF4 were determined using ELISA kits. Polyphosphate was probed with 4’,6-diamidino-2-phenylindole and monitored using a fluorometer. The body composition of the donors was determined using a bathroom weighing scale.

Results

The levels of TGFβ1 and VEGF were significantly lower in pro-athletes than in non-athletes, whereas PF4 levels were significantly higher in pro-athletes. No significant difference was found in PDGF-BB levels between these groups. Biomolecule levels were not correlated with polyphosphate levels.

Conclusion

TGFβ1, VEGF, and PDGF-BB levels in pro-athletes were not higher than those in non-athletes. These findings suggest that growth factor levels in PRP may not be a predominant determinant of the clinical effectiveness of PRP therapy in pro-athletes. Increased PF4 levels in pro-athletes suggest an immunological function of PRP that may positively influence tissue regeneration.

The impact of an early intervention home-based program on body composition in preterm-born preschoolers with very low birth weight

Background and aims

Early child interventions focused on the family prevented neurodevelopmental and behavioral delays and can provide more knowledge regarding responsive feeding, thus creating learning opportunities to promote better quality nutrition and preventing failure to thrive. The aim is to verify the impact of a continuous program of early home-based intervention on the body composition of preschool infants who were born preterm with very low birth weight (VLBW).

Methods

This is a longitudinal analysis from a randomized controlled trial, including VLBW preterm children, born in a tertiary hospital in Southern Brazil and followed up at the high-risk institutional ambulatory clinic. Participants were divided into the intervention group (IG): skin-to-skin care with the mother (kangaroo care), breastfeeding policy, and tactile-kinesthetic stimulation by mothers until hospital discharge. Subsequently, they received a program of early intervention with orientation and a total of 10 home visits, independently from the standard evaluation and care that was performed following the 18 months after birth; conventional group (CG): standard care according to the routine of the newborn intensive care unit (NICU), which includes kangaroo care, and attending to their needs in the follow-up program. Body composition estimation was performed using bioelectrical impedance analyses (BIA), and physical activity and feeding practices questionnaires were evaluated at preschool age, as well as anthropometric measurements and biochemical analysis.

Results

Data of 41 children at 4.6 ± 0.5 years old were evaluated (CG n = 21 and IG n = 20). Body weight, height, body mass index, waist and arm circumferences, and triceps and subscapular skinfold did not differ between groups. The IG presented higher segmented fat-free mass (FFM) when compared to the CG (right arm FFM: 0.74 vs. 0.65 kg, p = 0.040; trunk FFM: 6.86 vs. 6.09 kg, p = 0.04; right leg FFM: 1.91 vs. 1.73 kg, p = 0.063). Interaction analyses showed that segmented FFM and FFM Index were associated with higher iron content in the IG. In the CG, interaction analyses showed that increased visceral fat area was associated with higher insulin resistance index.

Conclusion

An early intervention protocol from NICU to a home-based program performed by the mothers of VLBW preterm children of low-income families presents a small effect on FFM.

Does Body Position Influence Bioelectrical Impedance? An Observational Pilot Study

As the availability of various bioelectric impedance analysis (BIA) tools is increasing, the patient's position during the test may be of significant importance for the comparability of the results. An observational pilot study was undertaken between March and May 2021 at the Center for Innovative Research in Medical and Natural Sciences at the University of Rzeszow, Rzeszów, Poland. All participants (n = 49: M: 21.05 y ± 1.12 vs. F: 21.34 y ± 2.06) were subjected to measurements of selected nutritional status indicators and body components in three positions: lying, sitting and standing. The body composition indicators were obtained using a bioelectrical impedance device, AKERN BIA 101 Anniversary Sport Edition Analyzer (Akern SRL, Pontassieve, Florence, Italy). The results were analyzed using dedicated software (BodygramPlus 1.2.2.12 from AKERN 2016, Florence, Italy). Our observations indicate that there is a significant difference between lying and standing as well as sitting and standing with respect to anthropometric and nutritional indicators (resistance, reactance, phase angle, standardized phase angle, body cell mass index and fat-free mass index) and body composition components, with particular reference to intracellular and extracellular water. The described differences are significant for both sexes. This study showed that this significantly influenced the scores of components directly related to resistance, reactance and hydrated cell mass, while not affecting the percentages or absolute values of fat and fat-free mass.

Nutrition support for critically ill patients during the COVID-19 pandemic: the Italian SIAARTI survey

Background

Critically ill, COVID-19 patients are characterized by a hypermetabolic state and a reduced food intake and are at high risk of malnutrition and lean body mass loss. An appropriate metabolic-nutritional intervention aims to reduce complications and improve the clinical outcomes. We conducted a cross-sectional, multicenter, observational, nationwide online survey involving Italian Intensivists to assess the nutritional practices in critically ill patients with COVID-19.

Results

A group of experts in nutrition of the Italian Society of Anaesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) developed a 24-item questionnaire; the 9000 members of the Society were invited to participate through emails and social networks. Data was collected from June 1 to August 1, 2021.

A total of 545 responses were collected: 56% in northern, 25% in central, and 20% in southern Italy. Artificial nutrition support is directly handled by intensivists in > 90 of the cases; the nutritional status is assessed as suggested by the guidelines in more than 70% of the cases, and a form of nutrition support is started within the first 48 h from ICU admission by > 90% of the respondents. Nutritional targets are reached in 4–7 days in > 75% of the cases, mainly by the enteral route. Indirect calorimetry, muscle ultrasound, and bioimpedance analysis are used by a limited part of the interviewees. Only about a half of the respondents reported the nutritional issues in the ICU discharge summary.

Conclusions

This survey among Italian Intensivists during the COVID-19 epidemic showed how the beginning, progression, and route of nutritional support adhere to international recommendations, while recommendations on the tools to set the target and monitor the efficacy of the metabolic support are less followed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s44158-022-00063-6.

[Assessment and technical monitoring of nutritional status of patients in intensive and intermediate care units : Position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI)]

Die Erhebung des Ernährungsstatus zum Zeitpunkt der Aufnahme im Intensiv- oder Intermediate Care Bereich hat sowohl prognostische als auch therapeutische Relevanz im Hinblick auf die Planung einer individualisierten medizinischen Ernährungstherapie (engl. „medical nutrition therapy“, MNT). Diese Planung wird im Rahmen der Erstversorgung eines vital bedrohlichen Krankheitsbilds nachvollziehbar nicht priorisiert, jedoch im weiteren Verlauf häufig auch oft nicht mehr angemessen durchgeführt. Vor allem bei längerer Verweildauer besteht das Risiko einer Mangelernährung mit Aufbau eines kumulativen, prognoserelevanten Makro- und/oder Mikronährstoffdefizits. Bisher gibt es für Patient*innen auf Intensiv- und Intermediate Care Einheiten keine strukturierten Empfehlungen zur Erhebung des Ernährungsstatus. Das vorliegende Positionspapier der Sektion Metabolismus und Ernährung der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI) beinhaltet konsensbasierte Empfehlungen zur Erfassung und zum apparativen Monitoring des Ernährungsstatus von Patient*innen auf Intensiv- und Intermediate Care Stationen. Diese Empfehlungen ergänzen die aktuelle S2k-Leitlinie „Klinische Ernährung in der Intensivmedizin“ der Deutschen Gesellschaft für Ernährungsmedizin (DGEM) und der DIVI.

Bioelectric impedance body composition and phase angle in relation to 90-day adverse outcome in hospitalized COVID-19 ward and ICU patients: The prospective BIAC-19 study

BACKGROUND & AIMS

Gaining insight into readily obtainable baseline characteristics that allow prediction of adverse outcome in COVID-19 aids both treatment and healthcare planning. Bioelectric impedance (BIA) Phase Angle (PhA) is correlated with outcome in a multitude of diseases and may be of added value in predicting adverse outcome of COVID-19. We aimed to associate baseline body composition parameters with 90-day adverse outcome of COVID-19 including ICU-admission and to explore the added predictive value of baseline PhA.

METHODS

We performed a prospective observational study, conducting BIA amongst COVID-19 patients within 24 hours of hospital admission, with a follow-up of 90 days. Data were compared between ward-only and ICU-patients. Regression models were used to assess the associations between baseline characteristics, body composition and 90-day adverse outcome, including a composite outcome score of morbidity, ICU-admission, and mortality. An ROC-curve was used to explore the added predictive value of PhA to other clinical parameters at baseline for the prediction of adverse outcome.

RESULTS

One-hundred-and-fifty patients were included. Mean age was 68 (66-70) years, 67% were male. Forty-one (27%) patients were admitted to ICU and 77 (51%) met the criteria of the composite outcome score. In multiple regression, PhA was independently, inversely correlated with risk of ICU-admission (OR .531, p = .021), complications (OR .579, p = .031), hospital length of stay (OR .875, p = .037) and the composite outcome score (OR .502, p = .012). An ROC-curve showed that the incorporation of PhA in a composite risk-score improved the discriminative power for the composite outcome from poor to fair, compared to individual predictors (AUC 0.79 (95% CI 0.71-0.87)).

CONCLUSION

BIA measurements including Phase Angle are independently correlated with an adverse outcome of COVID-19. Interpretation of Phase Angle can be a valuable addition to risk assessment of adverse outcome of COVID-19 at hospital admission.

CLINICAL TRIAL REGISTRATION

Netherlands Trial Register number NL8562, registered 2020-04-21.