Mid-arm muscle circumference as a significant predictor of all-cause mortality in male individuals

Head and Neck Cancer and Sarcopenia: An Integrative Clinical and Functional Review

Sarcopenia is recognized as a crucial factor impacting the prognosis, treatment responses, and quality of life of HNC patients. This review discusses various mechanisms, including common etiological factors, such as aging, chronic inflammation, and metabolic dysregulation. Cancer-related factors, including tumor locations and treatment modalities, contribute to the development of sarcopenia. The clinical implications of sarcopenia in HNC patients extend beyond reduced muscle strength; it affects overall mobility, reduces quality of life, and increases the risk of falls and fractures. Sarcopenia serves as an independent predictor of postoperative complications, chemotherapy dose-limiting toxicity, and treatment outcomes, which affect therapy planning and perioperative management decisions. Methods to assess sarcopenia in HNC patients encompass various techniques. A sarcopenia assessment offers a potentially efficient and readily available tool for clinical practice. Interventions and management strategies for sarcopenia involve exercise interventions as a cornerstone; however, challenges arise due to patient-specific limitations during cancer treatment. A routine body composition analysis is proposed as a valuable addition to HNC patient management, with ongoing research required to refine preoperative exercise and nutrition programs for improved treatment outcomes and survival.

Effects of a Personalized Diet on Nutritional Status and Renal Function Outcome in Nephrectomized Patients with Renal Cancer

Nutritional therapy (NT) based on a controlled protein intake represents a cornerstone in managing chronic kidney disease (CKD). However, if a CKD patient is at the same time affected by cancer, oncologists and nutritionists tend to suggest a dietary regimen based on high protein intake to avoid catabolism and malnutrition. International guidelines are not clear when we consider onco-nephrological patients and, as a consequence, no clinical shared strategy is currently applied in clinical practice. In particular, no precise nutritional management is established in nephrectomized patients for renal cell carcinoma (RCC), a specific oncological cohort of patients whose sudden kidney removal forces the remnant one to start a compensatory mechanism of adaptive hyperfiltration. Our study aimed to investigate the efficacy of a low-normal-protein high-calorie (LNPHC) diet based on a Mediterranean model in a consecutive cohort of nephrectomized RCC patients using an integrated nephrologist and nutritionist approach. A consecutive cohort of 40 nephrectomized RCC adult (age > 18) patients who were screened for malnutrition (malnutrition screening tool, MST < 2) were enrolled in a tertiary institution between 2020 and 2022 after signing a specific informed consent form. Each patient underwent an initial nephrological and nutritional evaluation and was subsequently subjected to a conventional CKD LNPHC diet integrated with aproteic foods (0.8 g/Kg/die: calories: 30-35 kcal per kg body weight/die) for a period of 6 months (±2 months). The diet was structured after considering eGFR (CKD-EPI 2021 creatinine formula), comorbidities, and nutritional status. MST, body mass index (BMI), phase angle (PA), fat mass percentage (FM%), fat-free mass index (FFMI), body cell mass index (BCMI), extracellular/intracellular water ratio (ECW/ICW), extracellular matrix/body cell mass ratio (ECM/BCM), waist/hip circumference ratio (WHC), lab test exams, and clinical variables were examined at baseline and after the study period. Our results clearly highlighted that the LNPHC diet was able to significantly improve several nutritional parameters, avoiding malnutrition and catabolism. In particular, the LNPHC diet preserved the BCM index (delta on median, ΔM + 0.3 kg/m2) and reduced the ECM/BCM ratio (ΔM - 0.03 *), with a significant reduction in the ECW/ICW ratio (ΔM - 0.02 *), all while increasing TBW (ΔM + 2.3% *). The LNPHC diet was able to preserve FFM while simultaneously depleting FM and, moreover, it led to a significant reduction in urea (ΔM - 11 mg/dL **). In conclusion, the LNPHC diet represents a new important therapeutic strategy that should be considered when treating onco-nephrological patients with solitary kidney due to renal cancer.

The relationships between sarcopenia, frailty, bioelectrical impedance analysis, and anthropometry in patients with type two intestinal failure

INTRODUCTION

SARC-F (Strength, Assistance in walking, Rise from a chair, Climb stairs and Falls) is a validated screening questionnaire for rapidly assessing sarcopenia in older adults with a variety of diseases while the Rockwood clinical frailty scale (RCFS) is a commonly used tool for assessing frailty in older adults. However, there are no data regarding the use of these tools in patients with type two intestinal failure (T2IF). We aimed to compare SARC-F and RCFS to bioelectrical impedance analysis (BIA) and anthropometry in patients with T2IF.

METHODS

In this cross-sectional study, patients with T2IF admitted to a national U.K. reference centre had SARC-F, RCFS, BIA and anthropometry performed. A SARC-F score ≥4 indicated potential sarcopenia while a RCFS ≥5 indicated frailty. Statistical analyses were conducted to assess correlation, concordance and differences between measurements.

RESULTS

The study comprised 76 patients, of whom 59.2 % were female, with a mean age of 56.5 years ± 16. Seventy percent of patients had short bowel syndrome as an underlying cause of IF. Thirty eight percent of patients had a SARC-F ≥4 and 20 % had a RCFS ≥5. SARC-F was correlated with RCFS (rs 0.43, p < 0.001), phase angle (PA) (rs -0.55, p < 0.001) and hand grip strength (HGS) (rs -0.34, p 0.004). RCFS was correlated with HGS (rs -0.31, p 0.009). Significant differences emerged between PA (p 0.002) and HGS (p 0.003) values in patients with SARC-F scores ≥4 and < 4 and with HGS for patients with RCFS ≥5 and < 5 (p 0.01). Patients with SARC-F scores ≥4 had longer lengths of stays than those with scores <4 (p 0.002). Compared to PA and HGS, SARC-F had sensitivities of 39 % and 37 % and specificities of 92 % and 73 % respectively.

CONCLUSION

We demonstrated SARC-F is correlated with PA and HGS with comparable sensitivity and specificity to its original use in older individuals. There is a role for SARC-F as a means of rapidly assessing muscle quality and function in hospitalised patients with IF with RCFS providing some useful information about muscle function.

The L-shaped association of mid-upper arm circumference with all-cause and cause-specific mortality in US adults: a population-based prospective cohort study

BACKGROUND

The arm circumference is a feasible and reliable indicator in evaluating the nutritional status of children. However, its application in general adults has yet to be thoroughly investigated.

OBJECTIVE

This study aimed to evaluate the association between mid-upper arm circumferences (MUACs) and mortality in general adults.

METHODS

The nationally representative cohort from the National Health and Nutrition Examination Survey (1999-2018) was analyzed with mortality information obtained through linkage to the National Death Index. The baseline MUACs were collected as exposure. Survey-weighted Cox proportional hazard regressions were performed to estimate the hazard ratios (HRs) and 95% confidential intervals (CIs) of mortality risk for individuals with different MUACs. Restricted cubic spline analyses were performed to examine the nonlinear association of MUAC with all-cause and cause-specific mortality.

RESULTS

A total of 52,159 participants were included in this study. During a median follow-up time of 117 months, 7157 deaths were documented, with leading causes of cardiovascular disease (CVD), cancer, and respiratory disease. Individuals in the first quartile (Q1) of MUAC tended to have higher all-cause mortality risk than the rest after full adjustment. Similarly, CVD mortality risk in Q1 was higher than that in the second quartile (Q2) and the third quartile (Q3); respiratory mortality risk in Q1 was higher than in Q2. MUAC was non-linearly associated with all-cause mortality and CVD mortality. Individuals in Q1 MUAC (≤ 29.3) tended to have higher all-cause mortality risk, with HRs (95% CIs) estimated to be 0.76 (0.67-0.87) for Q2 (29.4, 32.5), 0.69 (0.59-0.81) for Q3 (32.6, 36.0), and 0.59 (0.46-0.75) for Q4 (≥ 36.1) after adjustment of demographic, lifestyle, and comorbidity covariates. Similarly, compared with Q1, HRs (95% CIs) for CVD mortality were estimated to be 0.73 (0.58-0.93) for Q2 and 0.57 (0.43-0.47) for Q3; HRs (95% CIs) for respiratory mortality was estimated to be 0.57 (95% CI, 0.37-0.87) for Q2 with other differences not significant.

CONCLUSION

The MUAC was inversely associated with long-term mortality in general adults in the United States and may serve as a valuable measurement in adult health evaluations.

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.

An Exploratory Study on a New Method for Nutritional Status Assessment in Patients with Chronic Kidney Disease

Malnutrition is a risk factor for disease progression and poor prognosis in chronic kidney disease (CKD). However, the complexity of nutritional status assessment limits its clinical application. This study explored a new method of nutritional assessment in CKD (stage 1-5) patients using the Subjective Global Assessment (SGA) as the gold standard and evaluated its applicability. The kappa test was used to analyze the consistency of the Renal Inpatient Nutrition Screening Tool (Renal iNUT) with SGA and protein-energy wasting. Logistic regression analysis was used to analyze the risk factors of CKD malnutrition and calculate the prediction probability of multiple indicators combined for the diagnosis of CKD malnutrition. The receiver operating characteristic curve of the prediction probability was drawn to evaluate its diagnostic efficiency. A total of 161 CKD patients were included in this study. The prevalence of malnutrition according to SGA was 19.9%. The results showed that Renal iNUT had a moderate consistency with SGA and a general consistency with protein-energy wasting. Age > 60 years (odds ratio, OR = 6.78), neutrophil-lymphocyte ratio > 2.62 (OR = 3.862), transferrin < 200 mg/dL (OR = 4.222), phase angle < 4.5° (OR = 7.478), and body fat percentage < 10% (OR = 19.119) were risk factors for malnutrition in patients with CKD. The area under the receiver operating characteristic curve of multiple indicators for the diagnosis of CKD malnutrition was 0.89 (95% confidence interval: 0.834-0.946, p < 0.001). This study demonstrated that Renal iNUT has good specificity as a new tool for the nutrition screening of CKD patients, but its sensitivity needs to be optimized. Advanced age, high neutrophil-lymphocyte ratio, low transferrin level, low phase angle, and low body fat percentage are risk factors for malnutrition in patients with CKD. The combination of the above indicators has high diagnostic efficiency in the diagnosis of CKD malnutrition, which may be an objective, simple, and reliable method to evaluate the nutritional status of patients with CKD.

Association of muscle wasting with mortality risk among adults: A systematic review and meta-analysis of prospective studies

The relationship between muscle wasting and mortality risk in the general population remains unclear. Our study was conducted to examine and quantify the associations between muscle wasting and all-cause and cause-specific mortality risks. PubMed, Web of Science and Cochrane Library were searched until 22 March 2023 for main data sources and references of retrieved relevant articles. Prospective studies investigating the associations of muscle wasting with risks of all-cause and cause-specific mortality in the general population were eligible. A random-effect model was used to calculate the pooled relative risk (RR) and 95% confidence intervals (CIs) for the lowest versus normal categories of muscle mass. Subgroup analyses and meta-regression were performed to investigate the potential sources of heterogeneities among studies. Dose-response analyses were conducted to evaluate the relationship between muscle mass and mortality risk. Forty-nine prospective studies were included in the meta-analysis. A total of 61 055 deaths were ascertained among 878 349 participants during the 2.5- to 32-year follow-up. Muscle wasting was associated with higher mortality risks of all causes (RR = 1.36, 95% CI, 1.28 to 1.44, I²  = 94.9%, 49 studies), cardiovascular disease (CVD) (RR = 1.29, 95% CI, 1.05 to 1.58, I²  = 88.1%, 8 studies), cancer (RR = 1.14, 95% CI, 1.02 to 1.27, I²  = 38.7%, 3 studies) and respiratory disease (RR = 1.36, 95% CI, 1.11 to 1.67, I²  = 62.8%, 3 studies). Subgroup analyses revealed that muscle wasting, regardless of muscle strength, was significantly associated with a higher all-cause mortality risk. Meta-regression showed that risks of muscle wasting-related all-cause mortality (P = 0.06) and CVD mortality (P = 0.09) were lower in studies with longer follow-ups. An approximately inverse linear dose-response relationship was observed between mid-arm muscle circumference and all-cause mortality risk (P < 0.01 for non-linearity). Muscle wasting was associated with higher mortality risks of all causes, CVD, cancer and respiratory disease in the general population. Early detection and treatment for muscle wasting might be crucial for reducing mortality risk and promoting healthy longevity.

Diagnosis, Prevalence and Significance of Obesity in a Cohort of CKD Patients

BACKGROUND

data regarding the association between obesity and morbidity/mortality in patients with chronic kidney disease (CKD) are uncertain and sometimes contradictory. The aims of our study were to determine the associations among different measures of obesity and adiposity, and the risk of all-cause mortality or dialysis entry in stage 3-5 CKD patients.

MATERIALS

this observational cohort study included 178 CKD patients followed for a median of 71 months. Biochemistry, anthropometric measures such as body mass index (BMI), waist-to-hip ratio, mid-arm muscle circumference (MAMC) and body composition by bioimpedance analysis were evaluated.

RESULTS

we found a weak agreement between BMI and other measures of adiposity. In multivariable regression analysis, all measures of obesity such as BMI, waist circumference and waist-to-height ratio were not associated with dialysis entry and/or mortality. Instead, MAMC was associated with dialysis entry HR 0.82 [95% CI: 0.75-0.89] and high FM% with mortality HR 2.08 [95% CI: 1.04-4.18].

CONCLUSIONS

in our CKD population, lower MAMC was predictive of dialysis commencing, while a higher percentage of fatty mass was a predictor of mortality. Instead, obesity, as defined by BMI, is not associated with dialysis commencing or all-cause mortality.

Comparison of nutritional risk screening with NRS2002 and the GLIM diagnostic criteria for malnutrition in hospitalized patients

Nutritional risk screening, to identify patients at risk of malnutrition, is the first step in the prevention and treatment of malnutrition in hospitalized patients, and should be followed by a thorough nutritional assessment resulting in a diagnosis of malnutrition and subsequent treatment. In 2019, a consensus on criteria has been suggested for the diagnosis of malnutrition by the Global Leadership Initiative for Malnutrition (GLIM). This study investigates the diagnosis of malnutrition in hospitalized patients using nutritional risk screening and the diagnostic assessment suggested by GLIM. Hospitalized patients (excluding cancer, intensive care, and transmissible infections) who underwent nutritional risk screening (by NRS2002) were included. Nutritional risk screening was followed by anthropometric measurements including measurement of muscle mass, assessment of dietary intake and measurement of serum C-reactive protein (CRP) for inflammation in all patients. Malnutrition was diagnosed according to the GLIM-criteria. In total, 328 patients (median age 71 years, 47% women, median length of stay 7 days) were included. Nutritional risk screening identified 143 patients as at risk of malnutrition, while GLIM criteria led to a diagnosis of malnutrition in 114 patients. Of these 114 patients, 77 were also identified as at risk of malnutrition by NRS2002, while 37 patients were not identified by NRS2002. Malnutrition was evident in fewer patients than at risk of malnutrition, as expected. However, a number of patients were malnourished who were not identified by the screening procedure. More studies should investigate the importance of inflammation and reduced muscle mass, which is the main difference between nutritional risk screening and GLIM diagnostic assessment.

The Relation of Serum Dehydroepiandrosterone Sulfate Level to Protein Energy Wasting in Hemodialysis Patients

Protein-energy wasting (PEW) is a major risk for morbidity and mortality in hemodialysis (HD) patients. The change in the concentration of dehydroepiandrosterone sulfate (DHEA-S) may play a role in PEW. The aim of this work was to study the possible relationship between serum DHEA-S levels and various nutritional and inflammatory parameters in a cohort of HD patients. In total, 78 HD patients (47 males and 31 females) were included in this crosssectional observational study. In addition to taking their history, clinical examinations, and routine laboratory investigations, the nutritional status was assessed, and their serum DHEA-S was measured. Nutritional status was assessed by anthropometric measures, bioelectrical impedance analysis, malnutrition inflammation scores, and subjective global assessments. A diagnosis of malnutrition was made based on the recommendations of the International Society of Renal Nutrition and Metabolism. The relationship between DHEA-S and various nutritional parameters was analyzed. Eighteen patients (23.1%) suffered from PEW. Those with PEW had a longer duration of HD (P = 0.04), and lower serum levels of creatinine (P = 0.003), hemoglobin (P = 0.01), albumin (P <0.0001), cholesterol (P = 0.02), and DHEA-S (P = 0.01). Among the variables, serum DHEA-S levels were significant predictors of PEW in this cohort (odds ratio: 0.976; 95% confidence interval: 0.954-1.0; P = 0.04). PEW is frequently encountered in HD patients. Decreased serum DHEA-S levels were associated with PEW in male HD patients. Further studies are needed to assess the effect of hormone supplementation on this serious disorder in HD patients.

Nutritional screening and assessment in inflammatory bowel disease

Inflammatory bowel disease (IBD) is associated with increased risk of malnutrition and sarcopenia. Both malnutrition and sarcopenia negatively impact the clinical course, quality of life, response to therapy, and surgical outcomes in patients with IBD. This review article highlights the importance of nutritional assessment in patients with IBD and also discusses the different nutritional screening and assessment tools, and measures to detect sarcopenia in relation to IBD. Identification of malnutrition and sarcopenia will allow prioritization of the corrective actions, such as nutritional rehabilitation, to improve clinical outcomes. An approach to the evaluation of nutritional status in patients with IBD is also suggested.

Health-related quality of life and associated factors in HIV-positive transplant candidates and recipients from a HIV-positive donor

INTRODUCTION

HRQOL in transplant candidates and recipients who are also infected with HIV and are awaiting a kidney, or have received one from a HIV-positive donor, has not been previously investigated.

METHODS

The HRQOL of 47 HIV-positive kidney transplant candidates and 21 recipients from HIV-positive donors was evaluated using the Short Form-36 (SF-36) and face to face interviews at baseline and at 6 months. The correlation between SF-36 scores and sociodemographic, clinical and nutritional factors was determined.

RESULTS

68 patients completed the SF-36 at baseline and 6 months. Transplant candidates: transplant candidates had lower HRQOL than recipients. The main mental stressors were income, employment and waiting for a donor. Physical health complaints were body pain (BP) and fatigue. Pre-albumin and BMI was positively correlated with general health at baseline (r = 0.401, p = 0.031 and r = 0.338, p = 0.025). Besides a positive association with role physical (RP) and BP, albumin was associated with overall physical composite score (PCS) (r = 0.329, p = 0.024) at 6 months. Transplant recipients: Transplant recipients had high HRQOL scores in all domains. PCS was 53.8 ± 10.0 and 56.6 ± 6.5 at baseline and 6 months respectively. MCS was 51.3 ± 11.5 and 54.2 ± 8.5 at baseline and 6 months respectively. Albumin correlated positively with PCS (r = 0.464, p = 0.034) at 6 months and role emotional (RE) (r = 0.492, p = 0.024). Higher pre-albumin was associated with better RE and RP abilities and MCS (r = 0.495, p = 0.034). MAMC was associated with four domains of physical health and strongly correlated with PCS (r = 0.821, p = 0.000).

CONCLUSION

Strategies to improve HRQOL include ongoing social support, assistance with employment issues and optimising nutritional status.

Mid-Arm Muscle and Subcutaneous Fat Associated with All-Cause Mortality Independent of BMI: A Prospective Cohort Study

OBJECTIVE

This study aimed to systematically evaluate the association between triceps skinfold (TSF) thickness (which indicates subcutaneous fat) mid-arm muscle circumference (MAMC; which reflects muscle mass), mid-upper arm circumference (MUAC), and all-cause mortality.

METHODS

A total of 17,717 adults from the China Health and Nutrition Survey (1993-2015) were included. Cox proportional hazards models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause mortality. The joint effect of TSF thickness and MAMC was examined, and planned subgroup analyses were performed.

RESULTS

The highest quartiles of TSF thickness, MAMC, and MUAC were significantly associated with low all-cause mortality, independent of BMI (TSF thickness: HR = 0.704 [95% CI: 0.575-0.862]; MAMC: HR = 0.729 [95% CI: 0.607-0.876]; MUAC: HR = 0.713 [95% CI: 0.583-0.872]). A 1-SD increase showed comparable risk reductions for TSF thickness and MAMC (14.6% and 14.0%), with 16.1% risk reductions in MUAC. There were positive additive interactions between TSF thickness and MAMC. The inverse association existed in young, middle-aged, and elderly participants (P-heterogeneity > 0.05).

CONCLUSIONS

Mid-arm muscle and subcutaneous fat were inversely associated with all-cause mortality, independent of BMI, beyond the elderly population. Mid-arm muscle and subcutaneous fat made comparable contributions to and had positive joint effects on all-cause mortality.

Assessment of nutritional status of the cirrhotic patients on enteral and parenteral feeding

BACKGROUND

Cirrhosis is an irreversible disease that replaces healthy tissues with scar tissues. According to the Pakistan Medical Research Council's national general population survey (2008-2014), the ratio of cirrhosis was 4.8% among the population.

OBJECTIVES

To assess the nutritional status of cirrhotic patients on enteral and parenteral nutrition and to assess the degree of malnutrition among cirrhotic patients.

METHODS

A cross-sectional study was conducted at Shalamar and Shiekh Zayed Hospitals of Lahore from January-April 2017. The convenient sampling technique was used. Inclusion criteria were the patients with decompensated liver cirrhosis, whereas compensated patients were excluded from the study. Data were collected through the patient's file, nurse's, and dietitian's notes. The nutritional status of participants was assessed based on socio-demographic characteristics, anthropometric measurements, biochemical assessment, clinical signs, and dietary recall. Variables were categorized and compared to observe the level of significance in enteral and parenteral nutrition. SPSS version 22 was used to analyze data.

RESULTS

Patients on parenteral nutrition had a higher ratio of malnutrition with a significant Child-Pugh score-61.8% of patients belonged to Class C and 35.3% Class B, while in enteral support, 7.3% belonged to Class C and 43.9% patients belonged to Class B (p-value = 0.000). There was a definite relationship observed in the route of intake and malnutrition among cirrhotic patients.

CONCLUSION

Enteral route of nutrition is an effective and the safest way to provide appropriate nutrients according to the patient's demands.

Malnourished cirrhotic patient: what should we do?

Malnutrition and sarcopenia have a high prevalence in cirrhotic patients. Frailty generally overlaps with malnutrition and sarcopenia in cirrhosis, leading to increased morbidity and mortality. Rapid nutritional screening assessment should be performed in all patients with cirrhosis, and more specific tests for sarcopenia should be performed in those at high risk. The pathogenesis of malnutrition in cirrhosis is complex and multifactorial and it is not just due to reduction in protein and calorie intake. Nutritional management in malnourished patients with cirrhosis should be undertaken by a multidisciplinary team to achieve adequate protein/calorie intake. While the role of branched-chained amino acids remains somewhat contentious in achieving a global benefit of decreasing mortality- and liver-related events, these latter and vitamin supplements, are recommended for those with advanced liver disease. Novel strategies to reverse sarcopenia such as hormone supplementation, long-term ammonia-lowering agents and myostatin antagonists, are currently under investigation. Malnutrition, sarcopenia and frailty are unique, inter-related and multidimensional problems in cirrhosis which require special attention, prompt assessment and appropriate management as they significantly impact morbidity and mortality.

A narrative review of malnutrition in chronic liver disease

Interest in research on malnutrition is decreasing due to thoughts that the problem of malnutrition has been solved in an age of over-nourishment or obesity and defining malnutrition is not uniform. This study aimed to critically appraise the prevalence of malnutrition according to various diagnostic tools and proportion of severity used in previous studies. A literature review was performed using a total of 16 studies published between 1980 and 2020 regarding malnutrition in patients with chronic liver disease. Most of the analyzed studies were conducted before 2010, and only a few studies were conducted after 2010. Nutrition assessment tool (NAT) and nutrition screening tool (NST) to explain malnutrition were distinguished; however, there was no clear distinction between them. NST often used questionnaires while NST used various malnutrition measuring tools. Our results show that, in the age of over-nourishment, reduction in malnutrition in chronic liver disease still hasn’t been significant. Malnutrition prevalence in studies published prior to 2,000 ranged between 13.3% and 85% (mean, 37.6%), whereas that in studies published after 2,000 ranged between 13.3% and 78.5% (mean, 35.2%). Malnutrition prevalence largely depends on the diagnostic tool and proportion of disease severity in the target population. The prevalence of malnutrition in patients with chronic liver diseases varies widely. This big difference is related to various diagnostic tools, mixed etiologies, and different disease severity in different studies. The prevalence of malnutrition was 36.4% (10–80.3%) in all patients with liver disease, 39.9% (13.3–80.3%) in compensated liver disease, and 44.1% (26.7–93.6%) in decompensated cirrhosis. Malnutrition prevalence was 38.2% and 23.7% in alcoholism-related and hepatitis C virus (HCV)-related diseases, respectively. Malnutrition also largely depended on the judgement tool. Malnutrition prevalence according to the diagnostic tool was approximately 28–85% for subjective global assessment (SGA), 30.8–78.5% for anthropometric approach, and 21–80.3% for clinical judgment. It became similar over time.

Nonalcoholic Fatty Liver Disease and Sarcopenia: Where Do We Stand?

The link between metabolic syndrome (MetS) and sarcopenia has not been extensively studied, but it is evident that they share several common features. Crucial mechanisms involved in sarcopenia-nonalcoholic fatty liver disease (NAFLD) interplay are based on effects of insulin resistance, chronic inflammation, oxidative stress, and crosstalk between organs by secretion of cytokines (hepatokines, adipokines, and myokines). Currently, published studies confirm the association of sarcopenia with the degree of NAFLD defined by liver histology. However, prospective studies that will give us information regarding the causal effect of NAFLD and sarcopenia are still needed. Furthermore, there is a need for a patient-friendly, noninvasive, low-cost method for detection of loss of skeletal muscle mass, strength, and physical performance in the context of NAFLD. Moreover, potential treatment strategies such as physical exercise and nutritional supplementation, that are usually a part of management of sarcopenia, should also be investigated in NAFLD patients, especially given the fact that for now, we do not have a good treatment option for NAFLD. Therefore, future investigations should combine studies on NAFLD and sarcopenia in terms of physical activity and nutritional interventions such as vitamin D supplementation. This review aims to report recent evidence concerning the links between sarcopenia and NAFLD and methods to assess sarcopenia.

Frailty and Sarcopenia Assessment upon HospitalAdmission to Internal Medicine Predicts Length ofHospital Stay and Re-Admission: A ProspectiveStudy of 980 Patients

Background: Frailty and sarcopenia are associated with frequent hospitalizations and poor clinical outcomes in geriatric patients. Ascertaining this association for younger patients hospitalized in internal medicine departments could help better prognosticate patients in the realm of internal medicine. Methods: During a 1-year prospective study in an internal medicine department, we evaluated patients upon admission for sarcopenia and frailty. We used the FRAIL questionnaire, blood alanine-amino transferase (ALT) activity, and mid-arm muscle circumference (MAMC) measurements. Results: We recruited 980 consecutive patients upon hospital admission (median age 72 years (IQR 65–79); 56.8% males). According to the FRAIL questionnaire, 106 (10.8%) patients were robust, 368 (37.5%) pre-frail, and 506 (51.7%) were frail. The median ALT value was 19IU/L (IQR 14–28). The median MAMC value was 27.8 (IQR 25.7–30.2). Patients with low ALT activity level (<17IU/L) were frailer according to their FRAIL score (3 (IQR 2–4) vs. 2 (IQR 1–3); p < 0.001). Higher MAMC values were associated with higher ALT activity, both representing robustness. The rate of 30 days readmission in the whole cohort was 17.4%. Frail patients, according to the FRAIL score (FS), had a higher risk for 30 days readmission (for FS > 2, HR = 1.99; 95CI = 1.29–3.08; p = 0.002). Frail patients, according to low ALT activity, also had a significantly higher risk for 30 days readmission (HR = 2.22; 95CI = 1.26–3.91; p = 0.006). After excluding patients whose length of stay (LOS) was ≥10 days, 252 (27.5%) stayed in-hospital for 4 days or longer. Frail patients according to FS had a higher risk for LOS ≥4 days (for FS > 2, HR = 1.87; 95CI = 1.39–2.52; p < 0.001). Frail patients, according to low ALT activity, were also at higher risk for LOS ≥4 days (HR = 1.87; 95CI = 1.39–2.52; p < 0.001). MAMC values were not correlated with patients’ LOS or risk for re-admission. Conclusion: Frailty and sarcopenia upon admission to internal medicine departments are associated with longer hospitalization and increased risk for re-admission.

Utility of the simplified measurements of muscle mass in patients with gastrointestinal and chronic liver diseases

Sarcopenia is an important prognostic factor in patients with gastrointestinal and chronic liver diseases. Computed tomography and bioelectrical impedance analysis are the gold standards for measuring skeletal muscle mass for the diagnosis of decreased muscle mass, but there are some institutions where BIA and CT cannot be carried out. We evaluated the utility of simplified methods for measuring muscle mass; the psoas muscle mass index (PMI) method, simple PMI method, and arm muscle area (AMA) method. This retrospective study included 331 patients with gastrointestinal diseases and 81 patients with chronic liver diseases who were admitted from June 2018 to December 2019 at Municipal Hospital of Kofu. The skeletal muscle mass was measured using the PMI via the volume analyzer SYNAPSE VINCENT ver3.0, simple PMI based on CT imaging, and AMA method. Positive correlations were found between muscle mass measured by PMI and simple PMI, PMI and AMA, and simple PMI and AMA in patients with gastrointestinal diseases (correlation coefficients = 0.76, 0.57, 0.47, respectively, p < 0.001). Positive correlations were observed between muscle mass measured by PMI and simple PMI, PMI and AMA, and simple PMI and AMA in chronic liver diseases (correlation coefficients = 0.77, 0.53, 0.45, respectively, p < 0.001). Measurement of muscle mass by the AMA method showed some correlation with the PMI method. Measurement of muscle mass by the simple PMI method showed correlation with the PMI method. These simplified methods can be alternative methods of evaluating muscle mass in patients with gastrointestinal and chronic liver disease.

Comparison of selected body composition parameters in women using DXA and anthropometric method

Background

An excessive accumulation of the adipose tissue in women's organism is a frequent and important medical problem which should be monitored. The aim of this study was to explore correlations between the selected parameters of body composition assessed using DXA and anthropometric methods.

Materials and Methods

The study group consisted of 50 women aged 51-85. Both adipose mass and fat-free mass were assessed with the DXA method, and the nutritional status of the participants was evaluated with the anthropometric methods.

Results

The mean body mass index (BMI) value assessed with the DXA method amounted to 28.4 (±5.12). The Spearman's Rho correlation indicated the presence of a moderate association (0.27-0.50) between: (1) right arm lean and the circumference of the arm (P = 0.020), forearm (P = 0.011), and transverse cross-section of the arm (P = 0.020), (2) right leg fat and circumference of the thigh (P = 0.003), shin (P = 0.009), and also the musculature index of the lower extremity (P = 0.034), (3) visceral adipose tissue (VAT) mass and BMI (P = 0.050), Waist to HeightRatio (WtHR) (P = 0.031), (4) Android fat and WHtR (P = 0.044), and (5) gynoid fat and Škerlj index (P = 0.025).

Conclusion

The selected parameters assessed with DXA were significantly correlated with the selected parameters assessed with anthropometric methods. WHtR anthropometric parameter is significantly correlated with DXA parameters: VAT mass, gynoid region % fat and android region % fat.

Non-hip/non-vertebral fractures - How to treat best?

Fractures of the extremities in the elderly constitute more than two-thirds of all fragility fractures befalling frail, osteoporotic and sarcopenic patients. Although treatment controversies abound, consensus exists. Upper extremity fractures hinder activities of daily living and are debilitating. Open fractures or displaced fractures will need surgical intervention. Wrist fractures treated operatively allow early use of the hand. Most pelvic fractures are treated conservatively. In the lower extremities, fractures of the long bones, tibia and femur need surgical intervention. Non-displaced fractures around the foot may be treated with immobilisation and avoidance of full weight-bearing. As a rule, fractures take four months for consolidation. Individually tailored solutions are needed for frail patients with comorbidities. Maintaining joint mobility and muscle strength preserves mobility and autonomy. Caring for extremities trauma is team work, involving family and health care providers. Prevention efforts are mandatory.

EASL Clinical Practice Guidelines on nutrition in chronic liver disease

A frequent complication in liver cirrhosis is malnutrition, which is associated with the progression of liver failure, and with a higher rate of complications including infections, hepatic encephalopathy and ascites. In recent years, the rising prevalence of obesity has led to an increase in the number of cirrhosis cases related to non-alcoholic steatohepatitis. Malnutrition, obesity and sarcopenic obesity may worsen the prognosis of patients with liver cirrhosis and lower their survival. Nutritional monitoring and intervention is therefore crucial in chronic liver disease. These Clinical Practice Guidelines review the present knowledge in the field of nutrition in chronic liver disease and promote further research on this topic. Screening, assessment and principles of nutritional management are examined, with recommendations provided in specific settings such as hepatic encephalopathy, cirrhotic patients with bone disease, patients undergoing liver surgery or transplantation and critically ill cirrhotic patients.

Mid-arm muscle circumference: A significant factor of all-cause and cancer mortalities in individuals with elevated platelet-to-lymphocyte ratio

Platelet-to-lymphocyte ratio (PLR) is an inflammatory maker, and high PLR is associated with mortality in several diseases. The predictors of mortality in individuals with high PLR is still lacking. Our aims were to assess if mid-arm muscle circumference (MAMC) can predict all-cause mortality, cancer mortality, and cardiovascular mortality in individuals with high PLR. Adult participants from the National Health and Nutrition Examination Survey III (1988–1994) were included. All participants were divided into low PLR and high PLR groups with the cut-off point being the median PLR level, and each group was evaluated for risk factors of mortality. MAMC was divided into tertiles and the general characteristics of the study population related to MAMC were evaluated. The study included 14,221 adults with 6,701 (47.1%) male and 7,520 (52.9%) female participants. The median PLR ratio was 122. Higher levels of systolic blood pressure, total triglycerides, total cholesterol, low-density lipoprotein, C-reactive protein, uric acid, and glucose, as well as a higher age, were associated with increased risk of mortality in both groups. After adjusting for all the covariates, in the higher PLR group, the highest MAMC tertile was significantly associated with lower hazard ratios for all-cause and cancer mortalities compared with the lowest MAMC tertile. However, this association was not observed in the low PLR group. The highest MAMC tertile showed protective effects from all-cause and cancer mortalities compared with the lowest MAMC tertile in individuals with PLR ≥ 122. In conclusion, the highest MAMC tertile was significantly associated with decreasing HRs for all-cause and cancer mortalities compared with the lowest MAMC tertile in individuals with elevated PLR.

Sarcopenia in patients with hip fracture: A multicenter cross-sectional study

BACKGROUND

Sarcopenia is prevalent in older persons and is a risk factor for falls, fractures, and mortality. The aim of this study was to determine a) the feasibility of determining sarcopenia in patients with acute hip fracture, b) the prevalence of sarcopenia and c) associations of sarcopenia with nutritional status and comorbidities.

METHODS

A multicenter cross-sectional study on sarcopenia in male and female patients with acute hip fracture. Participants were previously ambulatory and living in the community. Sarcopenia was assessed postoperatively with muscle mass estimated by anthropometry using triceps skinfold, arm circumference, height, weight and sex. Grip strength was measured by Jamar dynamometer and pre-fracture mobility was by self-report using the New Mobility Score.

RESULTS

Out of 282 patients, 202 were assessed for sarcopenia of whom 74 (37%) were diagnosed as sarcopenic. Sarcopenia was associated with age, odds ratio (OR) 1.4 per 5 years, 95% confidence interval (CI) [1.1, 1.8], ASA Physical Status Classification System score, OR 2.3 per point, 95% CI [1.3, 4.3] and number of medications at discharge, OR 1.2 per medication, 95% CI [1.0, 1.3] and inversely associated with BMI, OR 0.8, 95% CI [0.7, 0.9] and serum albumin, OR 0.9, 95% CI [0.8,1.0].

CONCLUSIONS

Thirty-seven percent of assessed subjects were diagnosed with sarcopenia. Our data demonstrates that the prevalence of sarcopenia is associated with older age, malnutrition and comorbidities. Determining sarcopenia at the bedside was feasible in postoperative hip fracture patients by using grip strength, estimation of muscle mass by anthropometry and self-reported mobility.