CT-Determined Sarcopenia in GLIM-Defined Malnutrition and Prediction of 6-Month Mortality in Cancer Inpatients

AI-Assisted Body Composition Assessment Using CT Imaging in Colorectal Cancer Patients: Predictive Capacity for Sarcopenia and Malnutrition Diagnosis

(1) Background: The assessment of muscle mass is crucial in the nutritional evaluation of patients with colorectal cancer (CRC), as decreased muscle mass is linked to increased complications and poorer prognosis. This study aims to evaluate the utility of AI-assisted L3 CT for assessing body composition and determining low muscle mass using both the Global Leadership Initiative on Malnutrition (GLIM) criteria for malnutrition and the European Working Group on Sarcopenia in Older People (EWGSOP2) criteria for sarcopenia in CRC patients prior to surgery. Additionally, we aim to establish cutoff points for muscle mass in men and women and propose their application in these diagnostic frameworks. (2) Methods: This retrospective observational study included CRC patients assessed by the Endocrinology and Nutrition services of the Regional University Hospitals of Malaga, Virgen de la Victoria of Malaga, and Vall d'Hebrón of Barcelona from October 2018 to July 2023. A morphofunctional assessment, including anthropometry, bioimpedance analysis (BIA), and handgrip strength, was conducted to apply the GLIM criteria for malnutrition and the EWGSOP2 criteria for sarcopenia. Body composition evaluation was performed through AI-assisted analysis of CT images at the L3 level. ROC analysis was used to determine the predictive capacity of variables derived from the CT analysis regarding the diagnosis of low muscle mass and to describe cutoff points. (3) Results: A total of 586 patients were enrolled, with a mean age of 68.4 ± 10.2 years. Using the GLIM criteria, 245 patients (41.8%) were diagnosed with malnutrition. Applying the EWGSOP2 criteria, 56 patients (9.6%) were diagnosed with sarcopenia. ROC curve analysis for the skeletal muscle index (SMI) showed a strong discriminative capacity of muscle area to detect low fat-free mass index (FFMI) (AUC = 0.82, 95% CI 0.77-0.87, p < 0.001). The identified SMI cutoff for diagnosing low FFMI was 32.75 cm2/m2 (Sn 77%, Sp 64.3%; AUC = 0.79, 95% CI 0.70-0.87, p < 0.001) in women, and 39.9 cm2/m2 (Sn 77%, Sp 72.7%; AUC = 0.85, 95% CI 0.80-0.90, p < 0.001) in men. Additionally, skeletal muscle area (SMA) showed good discriminative capacity for detecting low appendicular skeletal muscle mass (ASMM) (AUC = 0.71, 95% CI 0.65-0.76, p < 0.001). The identified SMA cutoff points for diagnosing low ASMM were 83.2 cm2 (Sn 76.7%, Sp 55.3%; AUC = 0.77, 95% CI 0.69-0.84, p < 0.001) in women and 112.6 cm2 (Sn 82.3%, Sp 58.6%; AUC = 0.79, 95% CI 0.74-0.85, p < 0.001) in men. (4) Conclusions: AI-assisted body composition assessment using CT is a valuable tool in the morphofunctional evaluation of patients with colorectal cancer prior to surgery. CT provides quantitative data on muscle mass for the application of the GLIM criteria for malnutrition and the EWGSOP2 criteria for sarcopenia, with specific cutoff points established for diagnostic use.

Preoperative visceral fat index predicts the survival outcomes of patients with gastric cancer after surgery

Visceral adipose tissue and skeletal muscle mass are associated with carcinogenesis and clinical outcomes in patients with cancer. The aim of the present study was to determine the influence of body composition parameters on postoperative survival in patients with gastric cancer. Demographic data and systemic inflammatory response data were obtained from patients with gastric cancer undergoing radical gastrectomy. The patient's skeletal muscle and visceral fat were assessed using computed tomography, and the corresponding skeletal muscle index (SMI) and visceral fat index (VFI) were calculated. Univariate and multivariate analyses were then performed. Of the 342 patients from whom information was collected, 125 of these patients eventually succumbed to the disease. A total of 271 (79.24%) of the patients were male and 71 (20.76%) were female. Regarding the entire cohort, the mean age was 64 years [interquartile range (IQR), 56-74 years], while the mean body mass index collected was 21.53 (IQR, 19.27-24.22). The median SMI and VFI of the patients were 47.73 (IQR, 41.67-55.51) and 41.28 (IQR, 36.62-45.36), respectively. It was concluded that a low SMI and VFI were associated with worse survival outcomes. However, the neutrophil-to-lymphocyte ratio and perioperative blood transfusion were not significantly associated with overall survival (OS). Among the indicators assessed, a low VFI was an independent risk factor associated with the worst OS time (hazard ratio 1.59; confidence interval, 1.03-2.45; P=0.038). Finally, a prognostic nomogram was constructed which included the VFI to assist clinicians in making more informed decisions. In conclusion, after data collection and analysis, it was found that there was a significant correlation between a low VFI and a shorter OS time in patients with gastric cancer following gastrectomy, suggesting that VFI may be a promising therapeutic target for postoperative interventions to improve patient survival further.

Nutritional Assessment Tools for Patients with Cancer: A Narrative Review

Cancer patients are at high risk of malnutrition, which can lead to adverse health outcomes such as prolonged hospitalization, increased complications, and increased mortality. Accurate and timely nutritional assessment plays a critical role in effectively managing malnutrition in these patients. However, while many tools exist to assess malnutrition, there is no universally accepted standard. Although different tools have their own strengths and limitations, there is a lack of narrative reviews on nutritional assessment tools for cancer patients. To address this knowledge gap, we conducted a non-systematic literature search using PubMed, Embase, Web of Science, and the Cochrane Library from their inception until May 2023. A total of 90 studies met our selection criteria and were included in our narrative review. We evaluated the applications, strengths, and limitations of 4 commonly used nutritional assessment tools for cancer patients: the Subjective Global Assessment (SGA), Patient-Generated Subjective Global Assessment (PG-SGA), Mini Nutritional Assessment (MNA), and Global Leadership Initiative on Malnutrition (GLIM). Our findings revealed that malnutrition was associated with adverse health outcomes. Each of these 4 tools has its applications, strengths, and limitations. Our findings provide medical staff with a foundation for choosing the optimal tool to rapidly and accurately assess malnutrition in cancer patients. It is essential for medical staff to be familiar with these common tools to ensure effective nutritional management of cancer patients.

Ultrasound Muscle Evaluation for Predicting the Prognosis of Patients with Head and Neck Cancer: A Large-Scale and Multicenter Prospective Study

Head and neck cancer (HNC) is a prevalent and aggressive form of cancer with high mortality rates and significant implications for nutritional status. Accurate assessment of malnutrition in patients with HNC is crucial for optimizing treatment outcomes and improving survival rates. This study aimed to evaluate the use of ultrasound techniques for predicting nutritional status, malnutrition, and cancer outcomes in patients with HNC. A total of 494 patients with HNC were included in this cross-sectional observational study. Various tools and body composition measurements, including muscle mass and adipose tissue ultrasound evaluations, were implemented. Using regression models, we mainly found that high levels of RF-CSA (rectus femoris cross-sectional area) were associated with a decreased risk of malnutrition (as defined with GLIM criteria (OR = 0.81, 95% CI: 0.68-0.98); as defined with PG-SGA (OR = 0.78, 95% CI: 0.62-0.98)) and sarcopenia (OR = 0.64, 95% CI: 0.49-0.82) after being adjusted for age, sex, and BMI. To predict the importance of muscle mass ultrasound variables on the risk of mortality, a nomogram, a random forest, and decision tree models were conducted. RF-CSA was the most important variable under the random forest model. The obtained C-index for the nomogram was 0.704, and the Brier score was 16.8. With an RF-CSA < 2.7 (AUC of 0.653 (0.59-0.77)) as a split, the decision tree model classified up to 68% of patients as possessing a high probability of survival. According to the cut-off value of 2.7 cm2, patients with a low RF-CSA value lower than 2.7 cm2 had worse survival rates (p < 0.001). The findings of this study highlight the importance of implementing ultrasound tools, for accurate diagnoses and monitoring of malnutrition in patients with HNC. Adipose tissue ultrasound measurements were only weakly associated with malnutrition and not with sarcopenia, indicating that muscle mass is a more important indicator of overall health and nutritional status. These results have the potential to improve survival rates and quality of life by enabling early intervention and personalized nutritional management.

Malnutrition defined by GLIM criteria identifies a higher incidence of malnutrition and is associated with pulmonary complications after oesophagogastric cancer surgery, compared to ICD-10-defined malnutrition

BACKGROUND & OBJECTIVES

Low muscle mass, measured using computed tomography (CT), is associated with poor surgical outcomes. We aimed to include CT-muscle mass in malnutrition diagnosis using the Global Leadership Initiative on Malnutrition (GLIM) criteria, compare it to the International Classification of Diseases 10th Revision (ICD-10) criteria, and assess the impact on postoperative outcomes after oesophagogastric (OG) cancer surgery.

METHODS

One hundred and eight patients who underwent radical OG cancer surgery and had preoperative abdominal CT imaging were included. GLIM and ICD-10 malnutrition data were assessed against complication and survival outcomes. Low CT-muscle mass was determined using predefined cut-points.

RESULTS

GLIM-defined malnutrition prevalence was significantly higher than ICD-10-malnutrition (72.2% vs. 40.7%, p < 0.001). Of the 78 patients with GLIM-defined malnutrition, low muscle mass (84.6%) was the predominant phenotypic criterion. GLIM-defined malnutrition was associated with pneumonia (26.9% vs. 6.7%, p = 0.010) and pleural effusions (12.8% vs. 0%, p = 0.029). Postoperative complications did not correlate with ICD-10 malnutrition. Severe GLIM (HR: 2.51, p = 0.014) and ICD-10 (HR: 2.15, p = 0.039) malnutrition were independently associated with poorer 5-year survival.

CONCLUSIONS

GLIM criteria appear to identify more malnourished patients and more closely relate to surgical risk than ICD-10 malnutrition, likely due to incorporating objective muscle mass assessment.

Expert design thinking workshops to analyze users' perceived applicability of NUTRI-ONCOCARE algorithm to prevent and treat malnutrition in cancer patients under routine clinical practice conditions in Spain: the ALLIANCE study

PURPOSE

NUTRI-ONCOCARE algorithm has been developed to identify and treat patients with solid tumors who are at risk of malnutrition. The present study is aimed at analyzing users' opinion about this new tool and at assessing whether it is perceived as useful to achieve the behavioral change required for a successful integration of nutritional assessment into routine cancer care.

METHODS

Design thinking Double Diamond process was applied. A multidisciplinary team composed of ten potential end-users (four oncologists, three endocrinologists, one nutritionist, and two hospital pharmacists) participated in three different workshops aiming to analyze the different tasks included within the NUTRI-ONCOCARE algorithm.

RESULTS

Users agreed on the need to perform nutritional assessment around cancer diagnosis and through the course of the disease using standardized tools included in hospital nutritional protocols and involving healthcare professionals with nutrition expertise. Nutritional evaluation and intervention should be individual and comprehensive, considering not only nutritional parameters but also patients' functional status. According to participants' opinion, the implementation of nutritional screening in routine clinical practice is limited by the lack of time and staff to conduct nutritional assessments, the low level of nutrition expert participation, and the poor support provided by hospital managers, which are often unaware of nutrition's impact in cancer care.

CONCLUSIONS

Experts recognized the importance of considering nutritional status in cancer patients and identified the opportunity provided by the NUTRI-ONCOCARE algorithm for this purpose, as it meets main requirements for being used routinely in clinical practice.

Prevalence of malnutrition based on global leadership initiative in malnutrition criteria for completeness of diagnosis and future risk of malnutrition based on current malnutrition diagnosis: systematic review and meta-analysis

Background

The proposal of the global leadership initiative in malnutrition (GLIM) criteria has received great attention from clinicians. The criteria are mainly used in the research environment and have the potential to be widely used in the clinic in the future. However, the prevalence of malnutrition and risk of future malnutrition based on a current diagnosis of malnutrition are worth exploring.

Methods

A systematic search of PubMed, Embase, and the Cochrane Library was performed from the earliest available date to 1 February 2023. According to the diagnostic criteria of the GLIM, we analysed the prevalence of malnutrition by directly adopting the GLIM criteria for diagnosis without a previous nutritional risk screening (one-step approach) and by adopting the GLIM criteria for diagnosis after a nutritional risk screening (two-step approach). The main outcome was the prevalence of malnutrition based on the one-and two-step approaches. Secondary outcomes were the future risk of malnutrition based on the GLIM diagnosis, including mortality within and beyond 1 year. primary outcomes were pooled using random-effects models, and secondary outcomes are presented as hazard ratios (HRs) and 95% confidence intervals (CIs).

Results

A total of 64 articles were included in the study, including a total of 47,654 adult hospitalized patients and 15,089 malnourished patients based on the GLIM criteria. Malnutrition was diagnosed by the one-step approach in 18 studies and by the two-step approach in 46 studies. The prevalence of malnutrition diagnosed by the one-and two-step approaches was 53% (95% CI, 42%-64%) and 39% (95% CI, 0.35%-0.43%), respectively. The prevalence of malnutrition diagnosed by the GLIM criteria after a nutritional risk screening was quite different; the prevalence of malnutrition diagnosed by the Nutritional Risk Screening 2002 (NRS2002) GLIM tool was 35% (95% CI, 29%-40%); however, the prevalence of malnutrition diagnosed by the Mini Nutrition Assessment (MNA) GLIM tool was 48% (95% CI, 35%-62%). Among the disease types, the prevalence of malnutrition in cancer patients was 44% (95% CI, 36%-52%), while that in acute and critically ill patients was 44% (95% CI, 33%-56%). The prevalence in patients in internal medicine wards was 40% (95% CI, 34%-45%), while that in patients in surgical wards was 47% (95% CI, 30%-64%). In addition, the mortality risk within 1 year (HR, 2.62; 95% CI, 1.95-3.52; I² = 77.1%) and beyond 1 year (HR, 2.04; 95% CI, 1.70-2.45; I² = 59.9%) of patients diagnosed with malnutrition by the GLIM criteria was double that of patients with normal nutrition.

Conclusion

The prevalence of malnutrition diagnosed by the GLIM criteria after a nutritional risk screening was significantly lower than the prevalence of malnutrition diagnosed directly by the GLIM criteria. In addition, the mortality risk was significantly greater among malnourished patients assessed by the GLIM criteria.Systematic review registration: identifier CRD42023398454.

Standardization of Body Composition Status in Patients with Advanced Urothelial Tumors: The Role of a CT-Based AI-Powered Software for the Assessment of Sarcopenia and Patient Outcome Correlation

BACKGROUND

Sarcopenia is a well know prognostic factor in oncology, influencing patients' quality of life and survival. We aimed to investigate the role of sarcopenia, assessed by a Computed Tomography (CT)-based artificial intelligence (AI)-powered-software, as a predictor of objective clinical benefit in advanced urothelial tumors and its correlations with oncological outcomes.

METHODS

We retrospectively searched patients with advanced urothelial tumors, treated with systemic platinum-based chemotherapy and an available total body CT, performed before and after therapy. An AI-powered software was applied to CT to obtain the Skeletal Muscle Index (SMI-L3), derived from the area of the psoas, long spine, and abdominal muscles, at the level of L3 on CT axial images. Logistic and Cox-regression modeling was implemented to explore the association of sarcopenic status and anthropometric features to the clinical benefit rate and survival endpoints.

RESULTS

97 patients were included, 66 with bladder cancer and 31 with upper-tract urothelial carcinoma. Clinical benefit outcomes showed a linear positive association with all the observed body composition variables variations. The chances of not experiencing disease progression were positively associated with ∆_SMI-L3, ∆_psoas, and ∆_long spine muscle when they ranged from ~10-20% up to ~45-55%. Greater survival chances were matched by patients achieving a wider ∆_SMI-L3, ∆_abdominal and ∆_long spine muscle.

CONCLUSIONS

A CT-based AI-powered software body composition and sarcopenia analysis provide prognostic assessments for objective clinical benefits and oncological outcomes.

Current status of the association between malnutrition defined by the GLIM criteria and postoperative outcomes in gastrointestinal surgery for cancer: a narrative review

In 2018, the Global Leadership Initiative on Malnutrition consortium published global consensus diagnostic criteria for malnutrition and highlighted the association between malnutrition and poor postoperative outcomes in patients with gastrointestinal cancer. The aforementioned criteria consist of phenotypic and etiologic criteria to diagnose malnutrition in individuals who undergo conventional screening to determine the at-risk population. Recent studies have reported the usefulness of prediction of postoperative outcomes using body mass index, weight loss, and reduced muscle mass as phenotypic criteria. Reduced muscle mass is an essential diagnostic criterion for sarcopenia, which is associated with poor outcomes in patients with cancer. The Global Leadership Initiative on Malnutrition criteria define reduced muscle mass as undernutrition. Malnutrition diagnosed based on the Global Leadership Initiative on Malnutrition criteria is an important risk factor for postoperative complications and also an independent poor prognostic factor for long-term outcomes; greater severity of malnutrition is associated with poorer outcomes. The current Global Leadership Initiative on Malnutrition criteria for malnutrition accurately predict outcomes, including postoperative complications and long-term prognosis; however, a revision may be warranted to ensure consistency with the diagnostic criteria for sarcopenia. Patients diagnosed with malnutrition based on the Global Leadership Initiative on Malnutrition criteria should be targeted for nutritional intervention. Further accumulation of evidence is necessary to conclusively establish the role of nutritional interventions in patients with malnutrition to improve postoperative complications and long-term outcomes.

Androgen Deprivation Therapy for Prostate Cancer Influences Body Composition Increasing Risk of Sarcopenia

Computed tomography (CT) scans used in treatment response assessment in prostate cancer (PCa) patients are a useful tool for nutritional status evaluation. The aim of this study was to assess the nutritional status, including sarcopenia development based on CT scans, in PCa patients and its association with progression-free survival (PFS). Sixty-four PCa patients were included (group 1: 34 patients undergoing androgen deprivation therapy (ADT) with docetaxel due to newly diagnosed, hormone-sensitive, metastatic PCa and group 2: 30 patients with castration-resistant metastatic PCa continuing ADT therapy with enzalutamide or abiraterone acetate). Nutritional status was evaluated with anthropometrical parameters, Nutritional Risk Score (NRS), and CT scans at the L3 vertebrae. Survival analyses were performed. According to NRS, nutritional status was significantly related to PFS. In both groups, there was a significant reduction in muscle tissue (total muscle tissue and skeletal muscle index). A significant increase in the distribution of adipose tissue (subcutaneous fat, visceral fat, subcutaneous adipose tissue index, and visceral adipose tissue index) in group one was observed. Sarcopenia was diagnosed in patients but with no influence on PFS. Significant reduction in muscle mass and increase in fat mass was observed in patients treated for PCa with no impact on PFS. The NRS was related to PFS in PCa patients and associated with body composition, assessed by CT after the castration therapy. Long-term castration combined with abiraterone therapy with prednisone or enzalutamide significantly influenced muscle tissue and may lead to sarcopenia development.

Relationship between global leadership initiative on malnutrition (GLIM) defined malnutrition and survival, length of stay and post-operative complications in people with cancer: A systematic review

BACKGROUND & AIMS

The predictive validity of the GLIM criteria for survival, length of hospital stay (LOHS) and post-operative complications among people with cancer have not been systematically reviewed. This systematic review aims to determine whether GLIM malnutrition is predictive of these outcomes, and whether the predictive validity is affected by how phenotypic and etiologic criteria are assessed.

METHODS

Cohort studies published after 2018 were systematically reviewed according to PRISMA guidelines from Embase, Medline Complete and CINAHL Complete. Risk of bias and methodologic quality were assessed using the Journal of the Academy of Nutrition and Dietetics' Quality Criteria Checklist tool for Primary research.

RESULTS

In total, 21 studies were included, including 28,726 participants. All studies investigated survival, where 18 reported GLIM malnutrition is associated with decreased survival. LOHS was investigated in six studies, with all finding an association between GLIM malnutrition and longer LOHS. Post-operative complications were assessed in seven studies, of which five reported GLIM malnutrition was predictive of increased post-operative complications. Methods to assess the GLIM phenotypic and etiologic criteria varied, with consistent predictive ability for survival regardless of method of assessing reduced muscle mass. However, predictive ability was more variable across different measures of inflammation and reduced intake.

CONCLUSION

GLIM malnutrition was consistently predictive of worse clinical outcomes. Different measures of reduced muscle mass did not affect the predictive ability of GLIM for survival. However, variation in assessment of the etiologic criteria resulted in varying predictive ability of the GLIM diagnosis for survival.

Impact of malnutrition as defined by the GLIM criteria on treatment outcomes in patients with cancer: A systematic review and meta-analysis

BACKGROUND & AIMS

Malnutrition has been reported to lead to poor postoperative outcomes. The Global Leadership Initiative on Malnutrition (GLIM) criteria were published in 2019 as a global consensus on the criteria for diagnosing malnutrition. However, the relationship between GLIM-defined malnutrition and treatment outcomes in patients with cancer has not been fully investigated. Therefore, this study aimed to clarify the impact of GLIM-defined malnutrition on the treatment outcomes of patients with cancer.

METHODS

We searched MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, the World Health Organization International Clinical Trials Platform Search Portal, and ClinicalTrials.gov and identified observational studies published from inception to January 17, 2022. We conducted a systematic review and random-effects meta-analysis studies that included patients with cancer aged >18 years who received any kind of treatment and whose nutritional status was assessed using GLIM criteria. We independently assessed the risk of bias and quality of evidence using Quality In Prognosis Studies and Grading of Recommendations, Assessment, Development, and Evaluation approach. The primary outcomes were overall survival (OS) and postoperative complications. Hazard ratios and 95% confidence intervals (CIs) for OS and relative risk ratios and 95% CIs for postoperative complications were pooled. The protocol was published by PROSPERO (CRD42022304004).

RESULTS

Of 67 studies after screening, ten studies (n = 11,700) reported the impact of GLIM-defined malnutrition on postoperative outcomes. Compared with no malnutrition, GLIM-defined malnutrition may worsen OS (hazard ratio, 1.56; 95% CI, 1.38-1.75; I² = 37%) and increase postoperative complications (relative risk ratio, 1.82; 95% CI, 1.28-2.60; I² = 87%). The risk of bias in each study was either moderate or high. The certainty of the evidence was low because of publication bias and a moderate or high risk of bias.

CONCLUSIONS

GLIM-defined malnutrition may worsen OS and increase the risk of postoperative complications in patients with cancer undergoing treatment. Further studies are needed to confirm these findings and mitigate this risk.

Prognostic implications of the global leadership initiative on malnutrition criteria as a routine assessment modality for malnutrition in hospitalized patients at a university hospital

BACKGROUND & AIMS

Few studies have examined the association between mortality and malnutrition diagnosed using the Global Leadership Initiative on Malnutrition (GLIM) criteria for routine nutritional assessment; thus, this association is not well known. We aimed to clarify the association between GLIM-defined malnutrition and mortality in a large population of hospitalized patients.

METHODS

In this retrospective cohort study, we enrolled adult patients admitted to Aichi Medical University Hospital between April 2019 and March 2021, who underwent nutritional assessment using the GLIM criteria. In November 2021, we collected the following data from electronic medical records: demographic, clinical, and laboratory data upon admission; nutritional data assessed using GLIM criteria; and data on final patient outcomes.

RESULTS

In this study, we included 9372 hospitalized patients who were identified to be at risk by the validated nutritional screening tools (50.6% men, median age 75.0 [67.0-82.0] years, 69.2% patients aged ≥70 years). The number of patients with no, moderate, and severe GLIM-defined malnutrition was 4145 (44.2%), 2799 (29.9%), and 2428 (25.9%), respectively. Kaplan-Meier survival curve analysis showed a significant increase in mortality with worsening nutritional status (log-rank test, P < 0.001). After adjusting for age and sex, multivariable Cox regression analysis revealed that both moderate (Hazard ratio [HR] 2.0, 95% confidence interval [CI] 1.79-2.23, P < 0.001) and severe malnutrition (HR 3.06, 95% CI 2.74-3.40, P < 0.001) were independent risk factors for mortality. Moreover, multivariable analysis showed that four of the five GLIM sub-criteria (except low body mass index) were independently associated with prognosis.

CONCLUSION

Malnutrition and its severity, routinely assessed using the GLIM criteria, are associated with high mortality in hospitalized patients at nutritional risk. Further research is needed to evaluate the usefulness of the GLIM sub-criteria, including low body mass index, in these patients.

Association of CT-based diagnosis of sarcopenia with prognosis and treatment response in patients at risk of malnutrition - A secondary analysis of the Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) trial

BACKGROUND & AIM

CT-derived measures of muscle mass may help to identify patients with sarcopenia. We investigated the prognostic significance of CT-derived sarcopenia and muscle attenuation with nutritional markers, clinical outcomes and response to nutritional support in medical in-patients at nutritional risk.

METHOD

Within this secondary analysis of the randomized-controlled Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) comparing individualized nutritional support with usual care nutrition in medical inpatients, we investigated associations of CT-based sarcopenia and muscle attenuation at the level L3 with different nutritional and clinical outcomes, and the response to the nutritional intervention. The primary composite endpoint was adverse clinical outcome within 30 days of hospital admission.

RESULTS

We included 573 of 2028 EFFORT patients with available CT scans, of which 68.4% met the CT-based definition of sarcopenia and 72.9% had low muscle attenuation. In multivariate analysis, low skeletal muscle index was associated with higher nutritional risk (coefficient per NRS class -0.94 (95%CI -1.87 to -0.01) p = 0.049) and higher risk for adverse clinical outcomes (adjusted odds ratio 1.59 (95% CI 1.06 to 2.38), p = 0.024). Low muscle attenuation was also associated with adverse clinical outcome (adjusted odds ratio 1.67 (95%CI 1.08 to 2.58), p = 0.02). Nutritional support tended to be more effective in reducing mortality in non-sarcopenic patients compared to patients with CT-based sarcopenia (p for interaction 0.058).

CONCLUSIONS

Within a population of medical patients at nutritional risk, CT-based sarcopenia and muscle attenuation were associated with several nutritional parameters and predicted adverse clinical outcomes. Information from CT scans, thus may help to better characterize these patients, and may be helpful in guiding therapeutic interventions.

Compliance with a high-protein and energy-dense oral nutritional supplement in patients with disease-related malnutrition: a randomized open-label crossover trial

Introduction

Patient compliance with oral nutritional supplements (ONS) is not optimal for meeting energy and nutritional requirements in a high proportion of patients with disease-related malnutrition (DRM). Energy density or prescribed volume of ONS may impact compliance.

Methods

A randomized, open-label crossover trial was conducted in outpatients with DRM to compare compliance with a high energy-dense ONS (edONS, 2.4 kcal/mL) and a reference ONS (heONS, 2.0 kcal/mL; NCT05609006). Patients were randomly assigned to two 8-week treatment sequences of four-weeks periods: edONS + heONS (sequence A) or heONS + edONS (sequence B). Patients daily reported the amount of product left over gastrointestinal tolerance and satisfaction with ONS. A non-inferiority analysis was performed to compare the compliance rate (percentage of consumed energy over the prescribed) for each period and sequence.

Results

Fifty-three patients were assigned to sequence A and 50 to sequence B (55.7 ± 13.9 years, 37.0% female, 67.1% oncology patients). In sequence A, the compliance rates were 88.6% ± 14.3% vs. 84.1 ± 21.8% (p = 0.183), while in sequence B, they were 78.9% ± 23.8% vs. 84.4% ± 21.4% (p < 0.01). In both sequences, the lower range of the confidence interval for compliance with edONS was greater than the non-inferiority threshold (for sequence A Δ_Comp^A was 4.5% [95% CI, -2.0% to 10.0%], and for sequence, B Δ_Comp^B was 5.6% [95% CI, -3.0% to 14.0%]). The total discarded cost for each ONS was higher for heONS than edONS, being the difference statistically significant in sequence B. BMI increased slightly and not significantly in both sequences, and the percentage of patients with severe malnutrition was reduced. The frequency of gastrointestinal symptoms was low for both sequences, and satisfaction with ONS was slightly higher for edONS.

Conclusion

Our findings highlight that edONS was non-inferior to heONS in terms of consumed energy over the prescribed, with a lower amount of edONS discarded, which suggests a higher efficiency of edONS.

A scoping review on the GLIM criteria for malnutrition diagnosis: Understanding how and for which purpose it has been applied in studies on hospital settings

AIMS

This scoping review aimed to identify and map the literature on malnutrition diagnosis made using the GLIM criteria in hospitalized patients.

METHODS

The scoping review was conducted using the Joanna Briggs Institute's methodology. We searched PubMed, Embase, Scopus, and Web of Science (until 16 April 2022) to identify studies based on the 'population' (adults or elderly patients), 'concept' (malnutrition diagnosis by the GLIM criteria), and 'context' (hospital settings) framework. Titles/abstracts were screened, and two independent reviewers extracted data from eligible studies.

RESULTS

Ninety-six studies were eligible (35.4% from China, 30.2% involving oncological patients, and 30.5% with prospective data collection), 32 followed the two-step GLIM approach, and 50 applied all the criteria. All the studies evaluated body mass index (BMI), while 92.7% evaluated weight loss; 77.1%, muscle mass; 93.8%, inflammation; and 70.8%, energy intake. A lack of details on the methods adopted for criterion evaluation was observed in five (muscle mass evaluation) to 40 studies (energy intake evaluation). The frequency of the use of the GLIM criteria ranged from 22.2% (frequency of low BMI) to 84.7% (frequency of inflammation), and the malnutrition prevalence ranged from 0.96% to 87.9%. Less than 30% of studies aimed to assess the GLIM criterion validity, eight studies cited the guidance on validation of the GLIM criteria, and a minority implemented it.

CONCLUSIONS

This map of studies on the GLIM criteria in hospital settings demonstrated that they are applied in a heterogeneous manner, with a wide range of malnutrition prevalence. Almost 50% of the studies applied all the criteria, while one-third followed the straightforward two-step approach. The recommendations of the guidance on validation of the criteria were scarcely adhered to. The gaps that need to be explored in future studies have been highlighted.

Malnutrition diagnosed by the Global Leadership Initiative on Malnutrition criteria predicting survival and clinical outcomes of patients with cancer: A systematic review and meta-analysis

Objectives

Recently, some cohorts have looked into the use of Global Leadership Initiative on Malnutrition (GLIM) criteria in cancer patients. The objective of the current meta-analysis was to determine its utility in predicting clinical and survival outcomes for cancer patients.

Method

Searching and screening literature from PubMed, Web of Science and Embase until September 13, 2022 was performed by two researchers independently. According to the exclusion and inclusion criteria, articles reporting the impact of malnutrition diagnosed by GLIM on long-term survival and clinical outcomes were included. Data of interest were also extracted from the included papers. The stability of the pooled results was evaluated using sensitivity analysis. With the aid of subgroup analysis, heterogeneity was revealed. To assess publication bias, Egger's and Begg's tests were conducted. The influence of publication bias on the pooling risk estimate was examined using a trim-and-fill analysis.

Results

15 studies that qualified for our study were identified. Pooled hazard ratio (HR) from both multivariate and univariate regression analysis showed a worse overall survival in GLIM-defined malnourished cancer patients than those in well-nourished status. Meanwhile, disease-free survival was also poorer in malnourished patients. Moreover, pooled odds ratio (OR) demonstrated that malnourished cancer patients were more likely to develop overall postoperative complications, complications ≥ Clavien-Dindo grade IIa and complications ≥ Clavien-Dindo grade IIIa. Two articles reported negative relation between GLIM-defined malnutrition and 30-day readmission/mortality.

Conclusion

GLIM-defined malnutrition possesses value in predicting poorer survival and clinical outcomes for cancer patients.

Systematic review registration

[https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=321094], identifier [CRD42022321094].

Sarcopenia as Manifested by L3SMI Is Associated with Increased Long-Term Mortality amongst Internal Medicine Patients-A Prospective Cohort Study

Background: Sarcopenia and Frailty are syndromes that affect the clinical outcomes of patients suffering from a wide range of diseases. The use of Computed Tomography (CT) is well established for Sarcopenia evaluation via estimation of the Skeletal Muscle Index (SMI) at the level of the third lumbar vertebra (L3SMI). Nevertheless, the association of more readily available biomarkers of Sarcopenia and clinical outcomes is desired. Recent studies have associated low Alanine amino-transferase ALT (SGPT) levels with Sarcopenia and frailty. The current study aimed to establish the association between low L3SMI and the aforementioned indices of Sarcopenia, frailty and poor clinical outcomes. Methods: A cohort study of patients admitted to the internal medicine department at a tertiary medical center. Sarcopenia was determined as L3SMI, lower than 53 cm2/m2 in men and 41 cm2/m2 in women. Clinical and mortality data was collected from the medical record. Results: Of the 187 patients recruited (mean age 70.4 ± 9.2, 59% males), 116 (62%) had Sarcopenia, based on L3SMI values. Sarcopenic patients were older, predominantly male, had lower BMI, lower mid-arm muscle circumference (MAMC) and low ALT values upon admission. L3SMI values significantly correlated with age and MAMC among males (R = −0.38, p < 0.001, R = 0.35, p < 0.001, respectively). Sarcopenia was associated with higher, one-year mortality (HR = 2.60, 95% CI 1.06−6.37, p = 0.036) and shorter all-time survival (HR = 2.91, 95% CI 1.35−6.29, p = 0.007). The association with all-time survival remained after adjusting for age and sex (HR = 2.38, 95% CI 1.07−5.29, p = 0.034). Conclusion: As defined by low L3SMI value, Sarcopenia is a poor prognostic factor for the general internal ward patient population. As part of personalized medicine, physicians may benefit from measuring L3SMI value, as indicated by commonly performed CT scans, to objectively assess their patient’s risk of suffering from Sarcopenia and frailty-associated complications.

Muscular Ultrasonography in Morphofunctional Assessment of Patients with Oncological Pathology at Risk of Malnutrition

Background: Muscular ultrasonography is a technique that allows assessing the amount and quality of muscle in a specific body region. The aim of the study was to compare the value of muscle ultrasonography in diagnosis of malnutrition with techniques such as anthropometry, handgrip strength and impedanciometry in patients with oncological pathology. Methods: Cross-sectional study in 43 patients with oncological pathology and high nutritional risk. Classical anthropometry (body mass index (BMI), arm circumference (AC), calf circumference (CC) and estimated appendicular muscle mass index (ASMI)) was performed. Body composition was measured with impedanciometry (BIA), phase angle (PA) and fat-free mass index (FFMI) and muscle ultrasonography of quadriceps rectus femoris (muscle area (MARA) and circumference (MCR) in section transverse). Malnutrition was diagnosed using the GLIM criteria and sarcopenia was assessed using EWGSOP2 criteria. Results: The mean age was 68.26 years (±11.88 years). In total, 23/20 of the patients were men/women. The BMI was 23.51 (4.75) kg/m2. The ASMI was 6.40 (1.86) kg/m2. The MARA was 3.31 cm2 in ultrasonography. In impedanciometry, phase angle was 4.91 (0.75)°; the FFMI was 17.01 kg/m2 (±2.65 kg/m2). A positive correlation was observed between the MARA with anthropometric measurements (AC: r = 0.39, p = 0.009; CC: r = 0.44, p < 0.01; ASMI: r = 0.47, p < 0.001); and with BIA (FFMI: r = 0.48, p < 0.01 and PA: r = 0.45, p < 0.001). Differences were observed when comparing the MARA based on the diagnosis of sarcopenia (Sarcopenia: 2.47 cm2 (±0.54 cm2); no sarcopenia: 3.65 cm2 (±1.34 cm2); p = 0.02). Conclusions: Muscle ultrasonography correlates with body composition measurement techniques such as BIA and anthropometry in patients with cancer.

The Determination of a Consensus Nutritional Approach for Cancer Patients in Spain Using the Delphi Methodology

Malnutrition has a multifactorial origin and can be caused by cancer. This study determined the consensus of a panel of experts on the nutritional approach for cancer patients in Spain using a multidisciplinary approach. Using the Delphi methodology, a 74-question questionnaire was prepared and sent to 46 experts. The areas of knowledge addressed were the nutritional status of the cancer patient, nutritional screening, nutritional therapy, patient referral, and multidisciplinary care. A total of 91.7% of the experts agreed with the questions posed on nutritional status, 60.0% with those on nutritional screening, 76.7% with those on nutritional therapy, and the entire panel of experts agreed with the questions posed on patient referral and multidisciplinary care. The experts agreed upon a high prevalence of malnutrition among cancer patients in Spain. Unlike medical and radiation oncologists, medical nutrition specialists believe that body composition assessment should not be carried out in all types of cancer patients during nutritional screening and that interventions can be conducted outside the oncology clinic. In general, it is recommended that nursing staff routinely perform nutritional screening before starting cancer treatment. It is necessary to develop a multidisciplinary action protocol that includes nutritional and/or sarcopenia screening.

Strategies to Mitigate Chemotherapy and Radiation Toxicities That Affect Eating

Background: Cancer and its therapy is commonly associated with a variety of side effects that impact eating behaviors that reduce nutritional intake. This review will outline potential causes of chemotherapy and radiation damage as well as approaches for the amelioration of the side effects of cancer during therapy. Methods: Information for clinicians, patients, and their caregivers about toxicity mitigation including nausea reduction, damage to epithelial structures such as skin and mucosa, organ toxicity, and education is reviewed. Results: How to anticipate, reduce, and prevent some toxicities encountered during chemotherapy and radiation is detailed with the goal to improve eating behaviors. Strategies for health care professionals, caregivers, and patients to consider include (a) the reduction in nausea and vomiting, (b) decreasing damage to the mucosa, (c) avoiding a catabolic state and muscle wasting (sarcopenia), and (d) developing therapeutic alliances with patients, caregivers, and oncologists. Conclusions: Although the reduction of side effects involves anticipatory guidance and proactive team effort (e.g., forward observation, electronic interactions, patient reported outcomes), toxicity reduction can be satisfying for not only the patient, but everyone involved in cancer care.