The Role of Ultrasound Muscle Parameters for Myosteatosis and Myofibrosis Measurement in Young, Older, and Obese Subjects

OBJECTIVES

The aim of the study was to compare quantitative and qualitative ultrasound parameters between healthy young adults and post-acute hospitalized older adults with and without physical disability, as well as between normal weight and overweight/obese persons.

DESIGN

Cross-sectional observational study.

SETTING AND PARTICIPANTS

A total of 120 individuals were recruited: 24 healthy young adults, 24 normal weight and 24 overweight/obese community-dwelling adults, and 48 post-acute hospitalized older adults with different degrees of functional autonomy.

METHODS

The rectus femoris cross-sectional area (CSA), subcutaneous adipose tissue (SCAT) thickness, echogenicity, strain elastography, and compressibility were measured with ultrasound echography.

RESULTS

Post-acute older adults with a good level of autonomy showed higher echogenicity, a higher compressibility index and elastometry strain, and lower rectus femoris thickness and CSA as compared with young persons. Post-acute individuals with physical disability showed lower echogenicity and a greater stiffness compared with their still autonomous counterparts. Normal weight individuals showed lower stiffness as evaluated with elastometry and a lower SCAT thickness, as compared with individuals with age-matched overweight or obesity. From multiple regression analyses, using CSA as an independent variable, an inverse association with female sex and age was observed, explaining 16% and 51% of variance. Echogenicity was directly associated with age (34% of variance) and with the Barthel index (6% of variance). Elastometry showed association with age and body mass index (BMI), 30% and 16% of variance, respectively. Considering compressibility as a dependent variable, a direct association with age and an inverse association with BMI were observed, with 5% and 11% of variance respectively.

CONCLUSIONS AND IMPLICATIONS

Muscle mass decreases with age and with physical disability. Echogenicity, which increases with age and disability level, seems to be associated with myofibrosis. Conversely, elastometry seems useful in the characterization of muscle quality in overweight or obese individuals and as a reliable indirect measure of myosteatosis.

Epicardial adipose tissue volume and CT-attenuation as prognostic factors for pulmonary embolism and mortality in critically ill patients affected by COVID-19

BACKGROUND/OBJECTIVES

The aim of this post-hoc analysis was to evaluate if epicardial adipose tissue (EAT) quantity and quality, as evaluated by computed tomography (CT), have a different role in the risk of mortality and pulmonary embolism in critically ill COVID-19 patients admitted to an intensive care unit (ICU).

SUBJECTS/METHODS

CT derived EAT volume and density, as well as anthropometric and blood biomarkers, were evaluated in a sample of 138 subjects, 109 men and 29 women, for whom CT images and information on pulmonary embolism were available from a total of 313 subjects who were consecutively admitted to the ICU for COVID-19 from the REINSURE-ARDS prospective registry.

RESULTS

A total of 28 patients (20.3%) died during the first 28 days after ICU admission. 26 subjects out of 138 had pulmonary embolism (18.8%). Age, weight, BMI, IL-6 levels and pulmonary embolism prevalence were significantly higher across EAT volume tertiles. Subjects who died in the first 28 days from ICU admission were older, had higher EAT volume, D-dimer, LDH and IL-6 level. After adjustment for age and gender, participants in tertile 3 of EAT volume had lower survival at 28 days from ICU admission as compared to subjects in the tertile 1, HR 2.95 (95% C.I. 1.02-8.49), but after adjusting for potential confounders the relation was no longer significant. No relation between EAT density and mortality was observed. From a binary logistic regression, subjects in tertile 3 of EAT volume and in tertile 1 of EAT density showed a 4 times and 3.6 times increased risk of pulmonary embolism, respectively.

CONCLUSIONS

ICU subjects affected by severe COVID-19 with higher EAT volume and low EAT density should be carefully monitored and managed with a prompt and aggressive approach, to prevent serious and life-threatening consequences and the increase of hospital treatment costs.

Understanding sarcopenic obesity in young adults in clinical practice: a review of three unsolved questions

INTRODUCTION

Our aim was to summarize the available literature on three yet unsolved questions, namely: 1) the dilemma surrounding definition of sarcopenic obesity (SO), especially in young adults; 2) the potential impact of this phenotype on weight-loss programme outcomes; and 3) the strategies for optimum management (prevention/treatment) of SO in clinical practice.

EVIDENCE ACQUISITION

A literature review using the PubMed/Medline database was conducted, and data were summarized based on a narrative approach.

EVIDENCE SYNTHESIS

Firstly, SO can be screened by the 30-sec sit-to-stand test; ≤25 and ≤21; and confirmed by the ratio of (appendicular lean mass/Body Mass Index) ≤0.789 and 0.512 in males and females, respectively. Secondly, SO is associated with impaired physical fitness, reduced resting energy expenditure and an inactive lifestyle, that seems to negatively impact on weight-management outcomes, namely increasing early dropout and difficulty in maintaining weight loss in the long term. Finally, prevention/treatment of SO in young adults must be realized through tailored lifestyle intervention (diet+exercise) to preserve and improve strength and muscle mass, even where weight loss is necessary.

CONCLUSIONS

Our findings have clinical implications since they may help in screening, managing and improving the weight-loss outcomes of patients with SO in clinical settings.

The Role of Crosstalk between Adipose Cells and Myocytes in the Pathogenesis of Sarcopenic Obesity in the Elderly

As a result of aging, body composition changes, with a decline in muscle mass and an increase in adipose tissue (AT), which reallocates from subcutaneous to visceral depots and stores ectopically in the liver, heart and muscles. Furthermore, with aging, muscle and AT, both of which have recognized endocrine activity, become dysfunctional and contribute, in the case of positive energy balance, to the development of sarcopenic obesity (SO). SO is defined as the co-existence of excess adiposity and low muscle mass and function, and its prevalence increases with age. SO is strongly associated with greater morbidity and mortality. The pathogenesis of SO is complex and multifactorial. This review focuses mainly on the role of crosstalk between age-related dysfunctional adipose and muscle cells as one of the mechanisms leading to SO. A better understanding of this mechanisms may be useful for development of prevention strategies and treatments aimed at reducing the occurrence of SO.

Approaching Sarcopenic Obesity in Young and Middle-Aged Female Adults in Weight Management Settings: A Narrative Review

This paper presents a review of the available literature on sarcopenic obesity (SO) in young and middle-aged female adults with obesity in weight management settings. A literature review using the PubMed/Medline and Science Direct databases was conducted, and the data were summarized through a narrative approach. Firstly, some physical performance tests and questionnaires are available for screening young and middle-aged female adults with a high risk of SO. Secondly, these patients can undergo instrumental measurements such as dual-energy X-ray absorptiometry (DXA) and bioelectrical impedance analysis (BIA) to confirm or reject a diagnosis of SO, applying definitions that account for body mass. Thirdly, SO is a prevalent phenotype in females seeking weight management treatment, as well as being strongly associated (vs. non-SO) with obesity-related comorbidities that need to be promptly managed, initially with nutritional programs or/and in combination with medications. Finally, patients with SO have a reduced baseline resting energy expenditure and more sedentary behaviors, which seem to account for the relationship between SO and poorer weight management outcomes, such as a higher early dropout rate and major later difficulties in weight loss maintenance. Therefore, specific strategies for personalized weight management programs for patients with SO should be incorporated to determine a successful management of this phenotype.

Is handgrip strength a marker of muscle and physical function of the lower limbs? Sex differences in older adults with obesity

BACKGROUND AND AIMS

In this cross-sectional study we investigate the association between handgrip strength (HGS) and muscle function of the lower limbs and the predictors of the appendicular lean mass index (ALMI) in older adults with obesity of both sexes.

METHODS AND RESULTS

Eighty-four older (67 ± 5 years) men (N = 44) and women (N = 40) with obesity (body mass index (BMI) 33 ± 4 kg/m²) performed: the HGS, isokinetic knee extensors (KE) and flexors (KF) muscle strength and power and Short Physical Performance Battery (SPPB). The correlation between HGS and lower limbs muscle function was evaluated, and four multiple hierarchical linear models were built to assess the contribution of each ALMI predictor (i.e., HGS, BMI, SPPB, muscle strength and power). In men, HGS was weakly-to-moderately associated (p < 0.05) with KE, KF muscle function and physical performance. In women, HGS showed a weak association (p < 0.05) with KE muscle function. The significant predictors of ALMI were only the BMI in women, whereas in the group of men BMI, KE maximal strength and power better explain the variance in ALMI than HGS alone.

CONCLUSION

Our results suggest that HGS should not be used alone as a marker of lower muscle nor physical function. Sex differences exist with the BMI that is a contributor of ALMI both in men and women. However, at least in the group of men, markers related to strength and power of the lower limbs can better describe variations in ALMI compared to HGS in this kind of population.

CLINICAL TRIAL REGISTRATION

NA.

Exercise and physical performance in older adults with sarcopenic obesity: A systematic review

Background

Sarcopenic obesity is characterized by low muscle mass and high body fat; prevalence increases with age, particularly after age 65 years. For this systematic literature review we searched scientific databases for studies on exercise interventions for improving physical performance in adults with sarcopenic obesity; also, we identified potential gaps in clinical practice guidelines that need to be addressed.

Methods

We followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The databases were searched for studies published through November 2021 that measured physical performance in adults with sarcopenic obesity.

Results

Most of the studies applied a strength training protocol in which improvement was noted post-treatment on the Time Chair Rise (TCR), 30-s Chair Stand, and Single Leg Stance (SLS) tests. Discrepancies between the studies were observed when resistance training was combined with or without elastic bands or electromyostimulation, as measured with the Short Physical Performance Battery (SPPB), Physical Performance Test (PPT), Gait Speed, and Timed Up & Go (TUG) test. Post-intervention SPPB, PPT, and gait speed scores showed an increase or maintenance of performance, while TUG test scores were higher according to one study but lower according to another.

Conclusions

Engagement in physical exercise, and resistance training in particular, can improve or maintain physical performance in adults with sarcopenic obesity. Study samples should include more men. A future area of focus should be the impact of different types of training (aerobic, power training, combined modalities). Finally, studies with longer intervention periods and follow-up periods are needed to gain a better understanding of the effectiveness of exercise on physical function in adults with sarcopenic obesity.

Exploring the association between handgrip, lower limb muscle strength, and physical function in older adults: A narrative review

Widely used in daily practice, handgrip strength (HGS) is a low cost, easy-to-use, and portable test to assess overall muscle and physical function. It can be used as a stand-alone or a first-line tool for evaluating muscle weakness, though controversy surrounds its use for assessing global or lower limb muscle function. Lower limb mobility and physical activity are reduced with advancing age. This decline is difficult to quantify with isokinetic or isometric devices in routine settings (hospital and nursing home). For this narrative review we explored and summarized the findings of studies that investigated the association between HGS, lower limb muscle strength, and physical performance in older adults. The review also provides directions for future research. We noted contrasting findings for an association between HGS, lower limb strength, and physical performance. We found insufficient evidence for endorsing the handgrip dynamometer as a definitive tool for measuring overall muscle strength and physical function. More evidence is needed from comparable studies involving larger samples of men and women and investigating other areas such as lifestyle, daily physical activity levels, and health-related disorders.

Arterial Stiffness, Subendocardial Impairment, and 30-Day Readmission in Heart Failure Older Patients

Arterial stiffness and subendocardial perfusion impairment may play a significant role in heart failure (HF) outcomes. The aim of the study was to examine the main predictors of 30-day readmission in geriatric patients, hospitalized with HF, explore hemodynamical parameters, arterial stiffness indexes, and subendocardial viability ratio (SEVR). In total, 41 hospitalized patients, affected by HF, were included; they underwent clinical evaluation, routine laboratory testing, and echocardiography. At the time of admission, after the achievement of clinical stability (defined as switching from intravenous to oral diuretic therapy), and at discharge, arterial tonometry was performed to evaluate carotid-femoral pulse wave velocity (PWVcf) and SEVR (then corrected for hemoglobin concentration and oxygen saturation). Through the evaluations, a significant progressive decrease in PWVcf was described (17.79 ± 4.49, 13.54 ± 4.54, and 9.94 ± 3.73 m/s), even after adjustment for age, gender, mean arterial pressure (MAP) variation, and left ventricular ejection fraction (LVEF). A significant improvement was registered for both SEVR (83.48 ± 24.43, 97.94 ± 26.84, and 113.29 ± 38.02) and corrected SEVR (12.74 ± 4.69, 15.71 ± 5.30, and 18.55 ± 6.66) values, and it was still significant when adjusted for age, gender, MAP variation, and LVEF. After discharge, 26.8% of patients were readmitted within 30 days. In a multivariate binary logistic regression analysis, PWVcf at discharge was the only predictor of 30-day readmission (odds ratio [OR] 1.957, 95% CI 1.112–3.443). In conclusion, medical therapy seems to improve arterial stiffness and subendocardial perfusion in geriatric patients hospitalized with heart failure. Furthermore, PWVcf is a valid predictor of 30-day readmission. Its feasibility in clinical practice may provide an instrument to detect patients with HF at high risk of rehospitalization.

Prevalence of obesity and diabetes in older people with sarcopenia defined according to EWGSOP2 and FNHI criteria

Background

Although the prevalence of sarcopenic obesity is increasing, nowadays a universally accepted definition still does not exist. Because, this clinical entity is defined as the combination of obesity and sarcopenia, the diagnosis appears to be strictly linked to criteria used for sarcopenia and the available prevalence data are not uniform. To investigate the prevalence of sarcopenic obesity in older persons according to EWGSOP2 and FNIH criteria. Second, to evaluate the prevalence of diabetes in patients with sarcopenia diagnosed by the two definitions.

Methods

Observational multicenter study performed in 2014 on older patients admitted to 12 Italian hospitals (GLISTEN Study). Data were collected through standardized questionnaires, which assessed: socio-demographic data, cognitive status, functional abilities, pharmacological therapy, comorbidities, and blood tests. Moreover, muscle mass and strength and physical performance were evaluated.

Results

Six hundred and ten were included in the analyses. Among sarcopenic patients, the prevalence of sarcopenic obesity was 30.8% with FNIH and 0% with EWGSOP2 criteria. According to EWGSOP2 criteria, 23.7% of sarcopenic and 30.8% of non-sarcopenic patients were affected by diabetes (p = 0.101); otherwise, using FNIH criteria, 36.3% of sarcopenic and 26.9% of non-sarcopenic patients were diabetic (p = 0.030). After adjustment for potential confounders, diabetic patients had a 73% higher probability of being sarcopenic according to FNIH criteria (OR 1.73; 95% CI 1.13–2.64).

Conclusions

The EWGSOP2 and FNIH sarcopenia criteria are differently related to the prevalence of obesity and diabetes. The EWGSOP2 criteria seem to be not suitable to identify people with sarcopenic obesity.

Impaired subendocardial perfusion in patients with metabolic syndrome

BACKGROUND

Metabolic Syndrome (MS) is associated to vascular damage, increased arterial stiffness, and impaired myocardial perfusion. Subendocardial viability ratio (SEVR) is a noninvasive estimation of myocardial workload, oxygen supply, and perfusion. The aim of the study was to describe the relation between arterial stiffness, SEVR, and cardio-metabolic risk factors.

METHODS

A cohort of 55 patients, aged 59.9 ± 10.8 years, was studied; 28 subjects (50.9%) had metabolic syndrome. All patients underwent a clinical evaluation and blood venous sampling, to assess glico-lipid profile. Applanation tonometry was performed, to obtain pulse wave analysis and SEVR values.

RESULTS

In the overall study population, SEVR showed negative associations with mean (r = -0.301; p = 0.026) and systolic (borderline relation, r = -0.257; p = 0.058) arterial pressure. Metabolic syndrome patients presented lower level of SEVR (p = 0.012), even after adjusting for age, sex, and mean arterial pressure (p = 0.040). Subdividing the study population by the number of metabolic syndrome components, SEVR significantly decreased as the number of Metabolic Syndrome components increased (p for trend 0.005). In a logistic backward regression analysis, both metabolic syndrome and mean arterial pressure resulted significant predictors of SEVR, accounting for 18% of variance.

CONCLUSION

The reduced SEVR in metabolic syndrome patients could be an important pathophysiological determinant of the increased cardiovascular risk.

Prognostic interplay of kidney function with sarcopenia, anemia, disability and cognitive impairment. The GLISTEN study

BACKGROUND

Interactions between chronic kidney disease (CKD) and several comorbidities may potentially affect prognosis of older hospitalized patients. This study aims at evaluating the prognostic interactions between estimated glomerular filtration rate (eGFR), anemia, sarcopenia, functional and cognitive dysfunction, and 3-year mortality among older patients discharged from acute care hospitals.

METHODS

Our series consisted of 504 older adults enrolled in a multicenter observational study carried out in twelve Acute Geriatric and Internal Medicine wards throughout Italy. CKD was defined as an eGFR< 60 ml/min/1.73 m². Anemia, Short Portable Status Mental Questionnaire (SPMSQ), Basic Activities of Daily Living (BADL), sarcopenia, and Charlson index were considered in the analysis. 3-year survival was investigated by Cox regression and prognostic interactions among study variables were assessed by survival tree analysis. Accuracy of different survival models was investigated by C-index.

RESULTS

eGFR < 30 mL/min/1.73 m², anemia, sarcopenia, SPMSQ ≥ 5, and impairment in 1 or more BADL were significantly associated with mortality. Survival tree analysis showed that patients with eGFR < 35.32 ml/min/1.73 m² and SPMSQ ≥ 5 had the highest risk of mortality [hazard ratio (HR): 5.49, 95%CI: 3.04-9.94] followed by those with eGFR < 35.32 ml/min/1.73 m², hemoglobin < 11.95 g/dL and SPMSQ < 5 (HR:3.65; 95%CI: 2.21-6.02) and those with eGFR 35.32-47.99 ml/min/1.73 m² and sarcopenia (HR:3.65; 95%CI: 1.99-6.69). Survival tree leaf node membership had good accuracy in predicting the study outcome (C-index: 0.73, 95%CI:0.70-0.76).

CONCLUSIONS

Interactions among study risk factors designed distinct risk profiles in older patients discharged from acute care hospitals, that may help identify patients needing targeted interventions and appropriate follow-up after discharge.

The Mini Sarcopenia Risk Assessment (MSRA) Questionnaire score as a predictor of skeletal muscle mass loss

BACKGROUND

Previous studies showed a strong relationship between reduction of appendicular muscle mass and worsening disability; hence, accuracy in assessing muscle mass is considered a key feature for a sarcopenia screening tool.

AIM

The aim of the study was to evaluate if the 7 items of Mini Sarcopenia Risk Assessment (MSRA) questionnaire predict muscle mass loss in a population of community-dwelling elderly subjects over a 5.5-y follow-up.

METHODS

The study included 159 subjects, 92 women and 67 men aged 71.5 ± 2.2 years and with mean body mass index of 26.7 ± 4.0 kg/m². Appendicular skeletal muscle mass (ASMM) as measured with Dual-Energy X-ray absorptiometry (DXA), was obtained at baseline and after 2 and 5.5 years of follow-up where the skeletal muscle index (SMI) was calculated.

RESULTS

A significant reduction of ASMM and SMI was observed at two and 5.5 years of follow-up, in both, men and women. Repeated-measures analysis of variance (ANOVA) found a significant time effect on ASMM for both subjects with MSRA > 30 and ≤ 30 (P < 0.01 and P < 0.001). The group × time interaction was significant (P < 0.001), after even considering separately subjects with normal muscle mass and low muscle mass at baseline (P < 0.05 and P = 0.005). Similar results were obtained for SMI. Considering only the subjects with normal SMI at baseline, subjects with MSRA questionnaire ≤ 30 showed 5.7 (95% CI 1.73-19.03) higher risk of exceeding the low muscle mass threshold.

CONCLUSION

In a population of community-dwelling elderly men and women, MSRA score of 30 is predictive of a steeper decline in ASMM and SMI and of a higher risk of exceeding the low muscle mass EWGSOP threshold.

Should cats be allowed outdoors? A research survey on animal welfare risks for free-ranging cats in Brazil

A need exists for research that contributes to estimating the risk factors associated with the management of outdoor cats (Felis silvestris catus) and addresses the lack of such surveys in Brazil and other Latin American countries. With this in mind we aimed to: i) identify the causal factors affecting the practice of owners allowing their cats to roam freely and; ii) evaluate potential welfare risks associated with the allowance of outdoor access, based on cat owners' reports. An online questionnaire consisting of 25 questions was answered by 8,485 Brazilian cat owners and logistic regression models used to obtain odds ratios. A number of the factors significantly related to owners allowing their cats to have outdoor access were unneutered cats, the manner in which the cat was acquired, residence in rural areas, the number of cats owned, the presence of other pets in the house, younger owner age, owner declaration of not being responsible for the cat, owner perception about the role of the cat in the house, owner knowledge about cats' potential for transmitting diseases, a lack of knowledge about zoonoses, and a lack of knowledge regarding toxoplasmosis. The practice of allowing outdoor access was associated with significantly higher odds of owners reporting several welfare issues, such as frequent flea contamination, sporotrichosis, going missing, poisoning, mistreatment, and accidents. We conclude that the practice of allowing outdoor access, as reported by 37.1% of our respondents, may result in risks to feline welfare. Increasing public awareness through campaigns that highlight the risks associated with outdoor access would improve feline management practices and welfare.

Intermuscular Adipose Tissue as a Risk Factor for Mortality and Muscle Injury in Critically Ill Patients Affected by COVID-19

BACKGROUND

Muscular fatigue and injury are frequently observed in critically ill COVID-19 patients. The aim of this study was to determine whether different muscle adipose tissue depots are associated with mortality and muscle damage in patients affected by COVID-19 admitted to the ICU.

METHODS

CT images were obtained in 153 ICU patients with COVID-19 (121 males and 32 females). Height, weight, body mass index (BMI), C-reactive protein, Creatine PhosphoKinase (CPK), muscle density, and intermuscular adipose tissue (IMAT) were measured.

RESULTS

Participants in the highest tertile of IMAT/muscle had the shorter 28-day survival from ICU admission as compared to subjects in the first tertile. Estimates derived from the Cox proportional hazard models, after adjustment for age, sex, and BMI, confirmed the results of the survival analysis (HR 3.94, 95% CI: 1.03-15.09). Participants in the lowest tertile of muscle density had the shorter survival at 28 days from ICU admission as compared to subjects in the highest tertile (HR 3.27, 95% CI: 1.18-4.61), but the relationship was no longer significant when age was included in the model. Subjects in the second muscle density tertile did not show an increased risk.Participants in the highest tertile of IMAT/muscle and those in the lowest tertile of muscle density showed both significantly higher CPK adjusted for weight values as evaluated during the first 8 days of hospitalization.

CONCLUSION

Our data seem to suggest that higher levels of IMAT/muscle and low muscle density are both associated with higher risk of ICU mortality and muscle injury as evaluated with CPK level.

Prolonged unsupervised Nordic walking and walking exercise following six months of supervision in adults with overweight and obesity: A randomised clinical trial

BACKGROUND AND AIMS

This study is a randomized trial that examined the effects of 6 months of unsupervised Nordic walking (NW) and walking (W) exercise following 6 months of supervised training in overweight/obese adults.

METHODS AND RESULTS

After a 6-month program of diet and supervised training participants (n = 27) of NW (66 ± 7 yrs, body mass index (BMI) 34 ± 5) and W (66 ± 8 yrs, BMI 32 ± 5) group continue the training without supervision for other 6 months. Steps count and mean heart rate (HR_mean) were performed in each session; anthropometric and body composition, aerobic capacity and strength of the upper and lower limbs were evaluated at baseline, after 6 months of supervised and 6 months of unsupervised training. In the unsupervised training, monthly sessions and steps count decreased over time in both groups (p < 0.05), with no significant changes in HR_mean. Compared to the supervised phase, adherence decreased significantly only in the W group in the last 3 months of unsupervised training. Compared to baseline in both groups BMI did not change, but W group lost total fat; only the NW group maintained (p < 0.05) the gains in arm curl (33%) and chair stand (31%); both groups improved in six-minute walking test (p < 0.05).

CONCLUSION

Despite unsupervised training was not effective for a further increase in performance, participants, especially in NW, maintained some of the improvements achieved during the supervision. However, the presence of instructor that guides training, may enhance adherence and health benefits of NW and W exercise.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT03212391 (July 11, 2017).

Strength and Performance Tests for Screening Reduced Muscle Mass in Elderly Lebanese Males with Obesity in Community Dwellings

The reduction in skeletal muscle mass (SMM) is a common phenomenon in older adults. It is associated with several diseases, a reduction in physical fitness, longer periods of hospitalization and high rates of mortality. We aimed to identify the reliability of simple tools for screening for reduced SMM among older adult males in Lebanon. The Tanita MC-780MA bioimpedance analyzer (BIA) was used to assess body composition in a population of 102 community-dwelling elderly males with overweight or obesity, in order to be then categorized as with or without reduced SMM. Participants also performed the handgrip strength test and the 4 m gait speed test. Of the total sample of 102 participants (mean age 67.4 ± 6.96 years; BMI 30.8 6 ± 4.04 kg/m²), 32 (31.4%) met the criteria for reduced SMM. Partial correlation analysis showed that handgrip strength (ρ = 0.308, p = 0.002) and 4 m gait speed (ρ = 0.284, p = 0.004) were both associated with low SMM. Receiver operating characteristic (ROC) curve analysis identified discriminating cut-off points of 1.1 m/s for the 4 m gait speed test and 32.0 kg for the handgrip strength test. Our study showed that participants displayed a substantial prevalence of reduced SMM. Reduced 4 m gait speed and handgrip strength were associated with low SMM. Clear cut-off points for strength and functional tests for screening for this condition in Lebanese older men were identified.

Obesity as a risk factor for unfavourable outcomes in critically ill patients affected by Covid 19

BACKGROUND AND AIMS

Recent studies show that obesity is a risk factor for hospital admission and for critical care need in patients with coronavirus disease 2019 (COVID-19). The aim was to determine whether obesity is a risk factor for unfavourable health outcomes in patients affected by COVID-19 admitted to ICU.

METHODS AND RESULTS

95 consecutive patients with COVID-19 (78 males and 18 females) were admitted to ICU and included in the study. Height, weight, BMI, Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, CRP, CPK, ICU and hospital length of stay and comorbidities were evaluated. Participants with obesity had a lower 28 day survival rate from ICU admission than normal weight subjects. Cox proportional hazard model-derived estimates, adjusted for age, gender and comorbidity, confirmed the results of the survival analysis (HR:5.30,95%C.I.1.26-22.34). Obese subjects showed longer hospital and ICU stay as compared with normal weight counterpart.Subjects with obesity showed significantly higher CRP and CPK levels than normal weight subjects.

CONCLUSION

In individuals with obesity, careful management and prompt intervention in case of suspected SARS-CoV-2 infection is necessary to prevent the progression of the disease towards severe outcomes and the increase of hospital treatment costs.

Full characterisation of knee extensors' function in ageing: effect of sex and obesity

BACKGROUND/OBJECTIVES

Muscle function is a marker of current and prospective health/independence throughout life. The effects of sex and obesity (OB) on the loss of muscle function in ageing remain unresolved, with important implications for the diagnosis/monitoring of sarcopenia. To characterise in vivo knee extensors' function, we compared muscles torque and power with isometric and isokinetic tests in older men (M) and women (W), with normal range (NW) of body mass index (BMI) and OB.

SUBJECTS/METHODS

In 70 sedentary older M and W (69 ± 5 years), NW and OB (i.e. BMI < 30 kg m^-2 and ≥30 kg m^-2, respectively) we tested the right knee's extensor: (i) isometric torque at 30°, 60°, 75° and 90° knee angles, and (ii) isokinetic concentric torque at 60, 90, 150, 180 and 210° s^-1 angular speeds. Maximal isometric T-angle, maximal isokinetic knee-extensor torque-velocity, theoretical maximal shortening velocity, maximal power, optimal torque and velocity were determined in absolute units, normalised by body mass (BM) and right leg lean mass (LLM_R) and compared over sex, BMI categories and angle or angular speeds by three-way ANOVA.

RESULTS

In absolute units, relative to BM and LLM_R, sex differences were found in favour of M for all parameters of muscle function (main effect for sex, p < 0.05). OB did not affect either absolute or relative to LLM_R isometric and isokinetic muscle function (main effect for BMI, p > 0.05); however, muscle function indices, when adjusted for BM, were lower in both M and W with OB compared to NW counterparts (p < 0.05).

CONCLUSIONS

We confirmed sex differences in absolute, relative to BM and LLM_R muscle function in favour of men. While overall muscle function and muscle contractile quality is conserved in individuals with class I OB, muscle function normalised for BM, which defines the ability to perform independently and safely the activities of daily living, is impaired in comparison with physiological ageing.

Adipokines and Arterial Stiffness in the Elderly

INTRODUCTION

The aim of this study was to evaluate the relationship between adipokines and arterial stiffness in a group of 85 elderly subjects and the role of leptin and adiponectin on subclinical vascular damage, defined by a PWV>10 m/s.

METHODS

In each subject, we evaluated anthropometry, body composition by DXA (fat mass, fat mass%, lean mass), metabolic variables, leptin, adiponectin, systolic, diastolic, mean arterial pressure and pulse pressure (SBP, DBP, MAP, PP), carotid-femoral pulse wave velocity (cfPWV) and carotid-radial pulse wave velocity (crPWV).

RESULTS

In the study population, significant associations were observed between cfPWV and crPWV, age, SBP, MAP, waist circumference, fat body mass and leptin. The study population was subdivided in 2 subgroups according to adipokine patterns: group 1 included patients with high adiponectin and low leptin, and group 2 patients had high leptin and low adiponectin. SBP, PP, cfPWV were significantly higher in subjects with high leptin and low adiponectin (group 2). Even after adjustment for gender, fat mass%, MAP, HDL cholesterol and triglycerides, cfPWV was higher in group 2 than group 1. In a logistic binary regression on the entire population, considering subclinical vascular damage as a dependent variable and age, gender, MAP, fat mass%, triglycerides, HDL cholesterol and category of subjects with high leptin and low adiponectin as independent variables, MAP and category of subjects with high leptin and low adiponectin were significant predictors (OR, respectively, 1.09 and 3.61).

CONCLUSION

In conclusion, in the elderly, the presence at the same time of high leptin levels and low adiponectin levels seems to have synergic effects on arterial stiffness.

Musculoskeletal adaptations to strength training in frail elderly: a matter of quantity or quality?

BACKGROUND

The improvement in muscle strength generally exceeds the increase in muscle size following strength training in frail elderly, highlighting the complex aetiology of strength deficit in aging. The aim of this study was to investigate the effect of heavy-load strength training on a broad number of factors related to specific strength in frail elderly.

METHODS

Thirty-four frail elderly men (n = 18) and women (n = 16) aged 67 to 98 (86 ± 7 years) were randomized to either a group performing strength training twice a week for 10 weeks (ST) or a non-exercising control group (CON). Knee extensor muscle strength was tested as one-repetition maximum (1RM) and isometric maximal voluntary contraction (MVC) torque. Muscle activation was assessed by the interpolated twitch technique, and muscle density [mean Hounsfield units (HU)] and intermuscular adipose tissue (IMAT) by computed tomography scans of the quadriceps femoris. Muscle biopsies from the vastus lateralis were obtained to investigate changes in intramyocellular lipids and single-fibre specific tension.

RESULTS

In ST, knee extension 1RM and MVC improved by 17 and 7%, respectively. Muscle cross-sectional area of the quadriceps femoris increased by 7%, accompanied by a 4% increase of muscle density. No changes in IMAT, voluntary activation level, single-fibre specific tension, or lipid content were observed.

CONCLUSIONS

In contrast to several previous reports, the improvements in isometric muscle strength and muscle area were in good agreement in the present study. The training-induced increase in muscle density was not due to changes in skeletal muscle lipid content. Instead, the increase in muscle density may reflect increased packing of contractile material or simply an increased ratio of muscle tissue relative to IMAT.

Worsening Disability and Hospitalization Risk in Sarcopenic Obese and Dynapenic Abdominal Obese: A 5.5 Years Follow-Up Study in Elderly Men and Women

Background/Objectives: A general lack of studies comparing the effect of both dynapenic abdominal obesity and sarcopenic obesity on worsening disability and hospitalization risk should be recognized. The aim of the current study was to evaluate, with a 5.5-year follow-up, the prognostic value of sarcopenic obesity and dynapenic abdominal obesity definitions on worsening disability and hospitalization risk in a sample of older adults. Subjects/Methods: In 177 women and 97 men aged 68-78 years, the following outcomes were evaluated at baseline: appendicular skeletal muscle mass (ASMM), percent fat mass (FM%), leg isometric strength, body mass index (BMI), lipid profile, vitamin D3, albumin, fibrinogen, glycemia, physical activity level, income, smoking status, and comorbidities. The rate of reported disabilities and hospitalization were also assessed at baseline, 1, 2, 3, and 5.5-years follow-up. The study population was classified into: (i) non-sarcopenic/obese (NS/O), sarcopenic/non-obese (S/NO), sarcopenic/obese (S/O), non-sarcopenic/non-obese (NS/NO, reference category) according to relative ASMM/FM% tertiles; (ii) non-dynapenic/abdominal obese (ND/AO), dynapenic/non-abdominal obese (D/NAO), dynapenic/abdominal obese (D/AO), non-dynapenic/non-abdominal obese (ND/NAO, reference category) according to muscle strength/waist circumference tertiles. Results: The prevalence of D/AO and S/O was 12.0 and 8.0%, respectively. Only 2 subjects were both D/NAO and S/O (0.8%). D/NAO subjects showed a worsening disability risk of 1.69 times (95% CI: 1.11-2.57), ND/AO subjects showed a 2-fold increased risk (95% CI: 1.34-2.98), while being D/AO more than trebled the risk, even after adjustment for confounding factors (HR: 3.39, 95%; CI: 1.91-6.02). By dividing the study population according to the relative ASMM/FM% tertiles, no groups showed an increased risk of worsening disability. The hospitalization risk, even after adjustment for potential confounders, was 1.84 (95% CI: 1.06-3.19) for D/AO. Dividing the study population according to the relative ASMM/FM% tertiles, no groups showed increased risk of hospitalization. Conclusions: Our results showed that dynapenic abdominal obesity and sarcopenic obesity seem to indicate two distinct phenotypes associated with different health risk profiles. The distribution of participants in waist circumference and muscle strength tertiles allowed for a more accurate risk stratification for worsening disability and hospitalization.

The effects of exercise and diet program in overweight people - Nordic walking versus walking

Purpose

Nordic walking (NW) has been recommended as a form of exercise for clinical populations. Despite intervention programs designed to face a clinical status may last several months, no longitudinal studies have compared the effect of NW to another usual form of exercise, like walking (W). We evaluated the effects of diet combined with a long-supervised NW versus W training on body composition, aerobic capacity and strength in overweight adults.

Patients and methods

Thirty-eight participants, randomized into a NW (n=19, 66±7 years, body mass index (BMI) 33±5)) and a W (n=19, 66±8 years, BMI 32±5) group, followed a diet and a supervised training routine 3 times/week for 6 months. The variables assessed at baseline, after 3 and 6 months were: anthropometric indexes (ie, BMI and waist circumference (WC)), body composition, aerobic capacity (oxygen consumption (VO_2peak), peak power output (PPO), 6-min walking test (6MWT)) and strength (maximal voluntary contraction of biceps brachialis (MVC_BB) and quadriceps femoris (MVC_QF), chair stand and arm curl (AC)).

Results

After 6 months both NW and W group decreased significantly BMI (6% and 4%, respectively) and WC (8% and 4%, respectively), but only the NW group reduced (P<0.05) total body fat (8%), android fat (14%) and leg fat (9%). After 6 months, PPO increased (P<0.05) in both groups, but VO_2peak improved (P<0.05) only in the NW group (8%). After 6 months, 6MWT increased (P<0.001) in both groups and only the NW group improved (P<0.05) in MVC_BB (14%), MVC_QF (17%) and AC (35%).

Conclusion

Our results suggest that NW can give in some relevant health parameters, greater and faster benefits than W. Thus, NW can be a primary tool to counteract the obesity and overweight state in middle-aged adults.

Comparing EWGSOP2 and FNIH Sarcopenia Definitions: Agreement and Three-Year Survival Prognostic Value in Older Hospitalized Adults. The GLISTEN Study

Background

Sarcopenia is common among older hospitalized adults but estimates vary according to definitions used. Aims of this study were to investigate the agreement between the European Working Group on Sarcopenia in Older People (EWGSOP2) and the Foundation for the National Institutes of Health (FNIH) Sarcopenia Project criteria and to compare the predictive value of both definitions for 3-year mortality.

Methods

Analysis was performed on 610 older hospitalized patients enrolled in the GLISTEN study. Participants were categorized as sarcopenic or not sarcopenic according to EWGSOP2 and FNIH definitions separately and in a four-group variable (neither criterion positive, only EWGSOP2, only FNIH, both criteria).

Results

Sarcopenia prevalence was 22.8% and 23.9% using EWGSOP2 and FNIH criteria respectively, with a low classification agreement (Cohen’s kappa statistic: 0.29). Sarcopenic participants by each definitions had higher mortality rate when compared to those not sarcopenic (both log-rank test: p<0.001). Participants that met both positive criteria had the shorter survival as compared with the other three groups. Cox models showed that, after adjustment for potential confounders, only EWGSOP2 definition predicted 3-years mortality (HR 1.84; 95%C.I. 1.33-2.57). When the four-group variable was used, compared with the NO EWGSOP2/NO FNIH group, significant mortality risk was found for the EWGSOP2 (HR 2.08; 95%C.I. 1.38-3.16) and the combined EWGSOP2/FNIH group (HR 1.75; 95%C.I. 1.11-2.79).

Conclusions

Agreement between EWGSOP2 and FNIH definitions is poor. Sarcopenia on hospital admission is associated with increased risk of 3-year mortality and EWGSOP2 criteria seem to have the highest predictive value.

Effects of High-Intensity Interval Training and Isoinertial Training on Leg Extensors Muscle Function, Structure, and Intermuscular Adipose Tissue in Older Adults

We compared the effects of aerobic high-intensity training (HIT) and isoinertial resistance training (IRT) on the strength, mass, architecture, intermuscular adipose tissue (IMAT) quality, and neuromuscular activation of the quadriceps in elderly subjects. Twelve healthy men (69.3 ± 4.2 years; 77.8 ± 10.4 kg; 1.72 ± 0.05 m) were exposed to 8 weeks of HIT (7 × 2-min cycling repetitions at 90% of V.O_2peak, 3 times/week) and, after 4 months (detraining), to IRT (4 × 7 maximal concentric–eccentric knee extensions, 3 times/week). Before and after trainings, we measured knee extension isometric (T_MVC) and dynamic (T_C) maximal concentric torque, anatomical cross-sectional area (ACSA) at 25, 50, and 75% of femur length, quadriceps volume (Vol), IMAT, pennation angle (θ_p) of the fibers from the vastus lateralis, and voluntary activation (%Act). T_MVC and T_C were significantly larger only after IRT (P = 0.008); IRT was able to elicit a greater increase of ACSA than HIT; Vol increases similarly and significantly after HIT and IRT (P = 0.003–0.001); IMAT at 50% of femur length decreased after both HIT and IRT (P = 0.001–0.003); physiological cross-sectional area (PCSA) was larger after IRT than before (P = 0.025); specific torque did not change throughout the study (45.5 N cm^–2 ± 12.0); %Act of the quadriceps was significantly affected only by IRT (P = 0.011). Both HIT and IRT are able to elicit beneficial modifications of muscular mass, architecture, and quality (reducing IMAT) in elderly subjects in connection with an amelioration of strength. HIT and IRT caused a homogeneous increase of ACSA and of Vol of the quadriceps. PCSA increases, but specific strength per unit of PCSA did not change. The increases of functional torque seemed to be attributed to a parallel increase of %Act and muscle hypertrophy only after IRT. Data suggest that IMAT may be a prominent indicator to track metabolic-dependent activity and skeletal muscle quality.

Weight Loss and Hypertension in Obese Subjects

Arterial hypertension is strongly related to overweight and obesity. In obese subjects, several mechanisms may lead to hypertension such as insulin and leptin resistance, perivascular adipose tissue dysfunction, renal impairment, renin-angiotensin-aldosterone-system activation and sympathetic nervous system activity. Weight loss (WL) seems to have positive effects on blood pressure (BP). The aim of this review was to explain the mechanisms linking obesity and hypertension and to evaluate the main studies assessing the effect of WL on BP. We analysed studies published in the last 10 years (13 studies either interventional or observational) showing the effect of WL on BP. Different WL strategies were taken into account-diet and lifestyle modification, pharmacological intervention and bariatric surgery. Although a positive effect of WL could be identified in each study, the main difference seems to be the magnitude and the durability of BP reduction over time. Nevertheless, further follow-up data are needed: there is still a lack of evidence about long term effects of WL on hypertension. Hence, given the significant results obtained in several recent studies, weight management should always be pursued in obese patients with hypertension.

Weight Cycling as a Risk Factor for Low Muscle Mass and Strength in a Population of Males and Females with Obesity

OBJECTIVE

This study aimed to determine whether multiple weight cycles in adulthood are an independent predictor of lower muscle mass and reduced strength, with potential implication for sarcopenia in adults with obesity.

METHODS

A total of 60 males and 147 females with obesity were included, with a mean BMI of 37.9 ± 6.0 kg/m² and a mean age of 52.6 ± 12.4 years. Muscle strength was evaluated with handgrip and appendicular skeletal muscle mass was measured with dual-energy x-ray absorptiometry.

RESULTS

Participants were categorized into the following three groups: non-weight cyclers, mild weight cyclers, and severe weight cyclers. From a binary logistic regression that considered muscle mass categories as a dependent variable and weight cycling categories, age, and sex as independent variables, severe weight cyclers showed a 3.8-times increased risk of low muscle mass (95% CI: 1.42-10.01). Considering handgrip strength categories as a dependent variable and weight cycling categories, age, sex, and BMI as independent variables, severe weight cycling was associated with an increased risk of low muscle mass (about 6.3 times, 95% CI: 1.96-20.59). Severe weight cyclers showed a 5.2-times greater risk of developing sarcopenia.

CONCLUSIONS

In adults with obesity, weight cycling is associated with lower muscle mass and strength and a greater likelihood of developing sarcopenic obesity.

Predictors of self-reported adherence to direct oral anticoagulation in a population of elderly men and women with non-valvular atrial fibrillation

There is a general lack of studies evaluating medication adherence with self-report scales for elderly patients in treatment with direct oral anticoagulants (DOACs). The aim of the study was to assess the degree of adherence to DOAC therapy in a population of elderly outpatients aged 65 years or older affected by non-valvular atrial fibrillation (NVAF), using the 4-item Morisky Medication Adherence Scale, and to identify potential factors, including the geriatric multidimensional evaluation, which can affect adherence in the study population. A total of 103 subjects, anticoagulated with DOACs for NVAF in primary or secondary prevention, were eligible; 76 showed adequate adhesion to anticoagulant therapy, while 27 showed inadequate adherence. Participants underwent biochemical assessment and Morisky Scale, Instrumental Activities of Daily Living, CHA2DS2-VASc, HAS-BLED, mental status and nutritional evaluations were performed. 2% of subjects assumed Dabigatran at low dose, while 7.8% at standard dose, 9.7% assumed low-dose of Rivaroxaban and 30.1% at standard dose, 6.8% assumed Apixaban at low dose and 39.7% at standard dose, and finally 1% assumed Edoxaban at low dose and 2.9% at standard dose. Most subjects took the DOACs without help (80.6%), while 16 subjects were helped by a family member (15.5%) and 4 were assisted by a caregiver (3.9%). Binary logistic regression considered inappropriate adherence as a dependent variable, while age, male sex, polypharmacotherapy, cognitive decay, caregiver help for therapy assumption, duration of DOAC therapy and double daily administration were considered as independent variables. The double daily administration was an independent factor, determining inappropriate adherence with an OR of 2.88 (p = 0.048, CI 1.003-8.286).

Sarcopenia and obesity

PURPOSE OF REVIEW

Together with age-related body composition changes, the increased prevalence of obesity observed in the past few decades in older individuals has led to a condition called sarcopenic obesity, characterized by a mismatch between muscle mass and fat mass. The operative definition of sarcopenic obesity is still under discussion and creates difficulties in clinical practice. Muscle weakness, rather than low muscle mass, was previously proposed as an alternative criterion and, more recently, the dynapenic abdominal obese phenotype is of increasing interest because of its unfavorable health consequences and usability in clinical practice.

RECENT FINDINGS

This review focuses on the most recent findings of pathogenic inter-relationships between adipose tissue and muscle. Recent studies on health consequences of sarcopenic obesity and dynapenic abdominal obesity are also examined. Despite the lack of consensus on a definition for sarcopenic obesity, progress has been made in the delineation of the treatment principles for this condition.

SUMMARY

Further research is needed to compare different definitions of sarcopenic/dynapenic obesity to clarify the relationship between obesity and the most important adverse outcomes in the elderly. The next step will be the definition of best possible therapeutic approaches for this condition.

Physical performance measures in screening for reduced lean body mass in adult females with obesity

BACKGROUND & AIMS

Little is known about the reduction of lean body mass (LBM) in obesity, or how to identify it in standard clinical settings. We therefore aimed to assess the prevalence of low LBM in adult females with obesity, and to identify the reliability of simple tools for its screening in this population.

METHODS AND RESULTS

Dual-energy X-ray absorptiometry (DXA) body composition assessment was used to categorise 147 female participants with obesity as with or without low LBM, according to the new definition that takes into account both appendicular lean mass (ALM) and body mass index (BMI)-ALM/BMI <0.512. Participants were also administered the six-minute walking test, handgrip-strength test and 4-metre gait-speed test. Of the sample of 147 participants, 93 (63.3%) met the criteria for reduced LBM. Stepwise multivariate logistic regression analysis showed that the six-minute walking test was the only independent test associated with low LBM (OR = 0.992, 95%CI 0.987-0.998). Receiver operating characteristic (ROC) curve analysis found that the discriminating cut-off points of the tests considered were 470 m, 3.30 s (gait speed = 1.2 m/sec) and 23.5 kg respectively; the 4-metre gait-speed test seems to provide the best balance of sensitivity and specificity, and the greatest discriminatory power at 90% sensitivity.

CONCLUSIONS

Treatment-seeking adult females with obesity display a great prevalence of reduced LBM. The six-minute walking test was the only independent test associated with low LBM, but the 4-metre gait-speed test seems to be the most accurate functional test for screening for this condition in that population.

An update on methods for sarcopenia diagnosis: from bench to bedside

Sarcopenia has been recognized as an age-related syndrome characterized by low muscle mass, low muscle strength, and low physical performance that is associated with increased likelihood of adverse outcomes including falls, fractures, hospitalization, frailty and mortality. Therefore, it is necessary to identify the condition early for applying intervention and prevention of the disastrous consequences of sarcopenia if left untreated. Clinical definition and diagnostic criteria for sarcopenia have been developed in the last years and different tools have been proposed for screening subjects with sarcopenia, evaluating the muscle mass, the muscle strength and the physical performance. In this review we analyzed the diagnostic criteria of sarcopenia and examined the current assessment tools used for the diagnosis and screening of sarcopenia.

Association between hospitalization-related outcomes, dynapenia and body mass index: The Glisten Study

OBJECTIVE

To compare the prognostic value of dynapenia, as evaluated by handgrip, and body mass index (BMI) on length of stay (LOS), days of bed rest, and other hospitalization-related outcomes in a population of older adults admitted to 12 italian acute care divisions.

METHODS

Data on age, weight, BMI, comorbidities, ADL, physical activity level, muscle strength, were recorded at hospital admission. LOS, days of bed rest, intrahospital falls, and discharge destination were also recorded during the hospitalization. Subjects with BMI <18.5 kg/m² were classified as underweight, subjects with BMI 18.5-24.9 as normal weight, subjects with BMI ≥25 as overweight-obese.

RESULTS

A total of 634 patients, mean age 80.8 ± 6.7 years and 49.4% women, were included in the analysis. Overall dynapenic subjects (D) showed a longer period of LOS and bed rest compared with non-dynapenic (ND). When the study population was divided according to BMI categories, underweight (UW), normal weight (NW), and overweight-obese (OW-OB), no significant differences were observed in hospital LOS and days of bed rest. When analysis of covariance was used to determine the difference of LOS across handgrip/BMI groups, D/OW-OB and D/UW subjects showed significantly longer LOS (11.32 and 10.96 days, both p 0.05) compared to ND/NW subjects (7.69 days), even when controlling for age, gender, baseline ADL, cause of hospitalization and comorbidity. After controlling for the same confounding factors, D/OW-OB, D/NW and D/UW subjects showed significantly longer bed rest (4.7, 4.56, and 4.05 days, respectively, all p 0.05, but D/OW-OB p 0.01) compared to ND/NW subjects (1.59 days).

CONCLUSION

In our study population, LOS is longer in D/UW and D/OW-OB compared to ND/NW subjects and days of bed rest are mainly influenced by dynapenia, and not by BMI class.

A New Regimen of Cisplatin, Epirubicin and Methotrexate (PEM-3) as Primary Chemothfrapy for Locally Advanced Bladder Cancer

In this phase II study, 41 patients with locally advanced urothelial bladder cancer (T2-4, NO, MO) were treated with primary chemotherapy (cisplatin, epirubicin, methotrexate: PEM-3). All the patients were assessable for response and toxicity. Clinical monitoring was performed with computerized tomography and cystoscopy. Nineteen clinical complete remissions (46%) and 10 partial remissions (24.5%) were obtained (CR + PR, 70.5%; 95% confidence interval, 57%-85%). Ten patients were considered to have clinically stable disease (24.5%), and 2 patients progressed (5%). Surgery after chemotherapy was performed in 22 cases: in 6 patients (27%) a pathologic complete response was achieved. The pathologic stage was lower than the initial clinical stage in 13 patients (59%). After a median follow-up of 3 years (range, 1-4), the median time to progression was 104 weeks. At this writing, 20 patients, 12 of which were submitted to surgery and 8 were not operated, are disease-free. The 3-year survival rate is 52%. No one had to interrupt the treatment because of toxicity. In conclusion, the PEM-3 regimen is a very active and well-tolerated regimen in locally advanced bladder cancer.

Role of Anti-Inflammatory Cytokines on Muscle Mass and Performance Changes in Elderly Men and Women

OBJECTIVES

Investigate the presence of a correlation between systemic inflammatory profile of community-dwelling individuals and the loss of muscular mass and performance in old age over a 4.5y follow-up, focusing on the role of anti-inflammatory cytokines in muscular changes in elderly.

DESIGN

Longitudinal clinical study.

SETTING

Subjects were randomly selected from lists of 11 general practitioners in the city of Verona, Italy.

PARTICIPANTS

The study included 120 subjects, 92 women and 28 men aged 72.27±2.06 years and with BMI of 26.52±4.07 kg/m2 at baseline.

MEASUREMENTS

Six minutes walking test (6MWT), appendicular and leg fat free mass (FFM) as measured with Dual Energy X-ray absorptiometry, were obtained at baseline and after 4.5 years (4.5y) of mean follow-up. Height, weight, body mass index (BMI), and circulating levels of TNFα, IL-4, IL-10, and IL-13 were evaluated at baseline.

RESULTS

A significant reduction of appendicular FFM, leg FFM and 6MWT performance (all p<0.001) was observed after 4.5 y follow-up. In a stepwise regression model, considering appendicular FFM decline as dependent variable, lnIL-4, BMI, baseline appendicular FFM, lnTNFα and lnIL-13 were significant predictors of appendicular FFM decline explaining 30.8% of the variance. While building a stepwise multiple regression considering leg FFM as a dependent variable, lnIL-4, BMI and leg FFM were significant predictors of leg FFM decline and explained 27.4% of variance. When considering 6MWT decline as a dependent variable, baseline 6MWT, lnIL-13 and lnTNFα were significant predictors of 6MWT decline to explain 22.9% of variance.

CONCLUSIONS

Our study suggest that higher serum levels of anti-inflammatory markers, and in particular IL-4 and IL-13, may play a protective role on FFM and performance maintenance in elderly subjects.

Adipocytes WNT5a mediated dedifferentiation: a possible target in pancreatic cancer microenvironment

A significant epidemiological association between obesity and pancreatic ductal adenocarcinoma (PDAC) has previously been described, as well as a correlation between the degree of pancreatic steatosis, PDAC risk and prognosis. The underlying mechanisms are still not completely known.

After co-culture of 3T3-L1 adipocytes and MiaPaCa2 with an in vitro transwell system we observed the appearance of fibroblast-like cells, along with a decrease in number and size of remaining adipocytes. RT-PCR analyses of 3T3-L1 adipocytes in co-culture showed a decrease in gene expression of typical markers of mature adipocytes, in parallel with an increased expression of fibroblast-specific and reprogramming genes. We found an increased WNT5a gene and protein expression early in MiaPaCa2 cells in co-culture. Additionally, EMSA of c-Jun and AP1 in 3T3-L1 demonstrated an increased activation in adipocytes after co-culture. Treatment with WNT5a neutralizing antibody completely reverted the activation of c-Jun and AP1 observed in co-cultured adipocytes.

Increasing doses of recombinant SFRP-5, a competitive inhibitor for WNT5a receptor, added to the co-culture medium, were able to block the dedifferentiation of adipocytes in co-culture.

These data support a WNT5a-mediated dedifferentiation process with adipocytes reprogramming toward fibroblast-like cells that might profoundly influence cancer microenvironment.

Prevalence and Clinical Correlates of Sarcopenia, Identified According to the EWGSOP Definition and Diagnostic Algorithm, in Hospitalized Older People: The GLISTEN Study

Background

Prevalence of sarcopenia is substantial in most geriatrics settings, but estimates vary greatly across studies because of difference in population characteristics, diagnostic criteria, and methods used to assess muscle mass, muscle strength, and physical performance. We investigated the feasibility of the European Working Group on Sarcopenia in Older People (EWGSOP) algorithm assessment in hospitalized older adults and analyzed prevalence and clinical correlates of sarcopenia.

Methods

Cross-sectional analysis of 655 participants enrolled in a multicenter observational study of older adults admitted to 12 acute hospital wards in Italy. Sarcopenia was assessed as low skeletal mass index (kg/m2) plus either low handgrip strength or low walking speed (EWGSOP criteria). Skeletal muscle mass was estimated using bioimpedance analysis.

Results

Of the 655 patients (age 81.0 ± 6.8 years; women 51.9%) enrolled in the study, 275 (40.2%) were not able to perform the 4-m walking test because of medical problems. The overall prevalence of sarcopenia on hospital admission was 34.7% (95% confidence interval 28-37) and it steeply increased with aging (p < .001). In multivariable analysis, patients with sarcopenia on hospital admission were older and were more likely to be male and to have congestive heart failure, cerebrovascular disease, and severe basic activities of daily living disability. The prevalence of sarcopenia was inversely correlated with body mass index.

Conclusion

Based on EWGSOP criteria, prevalence of sarcopenia is extremely high among older adults on admission to acute hospital wards. Older age, male gender, congestive heart failure, cerebrovascular disease, severe activities of daily living disability, and body mass index were the clinical variables significantly associated with the presence of sarcopenia.

Dynapenic Abdominal Obesity as a Predictor of Worsening Disability, Hospitalization, and Mortality in Older Adults: Results From the InCHIANTI Study

Background

There are relatively few prospective studies evaluating the combined effect of abdominal obesity and low muscle strength on mortality, hospitalization, and incident disability. The aim of this study was to prospectively evaluate the prognostic value of dynapenic abdominal obesity on incident disability, hospitalization, and mortality in the population of the InCHIANTI study.

Methods

In 370 men and 476 women aged between 65 and 95 years, handgrip strength, waist circumference (WC), body mass index, interleukin-6, C-reactive protein, education, medications, smoking status, and comorbidities were evaluated at the baseline. Difficulties in performing basic activities of daily living were assessed at baseline and at 3-, 6-, and 9-year follow-ups, using a standardized questionnaire. Hospitalization and mortality rates were evaluated during an 11-year follow-up. The study population was categorized as nondynapenic nonabdominal obese (ND/NAO, reference group), dynapenic nonabdominal obese (D/NAO), nondynapenic abdominal obese (ND/AO), and dynapenic abdominal obese (D/AO), according to handgrip strength/WC tertiles.

Results

D/AO participants presented more than a twofold increase in risk of worsening disability (odds ratio = 2.10; 95% confidence interval [CI]: 1.14-3.88) and significantly higher risk of hospitalization (1.36; 95% CI: 1.04-1.78) compared with ND/NAO participants. After adjustment for potential confounders, the relative risk of death was 1.47 (95% CI: 1.09-1.97) for D/NAO compared with the ND/NAO group.

Conclusions

Dynapenic abdominal obese participants are at higher risk of worsening disability and hospitalization than ND/NAO participants. Mortality risk was higher in participants with dynapenia without central fat distribution compared with the reference group.

Role of adipose tissue in melanoma cancer microenvironment and progression

BACKGROUND

An epidemiological association between excess weight and increased risk of cancer has been described in melanoma, for which the physiopathological mechanisms are still unknown. The study of tumor microenvironment and of the role of adipocytes in cancer development, progression and metastasis has recently received great interest. However, the role of peritumoral adipocytes has been characterized only in a few types of cancer, and in melanoma it still remains to be defined.

METHODS

We investigated the interactions between adipocytes and melanoma cells using an in vitro co-culture system. We studied the morphological and functional properties of 3T3-L1 adipocytes before and after co-culture with A375 melanoma cells, in order to assess the role of adipocytes on melanoma migration.

RESULTS

Morphological analysis showed that after 6 days of co-culture 3T3-L1 adipocytes were reduced in number and size. Moreover, we observed the appearance of dedifferentiated cells with a fibroblast-like phenotype that were not present in controls and that had lost the expression of some adipocyte-specific genes, and increased the expression of collagen, metalloproteinases and genes typical of dedifferentiation processes. Through the Matrigel Invasion Test, as well the Scratch Test, it was possible to observe that co-culture with adipocytes induced in melanoma cells increased migratory capacity, as compared with controls. In particular, the increase in migration observed in co-culture was suppressed after adding the protein SFRP-5 in the medium, supporting the involvement of the Wnt5a pathway. The activation of this pathway was further characterized by immunofluorescence and western blot analysis, showing in melanocytes in co-culture the activation of β-catenin and LEF-1, two transcription factors involved in migration processes, neo-angiogenesis and metastasis.

CONCLUSIONS

These data allow us to hypothesize a dedifferentiation process of adipocytes toward fibroblast-like cells, which can promote migration of melanoma cells through activation of Wnt5a and the intracellular pathways of β-catenin and LEF-1.

Relationship between neck circumference, insulin resistance and arterial stiffness in overweight and obese subjects

Background Only a few studies have investigated the relationship between neck circumference and cardiometabolic risk. The aim of this study was to assess the relationships between neck circumference, waist circumference, metabolic variables and arterial stiffness in a group of overweight and obese subjects evaluating a possible independent role of neck circumference in determining arterial stiffness. Methods and results We studied 95 subjects (53 women) with an age range of 20-77 years and body mass index range from 25.69 to 47.04 kg/m². In each subject we evaluated body mass index, waist, hip and neck circumference, systolic and diastolic blood pressure, insulin, fasting glucose, cholesterol, low-density lipoprotein and high-density lipoprotein cholesterol and triglycerides. Arterial stiffness was assessed by carotid-femoral pulse wave velocity (PWVcf) and carotid-radial pulse wave velocity (PWVcr). Both PWVcf and PWVcr were higher in subjects with high values of neck circumference compared with subjects with normal values of neck circumference. Subjects with high values of neck circumference and abdominal obesity presented higher values of mean arterial pressure, PWVcr and homeostasis model assessment (HOMA) index and lower values of high-density lipoprotein than subjects with only abdominal obesity. Two models of stepwise multiple regression were performed in order to evaluate the combined effect of independent variables on arterial stiffness. In the first model PWVcf was considered a dependent variable, and age, gender, systolic blood pressure, triglycerides, high-density lipoprotein cholesterol, waist circumference, neck circumference, HOMA index and the use of anti-hypertensive medications were considered independent variables. Age, systolic blood pressure, triglycerides and waist circumference were significant predictors of PWVcf, explaining 65% of its variance. In the second model, in which PWVcr was considered a dependent variable, neck circumference and gender were significant predictors of PWVcr, explaining 24% of its variance. Conclusions These findings emphasise the need to measure not only waist but even neck circumference to better stratify and identify individuals at increased cardiometabolic risk, as upper-body subcutaneous fat is a novel, easily measured fat depot.

Work stress and burnout among physicians and nurses in Internal and Emergency Departments

Burnout has been defined as loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment. Work environment and working conditions exposes the individual to numerous factors of stress. Stress-related diseases are defined as burnout. The increased workload, the repeated reorganizations in the hospital with iterative downsizing suggestions and budget cuts, without any perspective of career progression, with a social culture of bureaucracy and blame, resulting both in subtracting direct care time with patients and in the fear by healthcare professionals from the burden of their responsibility, are the backgrounds on which more and more frequent cases of burnout may develop. We need to establish homogenous standards all over the national territory on workload and about the procedures that have to be implemented for the prevention of burnout in our wards.

Lack of application of the European Work Time Directive: effects on workload, work satisfaction and burnout among Italian physicians

The Italian Parliament has excluded hospital physicians from the application of the European Work Time Directive (EWTD), which imposes a maximum workweek of 48 h and compulsory resting periods. This resulted in extended and excessive work time for the category. This paper is aimed at evaluating the impact of this legislation gap, by assessing the presence of excessive work-related stress and risk for burnout syndrome among Italian physicians working in public hospitals. This observational study is based on an on-line survey conducted on a sample of 1925 Italian doctors (covering a wide range of age, work experience and contractual positions) from October 2014 to February 2015. The questionnaire included 30 questions concerning their personal and professional life (<em>e.g</em>., assessment of workloads, number of uncomfortable or extra shifts, unused days-off, <em>etc</em>.). On the basis of the results, it can be inferred that the average Italian doctor working in public hospitals is under considerable stress at work with negative consequences on his health. He is exposed to high risk of suffering from sleep disorders and cardiovascular diseases (due to the lack of time for private practice and eating regular meals). Overall, his perception is that his job worsens his quality of life. This study shows the relevance of the risk of burnout among Italian physicians employed in public hospitals due to severe workload and work conditions. The resulting impact on the quality of care and the significant cost involved - both in human and economic terms - calls for significant emergency measures by the Italian health work organization. An important increase and prolonged working time is associated with a worsening of the objective cognitive performance and an increase of clinical risk, but also to an increased risk of diseases for operators and of the burnout syndrome. Our survey shows that lack of application of the EWTD has adverse effects on the quality of life and performance of Italian doctors. Failure to respond by all Italian doctors is the greatest limitation of our survey.

Assessing the Risk of Sarcopenia in the Elderly: The Mini Sarcopenia Risk Assessment (MSRA) Questionnaire

OBJECTIVES

to validate the MSRA questionnaire proposed as prescreening tool for sarcopenia, in a population of community-dwelling elderly subjects.

DESIGN

observational study.

SETTING

community dwelling elderly subjects.

PARTICIPANTS

274 community dwelling elderly subjects, 177 women and 97 men, aged 66-78 years.

MEASUREMENTS

Based on EWGSOP diagnostic criteria subjects were classified as sarcopenic and non-sarcopenic. The Mini Sarcopenia Risk Assessment (MSRA) questionnaire, is composed of seven questions and investigates anamnestic and nutritional characteristics related to risk of sarcopenia onset (age, protein and dairy products consumption, number of meals per day, physical activity level, number of hospitalizations and weight loss in the last year).

RESULTS

33.5% of the study population, were classified as sarcopenic. With the 7-item MSRA score, subjects with a score of 30 or less, had a 4-fold greater risk of being sarcopenic than subjects with a score higher than 30 (OR:4.20;95% CI:2.26-8.06); area under the ROC curve was 0.786 (95% CI:0.725-0.847). In a logistic regression, considering as dependent variable the probability of being sarcopenic, and as independent variables the 7 items of the questionnaire, two items (number of meals and milk and dairy products consumption) showed non-significant diagnostic power. A 5-item score was then derived and the area under the ROC curve was 0.789 (95% IC:0.728-0.851). Taking into account the cost of false positive and false negative costs and the prevalence of sarcopenia, the "optimal" threshold of the original MSRA score (based on 7 items) is 30, with a sensitivity of 0.804 and a specificity of 0.505, while the "optimal" threshold of the MSRA score based on 5 items, is 45, with a sensitivity of 0.804 and a specificity of 0.604.

CONCLUSION

this preliminary study shows that the MSRA questionnaire is predictive of sarcopenia and can be suggested as prescreening instrument to detect this condition. The use of a short form of the MSRA questionnaire improves the capacity to identify sarcopenic subjects.

Optimizing Treatment of Elderly COPD Patients: What Role for Inhaled Corticosteroids?

The most recent international documents on the management and therapy of chronic obstructive pulmonary disease (COPD) recommend inhaled corticosteroids (ICS) in addition to long-acting bronchodilators as maintenance treatment for patients at high risk of exacerbations, namely patients with forced expiratory volume in 1 s (FEV1) of <50% predicted and/or more than one exacerbation per year. However, ICS are widely used in up to 70% of COPD patients, including those at low risk of exacerbations. In recent years, concerns about the potential adverse effects of this drug category have been raised, and both observational and clinical studies have shown that elderly subjects with COPD treated with ICS are at high risk of developing cataracts and diabetes and more severe and life-threatening conditions such as pneumonia and osteoporotic fractures. Moreover, aging is characterized by memory impairment, decline in muscle strength and body mass impaired coordination, as well as alterations in eyesight and hearing that can impede proper use of devices currently available for ICS administration. Thus, regular use of ICS in more elderly patients with COPD should follow guideline recommendations, be considered with caution, and be based upon carefully weighing up expected benefits with the risk of undesired, adverse effects.