Impact of Software Selection and ImageJ Tutorial Corrigendum on Skeletal Muscle Measures at the Third Lumbar Vertebra on Computed Tomography Scans in Clinical Populations

Quantification of Skeletal Muscle at the First Lumbar Level for Prognosis in Amyotrophic Lateral Sclerosis

BACKGROUND

Skeletal muscle parameters at the first lumbar vertebra (L1) level on computed tomography (CT) are common indicators for muscle mass. However, their relationship with the severity and prognosis of amyotrophic lateral sclerosis (ALS) patients remains unclear.

METHODS

This cohort study included ALS patients who underwent chest CT scans between January 2018 and January 2022 and healthy controls (HCs) matched for gender and age. Overall survival (OS) was determined from the date of chest CT to death, tracheal intubation or 1 January 2024. Using ImageJ software, skeletal muscle area and density (L1 SMA/SMD), skeletal muscle index (L1 SMI), paraspinal muscle area and density (L1 PMA/PMD) and subcutaneous fat area and density (L1 SFA/SFD) at L1 were quantified. The relationships between the quantified muscle parameters and both King's clinical stages and the Revised ALS Functional Rating Scale (ALSFRS-R) were analysed. The Cox proportional hazard model was used to evaluate the hazard ratio (HR) of skeletal muscle parameters as risk factors for outcome events, and to construct a nomogram.

RESULTS

Muscle parameters in ALS patients (n = 102; 36.27% female; mean age, 60.85 ± 10.58 years) were significantly lower compared with HCs (p < 0.001). L1 SMD (p = 0.047) and L1 PMD (p = 0.003) both differed significantly across the King's clinical stages. ALSFRS-R scores correlated with L1 SMA (r = 0.35, p < 0.001), L1 SMI (r = 0.34, p < 0.001), L1 PMA (r = 0.27, p = 0.007) and L1 PMD (r = 0.27, p = 0.007). Multivariate Cox regression analysis revealed that L1 SMA (HR = 0.96, 95% confidence interval [CI] = 0.94-0.98, p = 0.001), L1 SMD (HR = 0.92, 95% CI = 0.88-0.96, p < 0.001) and L1 PMA (HR = 1.06, 95% CI = 1.01-1.11, p = 0.022) significantly influenced ALS survival, with area under the curves (AUCs) of 0.687 and 0.851 for 1- and 3-year OS prediction. The consistency index (C-index) for the nomogram was 0.72 (95% CI = 0.641-0.793).

CONCLUSIONS

Skeletal muscle parameters at L1 level on CT are significantly associated with clinical severity and prognosis in ALS.

TRIAL REGISTRATION

Chinese Clinical Trial Registration Center: ChiCTR230078702.

Skeletal Muscle Mass Loss Leads to Prolonged Mechanical Ventilation and Higher Tracheotomy Rates in Critically Ill Patients

Background: Skeletal muscle mass depletion adversely affects critically ill patient outcomes. Standardized methods for assessing muscle mass in this population are limited, particularly regarding changes during ICU stays and their implications for risk stratification. Methods: In this secondary analysis of our prospective data registry of surgical ICU patients, we used a single slice extracted from a computed tomography scan to determine the patient's direction of absolute change in skeletal muscle mass between two different time points (-14 d to +0 d and +5 d to +21 d) during his or her critical illness. Results: In total, 98 surgical patients were included in the final analysis. A decrease in a patient's skeletal muscle mass is associated with prolonged mechanical ventilation compared to patients whose skeletal muscle mass remained the same or increased (415 vs. 42 h, p = 0.003). Patients losing skeletal muscle mass also needed to be ventilated more frequently (88.3% vs. 60.5%, p = 0.002), had a higher rate of tracheotomy (50.0% vs. 23.7%, p = 0.011), and had an increased ICU length of stay (22 vs. 13 days, p = 0.045). Conclusions: A decreased skeletal muscle index in early critical illness negatively impacts ventilation parameters, highlighting the importance of monitoring and managing muscle mass changes to optimize outcomes in ICU patients.

Objective comparison of commonly used computed tomography body composition analysis software

OBJECTIVES

Sarcopenia is defined as an age-related, involuntary loss of skeletal muscle mass and strength. This condition is increasingly gaining clinical attention, as it has proved a predictor of complications and unfavorable outcomes in several diseases. For analysis of body composition on computed tomography images, several different software packages are used. Extensive research is being conducted globally to establish general cutoff values for different patient groups by combining the results of different studies with meta-analysis. Therefore, it is important that the measurements are independent of the software used. However, clinical software comparisons suggest there are differences between analysis packages, which would complicate establishment of cutoff values. For this study, we compared the eight most used analysis software programs in an objective manner, using a phantom image, to assess if their results can be readily compared.

METHODS

Eight software packages (sliceOmatic, OsiriX, ImageJ/Fiji, Mimics, CoreSlicer, SarcoMeas, 3D Slicer, and Aquarius iNtuition) were objectively evaluated, by performing measurements in a standardized synthetic image, containing fixed muscle and fat compartments with homogeneous radiodensities. For all programs, the measured areas and radiodensities of the regions of interest were assessed.

RESULTS

For sliceOmatic, OsiriX, ImageJ/Fiji, Mimics, CoreSlicer, SarcoMeas, and 3D Slicer, identical results were found, all reporting correct values for muscle and fat areas as well as correct radiodensity values, whereas values reported by Aquarius iNtuition deviated ≤ 5% for area measurements and had slight variation in radiodensity measurements.

CONCLUSIONS

Seven of eight software packages (sliceOmatic, OsiriX, ImageJ/Fiji, Mimics, CoreSlicer, SarcoMeas, and 3D Slicer) perform identically, so their results can be readily compared and combined when assessing body composition in computed tomography images. Area measurements acquired with Aquarius iNtuition may differ slightly (≤ 5%) from the other packages.

A novel nomogram integrating body composition and inflammatory-nutritional markers for predicting postoperative complications in patients with adhesive small bowel obstruction

Background

Postoperative complications in adhesive small bowel obstruction (ASBO) significantly escalate healthcare costs and prolong hospital stays. This study endeavors to construct a nomogram that synergizes computed tomography (CT) body composition data with inflammatory-nutritional markers to forecast postoperative complications in ASBO.

Methods

The study's internal cohort consisted of 190 ASBO patients recruited from October 2017 to November 2021, subsequently partitioned into training (n = 133) and internal validation (n = 57) groups at a 7:3 ratio. An additional external cohort comprised 52 patients. Body composition assessments were conducted at the third lumbar vertebral level utilizing CT images. Baseline characteristics alongside systemic inflammatory responses were meticulously documented. Through univariable and multivariable regression analyses, risk factors pertinent to postoperative complications were identified, culminating in the creation of a predictive nomogram. The nomogram's precision was appraised using the concordance index (C-index) and the area under the receiver operating characteristic (ROC) curve.

Results

Postoperative complications were observed in 65 (48.87%), 26 (45.61%), and 22 (42.31%) patients across the three cohorts, respectively. Multivariate analysis revealed that nutrition risk score (NRS), intestinal strangulation, skeletal muscle index (SMI), subcutaneous fat index (SFI), neutrophil-lymphocyte ratio (NLR), and lymphocyte-monocyte ratio (LMR) were independently predictive of postoperative complications. These preoperative indicators were integral to the nomogram's formulation. The model, amalgamating body composition and inflammatory-nutritional indices, demonstrated superior performance: the internal training set exhibited a 0.878 AUC (95% CI, 0.802-0.954), 0.755 accuracy, and 0.625 sensitivity; the internal validation set displayed a 0.831 AUC (95% CI, 0.675-0.986), 0.818 accuracy, and 0.812 sensitivity. In the external cohort, the model yielded an AUC of 0.886 (95% CI, 0.799-0.974), 0.808 accuracy, and 0.909 sensitivity. Calibration curves affirmed a strong concordance between predicted outcomes and actual events. Decision curve analysis substantiated that the model could confer benefits on patients with ASBO.

Conclusion

A rigorously developed and validated nomogram that incorporates body composition and inflammatory-nutritional indices proves to be a valuable tool for anticipating postoperative complications in ASBO patients, thus facilitating enhanced clinical decision-making.

Combined Prognostic Impact of Low Muscle Mass and Hypoalbuminemia in Patients Hospitalized for Heart Failure: A Retrospective Cohort Study

BACKGROUND

Sarcopenia and hypoalbuminemia have been identified as independent predictors of increased adverse outcomes, including mortality and readmissions, in hospitalized older adults with acute decompensated heart failure (ADHF). However, the impact of coexisting sarcopenia and hypoalbuminemia on morbidity and death in adults with ADHF has not yet been investigated. We aimed to investigate the combined effects of lower muscle mass (LMM) as a surrogate for sarcopenia and hypoalbuminemia on in-hospital and postdischarge outcomes of patients hospitalized for ADHF.

METHODS AND RESULTS

A total of 385 patients admitted for ADHF between 2017 and 2020 at a single institution were retrospectively identified. Demographic and clinical data were collected, including serum albumin levels at admission and discharge. Skeletal muscle indices were derived from semi-automated segmentation software analysis on axial chest computed tomography at the twelfth vertebral level. Our analysis revealed that patients who had LMM with admission hypoalbuminemia experienced increased diagnoses of infection and delirium with longer hospital length of stay and more frequent discharge to a facility. Upon discharge, 27.9% of patients had higher muscle mass without discharge hypoalbuminemia (reference group), 9.7% had LMM without discharge hypoalbuminemia, 38.4% had higher muscle mass with discharge hypoalbuminemia, and 24.0% had LMM with discharge hypoalbuminemia; mortality rates were 37.6%, 51.4%, 48.9%, and 63.2%, respectively. 1- and 3-year mortality risks were highest in those with LMM and discharge hypoalbuminemia; this relationship remained significant over a median 23.6 (3.1-33.8) months follow-up time despite multivariable adjustments (hazard ratio, 2.03 [95% CI, 1.31-3.16]; P=0.002).

CONCLUSIONS

Hospitalization with ADHF, LMM, and hypoalbuminemia portend heightened mortality risk.

Computed tomography-determined skeletal muscle density predicts 3-year mortality in initial-dialysis patients in China

BACKGROUND

Skeletal muscle mass and quality assessed by computed tomography (CT) images of the third lumbar vertebra (L3) level have been established as risk factors for poor clinical outcomes in several illnesses, but the relevance for dialysis patients is unclear. A few studies have suggested a correlation between CT-determined skeletal muscle mass and quality at the first lumbar vertebra (L1) level and adverse outcomes. Generally, chest CT does not reach beyond L1. We aimed to determine whether opportunistic CT scan (chest CT)-determined skeletal muscle mass and quality at L1 are associated with mortality in initial-dialysis patients.

METHODS

This 3-year multicentric retrospective study included initial-dialysis patients from four centres between 2014 and 2017 in China. Unenhanced CT images of the L1 and L3 levels were obtained to assess skeletal muscle mass [by skeletal muscle index, (SMI), cm2 /m2 ] and quality [by skeletal muscle density (SMD), HU]. Skeletal muscle measures at L1 were compared with those at L3. The sex-specific optimal cutoff values of L1 SMI and L1 SMD were determined in relation to all-cause mortality. The outcomes were all-cause death and cardiac death. Cox regression models were applied to investigate the risk factors for death.

RESULTS

A total of 485 patients were enrolled, of whom 257 had both L1 and L3 images. Pearson's correlation coefficient between L1 and L3 SMI was 0.84 (P < 0.001), and that between L1 and L3 SMD was 0.90 (P < 0.001). No significant association between L1 SMI and mortality was observed (P > 0.05). Low L1 SMD (n = 280, 57.73%) was diagnosed based on the optimal cutoff value (<39.56 HU for males and <33.06 HU for females). Multivariate regression analysis revealed that the low L1 SMD group had higher risks of all-cause death (hazard ratio 1.80; 95% confidence interval 1.05-3.11, P = 0.034) and cardiac death (hazard ratio 3.74; 95% confidence interval 1.43-9.79, P = 0.007).

CONCLUSIONS

In initial-dialysis patients, there is high agreement between the L1 and L3 measures for SMI and SMD. Low SMD measured at L1, but not low SMI, is an independent predictor of both all-cause death and cardiac death.

Physical Activity Program for the Survival of Elderly Patients With Lymphoma: Study Protocol for Randomized Phase 3 Trial

BACKGROUND

The practice of regular physical activity can reduce the incidence of certain cancers (colon, breast, and prostate) and improve overall survival after treatment by reducing fatigue and the risk of relapse. This impact on survival has only been demonstrated in active patients with lymphoma before and after treatment. As poor general health status reduces the chances of survival and these patients are most likely to also have sarcopenia, it is important to be able to improve their physical function through adapted physical activity (APA) as part of supportive care management. Unfortunately, APA is often saved for patients with advanced blood cancer. As a result, there is a lack of data regarding the impact of standardized regular practice of APA and concomitant chemotherapy as first-line treatment on lymphoma survival.

OBJECTIVE

This study aimed to assess the impact of a new and open rehabilitation program suitable for a frail population of patients treated for diffuse large B-cell lymphoma (DLBCL).

METHODS

PHARAOM (Physical Activity Program for the Survival of Elderly Patients with Lymphoma) is a phase 3 randomized (1:1) study focusing on a frail population of patients treated for DLBCL. The study will include 186 older adult patients with DLBCL (aged >65 years) receiving rituximab and chemotherapy. Overall, 50% (93/186) of patients (investigational group) will receive APA along with chemotherapy, and they will be supervised by a dedicated qualified kinesiologist. The APA program will include endurance and resistance training at moderate intensity 3 times a week during the 6 months of chemotherapy. The primary end point of this study will be event-free survival of the patients. The secondary end points will include the overall survival, progression-free survival, prevalence of sarcopenia and undernutrition, and patients' quality of life. This study will be conducted in accordance with the principles of the Declaration of Helsinki.

RESULTS

Recruitment, enrollment, and data collection began in February 2021, and 4 participants have been enrolled in the study as of July 2022. Data analysis will begin after the completion of data collection. Future outcomes will be published in peer-reviewed health-related research journals and presented at national congress, and state professional meetings. This publication is based on protocol version 1.1, August 3, 2020.

CONCLUSIONS

The PHARAOM study focuses on highlighting the benefits of APA intervention on survival during the period of first-line treatment of patients with DLBCL. This study could also contribute to our understanding of how an APA program can reduce complications such as sarcopenia in patients with lymphoma and improve their quality of life. By documenting the prevalence and relationship between sarcopenia and exercise load, we might be able to help physicians plan better interventions in the care of patients with DLBCL.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04670029; https://clinicaltrials.gov/ct2/show/NCT04670029.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40969.

Multi-omics profiling reveals Chitinase-3-like protein 1 as a key mediator in the crosstalk between sarcopenia and liver cancer

Sarcopenia is prevalent in patients with hepatocellular carcinoma (HCC), and can adversely affect their outcomes. This study aims to explore the key mechanisms in the crosstalk between sarcopenia and HCC based on multi-omics profiling. A total of 136 male patients with HCC were enrolled. Sarcopenia was an independent risk factor for poor outcomes after liver transplantation (p < 0.05). Inflammatory cytokine and metabolomic profiling on these patients identified elevated plasma sTNF-R1/CHI3L1 and dysregulated lipid metabolism as related to sarcopenia and tumor recurrence risk concurrently (p < 0.05). Integrated analysis revealed close relationship between CHI3L1 and fatty acid metabolism. In mouse cachectic models by intraperitoneal injection of H22 cells, CHI3L1 was significantly elevated in the atrophic muscle tissue, as well as in circulation. In-vitro, CHI3L1 was up-regulated in muscle cells to protect itself from inflammatory damage through TNF-α/TNF-R1 signaling. CHI3L1 secreted by the muscle cells promoted the invasion of co-cultured HCC cells. Tumor tissue transcriptome data for 73 out of the 136 patients revealed that CHI3L1 may regulate fatty acid metabolism and oxidative stress. In vitro, CHI3L1 caused ROS and lipid accumulation. Targeted lipid profiling further proved that CHI3L1 was able to activate arachidonic acid metabolism, leading to lipid peroxide (LPO) accumulation. Meanwhile, LPO inhibition could compromise the remarkable pro-cancerous effects of CHI3L1. In conclusion, sarcopenia adversely affects the outcomes of liver transplantation for HCC. In sarcopenic patients, CHI3L1 was up-regulated and secreted by the skeletal muscle to protect itself through TNF-α/TNF-R1 signaling, which, in turn, can promote HCC tumor progression by inducing LPO accumulation.

Prevention of muscle atrophy in ICU patients without nerve injury by neuromuscular electrical stimulation: a randomized controlled study

Background

Extensive muscle atrophy is a common occurrence in orthopaedics patients who are bedridden or immobilized. The incidence is higher in intensive care unit (ICU) inpatients. There is still controversy about how to use neuromuscular electrical stimulation (NMES) in ICU patients. We aim to compare the effectiveness and safety of NMES to prevent muscle atrophy in intensive care unit (ICU) patients without nerve injury.

Methods

ICU patients without central and peripheral nerve injury were randomized into experimental group I (Exp I: active and passive activity training (APAT) + NMES treatment on the gastrocnemius and tibialis anterior muscle), experimental group II (Exp II: APAT + NMES treatment on gastrocnemius alone), and control group (Ctl: APAT alone). Changes in the strength of gastrocnemius, the ankle range of motion, and the muscle cross-section area of the lower leg were evaluated before and after the intervention. Also, changes in prothrombin time, lactic acid, and C-reactive protein were monitored during the treatment.

Results

The gastrocnemius muscle strength, ankle joint range of motion, and cross-sectional muscle area of the lower leg in the three groups showed a downward trend, indicating that the overall trend of muscle atrophy in ICU patients was irreversible. The decrease in gastrocnemius muscle strength in Exp I and Exp II was smaller than that in the control group (P < 0.05), but there was no difference between Exp I and Exp II. The decrease in active ankle range of motion and cross-sectional area of the lower leg Exp I and Exp II was smaller than that in the control group (P < 0.05), and the decrease in Exp I was smaller than that of Exp II (all P < 0.05). The curative effect in Exp I was better than in Exp II. There were no significant differences in the dynamic changes of prothrombin time, lactic acid, and C-reactive protein during the three groups (P > 0.05).

Conclusion

In addition to early exercise training, NMES should be applied to prevent muscle atrophy for patients without nerve injury in ICU. Also, simultaneous NMES treatment on agonist/antagonist muscle can enhance the effect of preventing muscle atrophy.

Trial registration

This study was prospectively registered in China Clinical Trial Registry (www.chictr.org.cn) on 16/05/2020 as ChiCTR2000032950.

Serum creatinine/cystatin C ratio as a screening tool for sarcopenia and prognostic indicator for patients with esophageal cancer

Background & aims

Sarcopenia is associated with poor clinical outcomes of patients who underwent esophagectomy. The current diagnostic criteria for sarcopenia are complex and laborious. We aimed to employ the simple and economic indicator sarcopenia index (SI = creatinine/cystatin C ×100) to screen for sarcopenia and to evaluate its prognostic value in patients with esophageal cancer (EC).

Methods

Older participants in the National health and nutrition examination survey (NHANES) database (1999–2002) were divided into three groups according to tertiles of the SI value to explore the feasibility of SI in the diagnosis of sarcopenia. Restricted cubic spline (RCS) was utilized to show the non-linear relationship between all-cause mortality and SI. Patients with EC admitted to Jinling Hospital were enrolled to validate the efficacy and prognostic value of SI. Cut-off values of SI were determined using receiver operating characteristic curves. Multivariable logistic analyses and Cox analyses were used to identify the independent factors of postoperative complications and long-term survival, respectively.

Results

A total of 989 participants were identified from the NHANES database. SI showed the diagnostic value of sarcopenia (tertile 1 vs. tertile 3: odds ratio [OR]=3.67, 95% confidence interval [CI]: 1.52–8.87, p=0.004; tertile 2 vs. tertile 3: OR=1.79, 95% CI: 0.75–4.28, p=0.191) adjusted for race, gender, and body mass index (BMI). Individuals with SI ≤ 68 had a poorer overall survival (OS) (hazard ratio [HR]=2.14, 95% CI: 1.71–2.68, p<0.001), and the RCS plot showed that the all-cause mortality risk gradually decreased with the increase in SI. Then, 203 patients with EC were enrolled, of which 76 patients were diagnosed with sarcopenia. There was a linear correlation between SI and skeletal muscle index and prealbumin, indicating that SI was reliable for diagnosing sarcopenia. Patients in the high sarcopenia risk group (Male: SI < 62; Female: SI < 55) showed a higher incidence of complications (OR=3.50, 95% CI: 1.85–6.61, p<0.001) and poorer long-term survival (HR=2.62, 95% CI: 1.02–6.77, p=0.046).

Conclusion

SI could be used to identify sarcopenia in patients with EC, and it is a useful prognostic factor of postoperative complications and long-term survival.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02925-8.

Low Thoracic Skeletal Muscle Area Is Not Associated With Negative Outcomes in Patients With COVID-19

OBJECTIVE

Sarcopenia has been related to negative outcomes in different clinical scenarios from critical illness to chronic conditions. The aim of this study was to verify whether there was an association between low skeletal muscle index and in-hospital mortality, intensive care unit admission, and invasive mechanical ventilation need in hospitalized patients with COVID-19.

DESIGN

This was a retrospective cohort study of a referral center for COVID-19. We included all consecutive patients admitted to the hospital between February 26 and May 15, 2020, with a confirmed diagnosis of COVID-19. Skeletal muscle index was assessed from a transverse computed tomography image at the level of twelfth thoracic vertebra with National Institutes of Health ImageJ software, and statistical analysis was performed to find an association between skeletal muscle index and in-hospital mortality, need of invasive mechanical ventilation, and intensive care unit admission.

RESULTS

We included 519 patients, the median age was 51 (42-61) yrs, and 115 patients (22%) had low skeletal muscle index. On multivariable analysis, skeletal muscle index was not associated with mortality, intensive care unit admission, or invasive mechanical ventilation need nor in a subanalysis of patients 65 yrs or older.

CONCLUSIONS

Skeletal muscle index determined by computed tomography at the level of twelfth thoracic vertebra was not associated with negative outcomes in hospitalized patients with COVID-19.

The ImageJ ecosystem: Open-source software for image visualization, processing, and analysis

For decades, biologists have relied on software to visualize and interpret imaging data. As techniques for acquiring images increase in complexity, resulting in larger multidimensional datasets, imaging software must adapt. ImageJ is an open-source image analysis software platform that has aided researchers with a variety of image analysis applications, driven mainly by engaged and collaborative user and developer communities. The close collaboration between programmers and users has resulted in adaptations to accommodate new challenges in image analysis that address the needs of ImageJ's diverse user base. ImageJ consists of many components, some relevant primarily for developers and a vast collection of user-centric plugins. It is available in many forms, including the widely used Fiji distribution. We refer to this entire ImageJ codebase and community as the ImageJ ecosystem. Here we review the core features of this ecosystem and highlight how ImageJ has responded to imaging technology advancements with new plugins and tools in recent years. These plugins and tools have been developed to address user needs in several areas such as visualization, segmentation, and tracking of biological entities in large, complex datasets. Moreover, new capabilities for deep learning are being added to ImageJ, reflecting a shift in the bioimage analysis community towards exploiting artificial intelligence. These new tools have been facilitated by profound architectural changes to the ImageJ core brought about by the ImageJ2 project. Therefore, we also discuss the contributions of ImageJ2 to enhancing multidimensional image processing and interoperability in the ImageJ ecosystem.

The inter- and intrarater reliability and feasibility of dietetic assessment of sarcopenia and frailty in potential liver transplant recipients: A mixed-methods study

Sarcopenia and frailty are associated with poorer outcomes in potential liver transplant (LT) recipients. We examined the reliability and feasibility of dietitians assessing sarcopenia and frailty. Seventy-five adults referred for LT underwent assessments of muscle mass (abdominal CTs), physical function (handgrip strength; HGS, short physical performance battery; SPPB), and frailty (Liver Frailty Index; LFI). Inter- and intrarater reliability and agreement were assessed in subsets of patients using intraclass correlation coefficients (ICCs) and Bland-Altman plots. CTs were analyzed by a dietitian and two independent experts, two dietitians assessed function and frailty. Feasibility assessed system, patient, and profession factors (staff survey). Inter- and intrarater reliability for CT-defined low muscle were excellent (ICCs > 0.97). Reliability between dietitians was excellent for HGS (0.968, 95% CI, 0.928-0.986), SPPB (0.932, 95% CI, 0.798-0.973), and LFI (0.938, 95% CI 0.861-0.973). Bland-Altman analysis indicated excellent agreement for HGS. All transplant clinicians valued sarcopenia and frailty in LT assessments and considered the dietitian appropriate to perform them. Seven saw no barriers to implementation into practice, while five queried test standardization, learning from repeat testing, and resource cost. Dietetic assessments of sarcopenia and frailty are reliable, feasible, and valued measures in the assessment of potential LT recipients.

Formula for the Cross-Sectional Area of the Muscles of the Third Lumbar Vertebra Level from the Twelfth Thoracic Vertebra Level Slice on Computed Tomography

The purpose of this study was to investigate a means by which to reflect muscle mass using chest computed tomography (CT). A cross-sectional study was conducted with patients aged ≥ 65 years having abdominal and chest CT scans. The formula to predict third lumbar vertebra (L3) cross-sectional area (CSA) of the muscles from the erector muscles of the spine at the twelfth thoracic vertebra (Th12) level slice on CT was created using the five-fold cross-validation method. Correlation between predicted L3 CSA and measured L3 CSA of the muscles was assessed by intraclass correlation coefficients (ICC) and correlation coefficients (r) in the data of the development, and predictability was examined with accuracy and F-values in the validation study. The development study included 161 patients. The developed formula was as follows: −1006.38 + 16.29 × age + 1161.80 × sex (if female, 0; if male, 1) + 55.91 × body weight + 2.22 × CSA of the erector muscles at Th12. The formula demonstrated strong concordance and correlation (ICC = 0.849 [0.800–0.887] and r = 0.858 [0.811–0.894]). The validation study included 34 patients. The accuracy and F-value between predicted CSA and measured CSA were high (accuracy = 0.889–0.944, F-value = 0.931–0.968). We developed a formula predicting CSA at L3 using Th12 CT slice. This formula could be used to assess decreased muscle mass even with chest CT alone.

Impact on Health-Related Quality of Life of Parenteral Nutrition for Patients with Advanced Cancer Cachexia: Results from a Randomized Controlled Trial

BACKGROUND

Malnutrition worsens health-related quality of life (HRQoL) and the prognosis of patients with advanced cancer. This study aimed to assess the clinical benefits of parenteral nutrition (PN) over oral feeding (OF) for patients with advanced cancer cachexia and without intestinal impairment.

MATERIAL AND METHODS

In this prospective multicentric randomized controlled study, patients with advanced cancer and malnutrition were randomly assigned to optimized nutritional care with or without supplemental PN. Zelen's method was used for randomization to facilitate inclusions. Nutritional and performance status and HRQoL using the European Organization for Research and Treatment of Cancer QLQ-C15-PAL questionnaire were evaluated at baseline and monthly until death. Primary endpoint was HRQoL deterioration-free survival (DFS) defined as a definitive deterioration of ≥10 points compared with baseline, or death.

RESULTS

Among the 148 randomized patients, 48 patients were in the experimental arm with PN, 63 patients were in the control arm with OF only, and 37 patients were not included because of early withdrawal or refused consent. In an intent to treat analysis, there was no difference in HRQoL DFS between the PN arm or OF arm for the three targeted dimensions: global health (hazard ratio [HR], 1.31; 95% confidence interval [CI], 0.88-1.94; p = .18), physical functioning (HR, 1.58; 95% CI, 1.06-2.35; p = .024), and fatigue (HR, 1.19; 95% CI, 0.80-1.77; p = .40); there was a negative trend for overall survival among patients in the PN arm. In as treated analysis, serious adverse events (mainly infectious) were more frequent in the PN arm than in the OF arm (p = .01).

CONCLUSION

PN improved neither HRQoL nor survival and induced more serious adverse events than OF among patients with advanced cancer and malnutrition. Clinical trial identification number. NCT02151214 IMPLICATIONS FOR PRACTICE: This clinical trial showed that parenteral nutrition improved neither quality of life nor survival and generated more serious adverse events than oral feeding only among patients with advanced cancer cachexia and no intestinal impairment. Parenteral nutrition should not be prescribed for patients with advanced cancer, cachexia, and no intestinal failure when life expectancy is shorter than 3 months. Further studies are needed to assess the useful period with a potential benefit of artificial nutrition for patients with advanced cancer.

Tutorial: A Step-by-Step Guide (Version 2.0) for Measuring Abdominal Circumference and Skeletal Muscle From a Single Cross-Sectional Computed-Tomography Image Using the National Institutes of Health ImageJ

BACKGROUND

In patients with acute and chronic illness, depleted skeletal muscle (SM) mass, also referred to as sarcopenia, is a condition associated with an underlying disease process and adverse outcomes. Because of software upgrades and errors related to installation, clarifications and a revised tutorial were needed for calculating SM cross-sectional area (CSA) using the National Institutes of Health (NIH) ImageJ.

METHODS

A pilot study was conducted to determine the usability of the tutorial version 2.0. Eight adults (≥18 years of age) who had no previous experience or background in body composition or computed-tomography imaging and owned a personal laptop computer (Mac or PC) were included in the pilot study. Participants were tested on the completion of 4 tasks: (1) installation of software, (2) updating the software, (3) following revised tutorial (version 2.0), and (4) transferring information from the software to a spreadsheet for calculation of SM CSA.

RESULTS

All participants completed the tutorial and all assigned tasks, 4/4 (100%). However, 38% (3/8) of the participants made errors while cutting and pasting values from the ImageJ results box to a spreadsheet for calculating SM CSA.

CONCLUSION

The tutorial version 2.0 was easy to follow and provided sufficient information for adults to install, update, and perform the steps of body composition for the NIH ImageJ software without major issues. Care should be taken when cutting and pasting results from the software as well as when using the Microsoft Excel spreadsheet for calculating SM CSA.

Computed tomography-based psoas skeletal muscle area and radiodensity are poor sentinels for whole L3 skeletal muscle values

Background and aims

Computed tomography (CT)-based measurement of skeletal muscle cross-sectional area (CSA) and Hounsfield unit (HU) radiodensity are used to assess the presence of sarcopenia and myosteatosis, respectively. The validated CT-based technique involves analysis of skeletal muscle at the third lumbar vertebral (L3) level. Recently there has been increasing interest in the use of psoas muscle alone as a sentinel. However, this technique has not been extensively investigated or compared with the previous validated standard approach.

Methods

Portovenous phase CT images at the L3 level were identified retrospectively from a single institution in 150 patients who had non-emergency scans and were analysed by a single assessor using SliceOmatic software v5.0 (TomoVision, Canada). Manual segmentation based upon validated HU thresholds for skeletal muscle density was performed for all skeletal muscle, as well as the individual muscle groups. The muscle CSA and mean radiodensity of each group were compared against the whole L3 slice values.

Results

When compared with whole L3 slice CSA, anterior abdominal wall CSA had the strongest correlation (r = 0.9315, p < 0.0001) followed by paravertebral (r = 0.8948, p < 0.0001), then psoas muscle (r = 0.7041, p < 0.0001). The mean ± SD density of the psoas muscle (42 ± 8.4 HU) was significantly higher than the whole slice radiodensity (32.3 ± 9.5 HU, p < 0.0001), with paravertebral radiodensity being a more accurate estimation (34.5 ± 10.8 HU). There was a significant difference in the prevalence of myosteatosis when the density measured from the psoas was compared with that of the whole L3 skeletal muscle (27.7% vs. 66.0%, p < 0.0001).

Conclusion

Whole L3 slice CSA correlated positively with psoas muscle CSA but was subject to wide variability in results. Psoas muscle radiodensity was significantly greater than whole L3 slice density and resulted in underestimation of the prevalence of myosteatosis. Given the lack of equivalence from individual muscle groups, we recommend that further work be undertaken to investigate which muscle group, or indeed whether the gold standard of whole L3 skeletal muscle, provides the best correlation with clinical outcomes.

The Relationship between Imaging-Based Body Composition Analysis and the Systemic Inflammatory Response in Patients with Cancer: A Systematic Review

Background and aim: Cancer is the second leading cause of death globally. Nutritional status (cachexia) and systemic inflammation play a significant role in predicting cancer outcome. The aim of the present review was to examine the relationship between imaging-based body composition and systemic inflammation in patients with cancer. Methods: MEDLINE, EMBASE, Cochrane Library and Google Scholar were searched up to 31 March 2019 for published articles using MESH terms cancer, body composition, systemic inflammation, Dual energy X-ray absorptiometry (DEXA), magnetic resonance imaging (MRI), ultrasound sonography (USS) and computed tomography (CT). Studies performed in adult patients with cancer describing the relationship between imaging-based body composition and measures of the systemic inflammatory response were included in this review. Results: The literature search retrieved 807 studies and 23 met the final eligibility criteria and consisted of prospective and retrospective cohort studies comprising 11,474 patients. CT was the most common imaging modality used (20 studies) and primary operable (16 studies) and colorectal cancer (10 studies) were the most commonly studied cancers. Low skeletal muscle index (SMI) and systemic inflammation were consistently associated; both had a prognostic value and this relationship between low SMI and systemic inflammation was confirmed in four longitudinal studies. There was also evidence that skeletal muscle density (SMD) and systemic inflammation were associated (9 studies). Discussion: The majority of studies examining the relationship between CT based body composition and systemic inflammation were in primary operable diseases and in patients with colorectal cancer. These studies showed that there was a consistent association between low skeletal muscle mass and the presence of a systemic inflammatory response. These findings have important implications for the definition of cancer cachexia and its treatment.

Influence of Methods Used to Establish Sarcopenia Cutoff Values for Skeletal Muscle Measures Using Unenhanced and Contrast-Enhanced Computed Tomography Images

BACKGROUND

Multiple cutoff values of computed tomography (CT)-based skeletal muscle measures have been proposed, but there is currently no consensus used to identify sarcopenia. We aimed to evaluate the influence of statistical methods used to establish sarcopenia cutoff values and to examine the impact of contrast enhancement on the skeletal muscle measures.

METHODS

The skeletal muscle area (SMA) and muscle radiation attenuation (MRA) of 316 healthy individuals were measured on unenhanced CT images at the third lumbar vertebra level, and the skeletal muscle index (SMI) was SMA divided by height squared. Possible cutoff values were established using 2 methods: 5^th percentile of individuals aged 20-60 years or mean - 2 × SD of individuals aged 20-50 years. The concordance was assessed using Cohen's κ coefficients and McNemar test. The skeletal muscle parameters on 3 phases from 30 CT examinations were compared.

RESULTS

The concordance between the 2 methods was almost perfect (κ coefficients: 0.830-0.849) for low MRA but slight to moderate (κ coefficients: 0.189-0.591) for low SMI, especially in the men (P < 0.01). Compared with the unenhanced images, the mean SMA, SMI, and MRA on the contrast-enhanced images increased by 0.8%-1.7%, 0.8%-1.8%, and 14.8%-21.6% (all P < 0.001), respectively, and only the changes in MRA were clinically significant.

CONCLUSIONS

The methods for establishing cutoff values and contrast enhancement influence the identification of low SMI and low MRA, respectively. Thus, the definition of sarcopenia should include the standardized method for establishing cutoff values and the phase of CT for analysis.