Impact of sarcopenic obesity on 30-day mortality in critically ill patients with intra-abdominal sepsis

Beyond body mass index: exploring the role of visceral adipose tissue in intensive care unit outcomes

Obesity is a worldwide health crisis and poses significant challenges in critical care. Many studies suggest an 'obesity paradox', in which obesity, defined by body mass index (BMI), is associated with better outcomes. However, the inability of BMI to discriminate between fat and muscle or between visceral adipose tissue and subcutaneous adipose tissue, limits its prediction of metabolic ill health. We suggest that the 'obesity paradox' may be more reflective of the limitations of BMI than the protective effect of obesity. We explore the biological processes leading to visceral fat accumulation, and the evidence linking it to outcomes in critical illness. In the 'spillover' hypothesis of adipose tissue expansion, caloric excess and impaired expansion of storage capacity in the subcutaneous adipose tissue lead to accumulation of visceral adipose tissue. This is associated with a chronic inflammatory state, which is integral to the link between visceral adiposity, type 2 diabetes mellitus, and ischaemic heart disease. We review the current evidence on visceral adiposity and critical illness outcomes. In COVID-19, increased visceral adipose tissue, irrespective of BMI, is associated with more severe disease. This is mirrored in acute pancreatitis, suggesting visceral adiposity is linked to poorer outcomes in some hyperinflammatory conditions. We suggest that visceral adiposity's chronic inflammatory state may potentiate acute inflammation in conditions such as COVID-19 and acute pancreatitis. Further work is required to investigate other critical illnesses, especially sepsis and acute respiratory distress syndrome, in which current evidence is scarce. This may give further insights into pathophysiology and inform tailored treatment and nutrition strategies based on body fat distribution.

CT scan-derived pectoralis muscle parameters are closely associated with COVID-19 outcomes: A systematic review and meta-analysis

BACKGROUND

The relationships between pectoralis muscle parameters and outcomes in patients with coronavirus disease 2019 (COVID-19) remain uncertain.

METHODS

We systematically searched PubMed, Embase, Web of Science and the Cochrane Library from 1 January 2019 to 1 May 2024 to identify non-overlapping studies evaluating pectoralis muscle-associated index on chest CT scan with clinical outcome in COVID-19 patients. Random-effects and fixed-effects meta-analyses were performed, and heterogeneity between studies was quantified using the I2 statistic. The risk of study bias was assessed using the Newcastle-Ottawa scale. Funnel plots for detecting small-study effects.

RESULTS

A total of 9 studies with 4109 COVID-19 patients were included. The meta-analysis findings revealed a correlation between pectoralis muscle parameters and COVID-19 prognosis. Specifically, patients with higher pectoralis muscle density (PMD) exhibited a lower mortality risk, with an odds ratio (OR) of 0.95 (95% CI: 0.92-0.99). The rate of intubation was lower in COVID-19 patients with a high pectoralis muscle index (PMI) (OR =  0.96, 95% CI: 0.92-1.00).

CONCLUSION

In summary, a low PMD is associated with a marginally elevated risk of mortality, whereas a decreased PMI represents a risk factor for intubation in COVID-19 patients. These findings suggest that pectoralis muscle parameters on chest CT may be a useful prognostic tool for COVID-19 patients.

Methodologies and clinical applications of lower limb muscle ultrasound in critically ill patients: a systematic review and meta-analysis

BACKGROUND

Reduced muscle mass upon admission and development of muscle wasting are frequent in critically ill patients, and linked to unfavorable outcomes. Muscle ultrasound is a promising instrument for evaluating muscle mass. We summarized the findings of lower limb muscle ultrasound values and investigated how the muscle ultrasound parameters of the examination or the patient characteristics influence the results.

METHODS

Systematic review and meta-analysis of studies of lower limb ultrasound critically ill adults. PubMed, CINAHL, Embase, PEDro and Web of Science were searched. PRISMA guidelines were followed, and studies evaluated with the appropriate NIH quality assessment tool. A meta-analysis was conducted to compare the values at admission, short and long follow-up during ICU stay, and the association between baseline values and patient characteristics or ultrasound parameters was investigated with a meta-regression.

RESULTS

Sixty-six studies (3839 patients) were included. The main muscles investigated were rectus femoris cross-sectional area (RF-CSA, n = 33/66), quadriceps muscle layer thickness (n = 32/66), and rectus femoris thickness (n = 19/66). Significant differences were found in the anatomical landmark and ultrasound settings. At ICU admission, RF-CSA ranged from 1.1 [0.73-1.47] to 6.36 [5.45-7.27] cm2 (pooled average 2.83 [2.29-3.37] cm2) with high heterogeneity among studies (I2 = 98.43%). Higher age, higher BMI, more distal landmark and the use of probe compression were associated with lower baseline muscle mass.

CONCLUSIONS

Measurements of muscle mass using ultrasound varied with reference to patient characteristics, patient position, anatomical landmarks used for measurement, and the level of compression applied by the probe; this constrains the external validity of the results and highlights the need for standardization.

STUDY REGISTRATION

PROSPERO CRD42023420376.

2024 Clinical Practice Guideline Update by the Infectious Diseases Society of America on Complicated Intra-abdominal Infections: Risk Assessment in Adults and Children

This paper is part of a clinical practice guideline update on the risk assessment, diagnostic imaging, and microbiological evaluation of complicated intra-abdominal infections in adults, children, and pregnant people, developed by the Infectious Diseases Society of America. In this paper, the panel provides a recommendation for risk stratification according to severity of illness score. The panel's recommendation is based on evidence derived from systematic literature reviews and adheres to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach.

Sarcopenia, sarcopenic obesity and the clinical outcome of the older inpatients with COVID-19 infection: a prospective observational study

OBJECTIVE

We aimed to investigate the impact of sarcopenia and sarcopenic obesity (SO) on the clinical outcome in older patients with COVID-19 infection and chronic disease.

METHODS

We prospectively collected data from patients admitted to Huadong Hospital for COVID-19 infection between November 1, 2022, and January 31, 2023. These patients were included from a previously established comprehensive geriatric assessment (CGA) cohort. We collected information on their pre-admission condition regarding sarcopenia, SO, and malnutrition, as well as their medical treatment. The primary endpoint was the incidence of intubation, while secondary endpoints included in-hospital mortality rates. We then utilized Kaplan-Meier (K-M) survival curves and the log-rank tests to compare the clinical outcomes related to intubation or death, assessing the impact of sarcopenia and SO on patient clinical outcomes.

RESULTS

A total of 113 patients (age 89.6 ± 7.0 years) were included in the study. Among them, 51 patients had sarcopenia and 39 had SO prior to hospitalization. Intubation was required for 6 patients without sarcopenia (9.7%) and for 18 sarcopenia patients (35.3%), with 16 of these being SO patients (41%). Mortality occurred in 2 patients without sarcopenia (3.3%) and in 13 sarcopenia patients (25.5%), of which 11 were SO patients (28%). Upon further analysis, patients with SO exhibited significantly elevated risks for both intubation (Hazard Ratio [HR] 7.43, 95% Confidence Interval [CI] 1.26-43.90, P < 0.001) and mortality (HR 6.54, 95% CI 1.09-39.38, P < 0.001) after adjusting for confounding factors.

CONCLUSIONS

The prevalence of sarcopenia or SO was high among senior inpatients, and both conditions were found to have a significant negative impact on the clinical outcomes of COVID-19 infection. Therefore, it is essential to regularly assess and intervene in these conditions at the earliest stage possible.

Obesity paradox in older sarcopenic adults - a delay in aging: A systematic review and meta-analysis

The prognostic significance of obesity in sarcopenic adults is controversial. This systematic review and meta-analysis aimed to investigate the effect of additional obesity on health outcomes in sarcopenia. MEDLINE, EMBASE, Scopus and CENTRAL were systematically searched for studies to compare health outcomes of adults with sarcopenic obesity (SO) to those of sarcopenic non-obese (SNO) adults. We also considered the methods of assessing obesity. Of 15060 records screened, 65 papers were included (100612 participants). Older community-dwelling SO adults had 15% lower mortality risk than the SNO group (hazard ratio, HR: 0.85, 95% confidence interval 0.76, 0.94) even when obesity was assessed by measurement of body composition. Additionally, meta-regression analysis revealed a significant negative linear correlation between the age and the HR of all-cause mortality in SO vs. SNO community-dwelling adults, but not in severely ill patients. Compared with SNO, SO patients presented lower physical performance, higher risk for metabolic syndrome, but similar cognitive function, risk of falls and cardiovascular diseases. Age-related obesity, SO and later fat loss leading to SNO represent consecutive phases of biological aging. Additional obesity could worsen the health state in sarcopenia, but above 65 years SO represents a biologically earlier phase with longer life expectancy than SNO.

The impact of muscle mass and myosteatosis on mortality in critically ill patients with Sars-Cov2-related pneumonia

BACKGROUND & AIMS

Sars-Cov-2 pneumonia can lead to severe complications, requiring invasive mechanical ventilation and admission to the intensive care unit (ICU). Low muscle quantity and quality (the latter evaluated by the amount of ectopic fat infiltration in the muscle [myosteatosis]) at ICU admission are associated with worse outcomes in critically ill patients. The purpose of the present study is to assess muscle mass and myosteatosis of paravertebral skeletal muscle, in critically ill patients with Sars-Cov2 pneumonia and its association with mortality.

METHODS

We conducted a retrospective observational study in 110 critically ill patients with severe Sars-Cov-2 pneumonia that had a high - resolution chest Computerized Tomography (HR-CT) at ICU admission. We acquired CT images at the level of the thoracic 12 (T12) vertebral body and measured skeletal muscle area (SMA), intermuscular adipose tissue (IMAT), and low attenuation muscle area (LAMA). Patients were followed until ICU mortality or discharge.

RESULTS

Patients were 59.8 ± 8.1 years old, 77% were male. Seventy-nine percent of patients were considered at nutritional risk, and 22% were obese. Average Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 17 ± 5.4, and the overall ICU mortality was 48,2% (53/110). At ICU admission, both parameters of myosteatosis were associated with higher mortality (IMAT [per 10% increase] HR: 2.01 (95% Confidence Interval [CI] 1.27 to 3.17), P = 0.003; LAMA HR [per 10% increase]: 1.53 (95% CI 1.10 to 2.13), P = 0.012).

CONCLUSION

Myosteatosis as assessed by CT scans plays a relevant role as a prognostic marker in critically ill patients with Sars-Cov2 severe pneumonia.

Predictive nomogram for in-hospital mortality among older patients with intra-abdominal sepsis incorporating skeletal muscle mass

BACKGROUND

Studies on prognostic factors for older patients with intra-abdominal sepsis are scarce, and the association between skeletal muscle mass and prognosis among such patients remains unclear.

AIMS

To develop a nomogram to predict in-hospital mortality among older patients with intra-abdominal sepsis.

METHODS

Older patients with intra-abdominal sepsis were prospectively recruited. Their demographics, clinical features, laboratory results, abdominal computed tomography-derived muscle mass, and in-hospital mortality were recorded. The predictors of mortality were selected via least absolute shrinkage and selection operator and multivariable logistic regression analyses, and a nomogram was developed. The nomogram was assessed and compared with Sequential Organ Failure Assessment score, Acute Physiology and Chronic Health Evaluation II score, and Simplified Acute Physiology Score II.

RESULTS

In total, 464 patients were included, of whom 104 (22.4%) died. Six independent risk factors (skeletal muscle index, cognitive impairment, frailty, heart rate, red blood cell distribution width, and blood urea nitrogen) were incorporated into the nomogram. The Hosmer-Lemeshow goodness-of-fit test and calibration plot revealed a good consistency between the predicted and observed probabilities. The area under the receiver operating characteristic curve was 0.875 (95% confidence interval = 0.838-0.912), which was significantly higher than those of commonly used scoring systems. The decision curve analysis indicated the nomogram had good predictive performance.

DISCUSSION

Our nomogram, which is predictive of in-hospital mortality among older patients with intra-abdominal sepsis, incorporates muscle mass, a factor that warrants consideration by clinicians. The model has a high prognostic ability and might be applied in clinical practice after external validation.

Prognostic Value of Diaphragm Diameter, Muscle Volume, and Bone Mineral Density in Critically Ill COVID-19 Patients

Objective: We aimed to analyze the prognostic value of muscle volume (MV), bone mineral density (BMD), and diaphragm diameter (DD) in COVID-19. Method: The study included 498 patients admitted to the intensive care unit (ICU) with a positive polymerase chain reaction test for COVID-19 from March 11, 2020, through August 31, 2022. The patients' laboratory and demographic data of the patients at the time of ICU admission were recorded. MV, DD, and BMD measurements were performed using computed tomography examinations. Muscle index (MI) was calculated as MV/height2. Quartiles were determined for all 4 measurements. Patients in the lowest quartile were recorded as having low MV, MI, DD, and BMD values. The parameters were evaluated for the whole group and compared according to gender and mortality. The multiple regression analysis was performed for the prediction of mortality. Results: In the mortality group, the male and female patients had significantly statistically lower values in MV (P < .001 and P = .002, respectively), MI (P < .001 and P = .005, respectively), DD (P < .001 and P < .001, respectively), and BMD (P = .002 and P < .001, respectively). In the multiple regression analysis, low MI (OR: 2.03, 95% CI: 1.14-3.61, P = .016) and DD (OR: 10.47, 95% CI: 5.59-19.59, P < .001) values remained significant for the prediction of mortality. Conclusion: BMD is a risk factor for mortality in patients with severe COVID-19, but cannot be used as an independent predictor. However, MI and DD can be used as independent predictors of mortality even in severe cases.

Prevalence and mortality risk of low skeletal muscle mass in critically ill patients: an updated systematic review and meta-analysis

Background

Patients with critical illness often develop low skeletal muscle mass (LSMM) for multiple reasons. Numerous studies have explored the association between LSMM and mortality. The prevalence of LSMM and its association with mortality are unclear. This systematic review and meta-analysis was performed to examine the prevalence and mortality risk of LSMM among critically ill patients.

Methods

Three internet databases (Embase, PubMed, and Web of Science) were searched by two independent investigators to identify relevant studies. A random-effects model was used to pool the prevalence of LSMM and its association with mortality. The GRADE assessment tool was used to assess the overall quality of evidence.

Results

In total, 1,582 records were initially identified in our search, and 38 studies involving 6,891 patients were included in the final quantitative analysis. The pooled prevalence of LSMM was 51.0% [95% confidence interval (CI), 44.5-57.5%]. The subgroup analysis showed that the prevalence of LSMM in patients with and without mechanical ventilation was 53.4% (95% CI, 43.2-63.6%) and 48.9% (95% CI, 39.7-58.1%), respectively (P-value for difference = 0.44). The pooled results showed that critically ill patients with LSMM had a higher risk of mortality than those without LSMM, with a pooled odds ratio of 2.35 (95% CI, 1.91-2.89). The subgroup analysis based on the muscle mass assessment tool showed that critically ill patients with LSMM had a higher risk of mortality than those with normal skeletal muscle mass regardless of the different assessment tools used. In addition, the association between LSMM and mortality was statistically significant, independent of the different types of mortality.

Conclusion

Our study revealed that critically ill patients had a high prevalence of LSMM and that critically ill patients with LSMM had a higher risk of mortality than those without LSMM. However, large-scale and high-quality prospective cohort studies, especially those based on muscle ultrasound, are required to validate these findings.

Systematic review registration

http://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022379200.

Signals for Muscular Protein Turnover and Insulin Resistance in Critically Ill Patients: A Narrative Review

Sarcopenia in critically ill patients is a highly prevalent comorbidity. It is associated with a higher mortality rate, length of mechanical ventilation, and probability of being sent to a nursing home after the Intensive Care Unit (ICU). Despite the number of calories and proteins delivered, there is a complex network of signals of hormones and cytokines that affect muscle metabolism and its protein synthesis and breakdown in critically ill and chronic patients. To date, it is known that a higher number of proteins decreases mortality, but the exact amount needs to be clarified. This complex network of signals affects protein synthesis and breakdown. Some hormones regulate metabolism, such as insulin, insulin growth factor glucocorticoids, and growth hormone, whose secretion is affected by feeding states and inflammation. In addition, cytokines are involved, such as TNF-alpha and HIF-1. These hormones and cytokines have common pathways that activate muscle breakdown effectors, such as the ubiquitin-proteasome system, calpain, and caspase-3. These effectors are responsible for protein breakdown in muscles. Many trials have been conducted with hormones with different results but not with nutritional outcomes. This review examines the effect of hormones and cytokines on muscles. Knowing all the signals and pathways that affect protein synthesis and breakdown can be considered for future therapeutics.

Thoracic sarcopenia as a predictive factor of SARS-COV2 evolution

PURPOSE

Evaluation of CT sarcopenia as a predictor of intensive care hospitalization during SARS-COV2 infection.

MATERIALS AND METHODS

Single-center retrospective study of patients admitted to hospital with SARS-COV2 infection. The estimation of muscle mass (skeletal muscle index (SMI)) for sarcopenia, measurement of muscle density for muscle quality and body adiposity, were based on CT views on the T4 and L3 levels measured at admission. Demographic data, percentage of pulmonary parenchymal involvement as well as the orientation of patients during hospitalization and the risk of hospitalization in intensive care were collected.

RESULTS

A total of 162 patients hospitalized for SARS-COV2 infection were included (92 men and 70 women, with an average age of 64.6 years and an average BMI of 27.4). The muscle area measured at the level of L3 was significantly associated with the patient's unfavorable evolution (124.4cm2 [97; 147] vs 141.5 cm2 [108; 173]) (p = 0.007), as was a lowered SMI (p < 0.001) and the muscle area measured in T4 (OR = 0.98 [0.97; 0.99]), (p = 0.026). Finally, an abdominal visceral fat area measured at the level of L3 was also associated with a risk of hospitalization in intensive care (249.4cm2 [173; 313] vs 147.5cm2 [93.1; 228] (p < 0.001).

CONCLUSION

This study demonstrates that thoracic and abdominal sarcopenia are independently associated with an increased risk of hospitalization in an intensive care unit, suggesting the need to assess sarcopenia on admission during SARS-COV2 infection.

Weight-adjusted urinary creatinine excretion predicts transplant outcomes in adult patients with acute myeloid leukemia in complete remission

Sarcopenia is a prognostic factor for cancer. Because creatinine is formed from creatine phosphate in muscle tissue, urinary creatinine excretion (UCE) serves as an index of muscle volume. However, as of yet, there are no studies assessing the clinical impact of UCE or weight- adjusted urinary creatinine excretion (WA-UCE) on allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients. We analyzed the association between pre-transplant WA-UCE and transplant outcomes among 164 adult patients with acute myeloid leukemia in complete remission who underwent their first allo-HSCT at our center. The patients were classified into a high (n = 106) and a low WA-UCE group (n = 58) for predicting overall survival (OS) based on the receiver operating characteristics curve. On multivariate analysis, low WA-UCE was associated with poor OS, progression-free survival and a high incidence of non-relapse mortality. WA-UCE has the potential to be an objective biomarker for predicting transplant outcomes, especially the incidence of infection-related death.

Low skeletal muscle index and myosteatosis as predictors of mortality in critically ill surgical patients

OBJECTIVES

After elective surgeries, low muscle mass and other specific body composition indexes, assessed by computed tomography (CT), are associated with adverse outcomes such as an increased risk for postoperative complications and higher mortality. However, limited information is available about the role of these indexes on short- and long-term outcomes in surgical patients admitted to the intensive care unit (ICU). The aim of this study was to assess the association of body composition indexes with 90-d mortality in this specific patient cohort.

METHODS

This was a retrospective study including adult surgical patients admitted to the ICU between 2014 and 2018 who underwent a CT scan at the time of admission. Total muscle area (TMA), total fat area (TFA), visceral fat area (VFA), and intramuscular fat area (IMFA) were measured. We then calculated skeletal muscle index (SMI; TMA/m2), myosteatosis (IMFA/TMA), and visceral fat-to-muscle ratio (VFA/TMA). We analyzed the effects of these indexes on mortality.

RESULTS

The study included 204 patients. Overall, 90-d mortality was 28%. Log-rank test and Cox multivariate analysis on 90-d mortality showed a significant association of low SMI and myosteatosis with 90-d mortality. Myosteatosis was also significantly associated with prolonged mechanical ventilation and increased ICU length of stay.

CONCLUSIONS

Specific body composition indexes may predict mortality in surgical patients admitted to the ICU. Low SMI and myosteatosis were independently associated with increased 90-d mortality.

Nutritional risk, not obesity, is associated with mortality in critically ill COVID-19 patients

Background

Despite the identification of obesity as a risk factor for higher rates of hospital and Intensive Care Unit (ICU) admissions and complications due to COVID-19, the association between obesity and mortality in critically ill COVID-19 patients remains controversial, and the nutritional risk is little considered. Hence, our study sought to evaluate the association between obesity, nutritional risk, and mortality in critically ill patients diagnosed with COVID-19.

Methods

Retrospective study were condutcted including adult critically ill COVID-19 patients admitted to an ICU between April 2020 and March 2021. Clinical and laboratory data were collected from electronic medical records. Obesity was classified by body mass index ≥ 30 kg/m^2. A mNUTRIC score of ≥ 5 indicated high nutritional risk. Multiple Cox Regression was used to estimate the association between mNUTRIC, obesity, and mortality.

Results

From 71 patients aged 59 (± 15) years, 71.8 % were male. The frequencies of obesity (58.7 %) and death (49.3 %) were high, but obesity was not associated with mortality. Based on mNUTRIC, 85.9 % of patients were at high nutritional risk, presenting a higher frequency of mortality than patients at low nutritional risk (50.8 % vs 40.0 %; p = 0.014). Multiple Cox Regression showed that for each unit increase in mNUTRIC score the probability of death almost doubled, regardless of the presence of obesity (HR = 1.74; p < 0.001).

Conclusions

A higher nutritional risk was positively associated with mortality in critically ill COVID-19 patients, regardless of obesity, showing the importance of early identification of nutritional risk for appropriate nutritional interventions in this population.

The impact of sarcopenia on short-term and long-term mortality in patients with septic shock

BACKGROUND

Despite medical advances, septic shock remains one of the main causes of high mortality in critically ill patients. Although sarcopenia is considered a predictor of mortality in septic shock patients, most studies have only investigated short-term mortality, and those on long-term prognosis are limited. We investigated the impact of sarcopenia on long-term mortality in a large patient population with septic shock.

METHODS

A retrospective cohort study comprising 905 patients with septic shock was conducted from 2008 to 2019. Sarcopenia was defined based on the measurement of the total abdominal muscle area, assessed using abdominal computed tomography scans. Thereafter, we stratified the patients into two groups-sarcopenia and non-sarcopenia groups-and compared the impact of sarcopenia on short-term (28 days) and long-term (1 year and overall) mortality using multivariable Cox proportional analysis.

RESULTS

A total of 905 patients were included, and the mean age was 65.7 ± 15.1 years. Among them, 430 (47.5%) patients were male and 407 (45.0%) had sarcopenia. We found that the 28 day, 1 year, and overall mortality rates in the sarcopenia group were significantly higher than those in the non-sarcopenia group (13.8% vs. 6.4%, P < 0.001; 41.8% vs. 21.7%, P < 0.001; 62.2% vs. 35.7%, P < 0.001, respectively). Univariable Cox analysis showed that the sarcopenia group had a significant association with the increase in each mortalities compared with the non-sarcopenia group (28 day mortality, hazard ratio (HR) = 2.230, 95% confidence interval (CI) [1.444-3.442], P < 0.001; 1 year mortality, HR = 2.189, 95% CI [1.720, 2.787], P < 0.001; overall mortality, HR = 2.254, 95% CI [1.859, 2.734], P < 0.001). Multivariable Cox analysis showed that both the short-term and long-term mortality rates remained significantly higher in the sarcopenia group than in the non-sarcopenia group, even after adjusting for confounding variables (28 day mortality, HR = 2.116, 95% CI [1.312, 3.412], P = 0.002; 1 year mortality, HR = 1.679, 95% CI [1.291, 2.182], P < 0.001; overall mortality, HR = 1.704, 95% CI [1.381, 2.102], P < 0.001).

CONCLUSIONS

Sarcopenia was associated with both short-term and long-term mortality in patients with septic shock. In clinical settings, close attention should be paid to these patients for both short-term and long-term outcomes.

Prevalence and prognostic value of preexisting sarcopenia in patients with mechanical ventilation: a systematic review and meta-analysis

BACKGROUND

Sarcopenia is defined as age-related loss of muscle mass, strength, and/or function in the context of aging. Mechanical ventilation (MV) is one of the most frequently used critical care technologies in critically ill patients. The prevalence of preexisting sarcopenia and the clinical impact of its prognostic value on patients with MV are unclear. This review sought to identify the prevalence and prognostic value of preexisting sarcopenia on MV patient health outcomes.

METHODS

Relevant studies were identified by searching MEDLINE, Embase, and the Cochrane library and were searched for all articles published as of December 2021. The prevalence of sarcopenia was determined using the authors' definitions from the original studies. Comparisons were made between patients who did and did not have sarcopenia for prognostic outcomes, including mortality, the number of days of MV, the length of intensive care unit stay, and the length of hospital stay. Odds ratios (ORs) and weighted mean differences with 95% confidence intervals (CIs) were used for pooled analyses of the relationships between sarcopenia and prognostic outcomes.

RESULTS

The initial search identified 1333 studies, 17 of which met the eligibility criteria for the quantitative analysis, including 3582 patients. The pooled prevalence was 43.0% (95% CI 34.0-51.0%; I2 = 96.7%). The pooled analyses showed that sarcopenia was related to increased mortality (OR 2.13; 95% CI 1.70, 2.67; I2 = 45.0%), longer duration of MV (MD = 1.22; 95% CI 0.39, 2.05; I2 = 97.0%), longer days of ICU stay (MD = 1.31; 95% CI 0.43, 2.19; I2 = 97.0%), and hospital stay (MD 2.73; 95% CI 0.58, 4.88; I2 = 98.0%) in patients with MV.

CONCLUSION

The prevalence of sarcopenia is relatively high in patients with MV, and it will have a negative impact on the prognosis of patients. However, further, large-scale, high-quality prospective cohort studies are required.

Visceral Adipose Tissue Influence on Health Problem Development and Its Relationship with Serum Biochemical Parameters in Middle-Aged and Older Adults: A Literature Review

Background

The amount of visceral adipose tissue (VAT) tends to increase with age and is associated with several health problems, such as cardiometabolic diseases, increased infections, and overall mortality.

Objectives

This review provides a general assessment of how visceral adiposity correlates with the development of health problems and changes in serum biochemical parameters in middle-aged and older adults.

Methods

We searched specific terms in the Virtual Health Library (VHL) databases for VAT articles published in the English language between 2009 and 2019 related to older adults.

Results

The search found twenty-three publications in this period, of which nine were excluded. The publications had a population aged between 42 and 83 years and correlated the VAT area ratio with several comorbidities (such as pancreatitis, depression, cancer, and coronary heart disease) and serum biochemical parameters.

Conclusion

Further research on the association between visceral obesity and the emergence of health problems and the relationship between VAT and changes in serum biochemical parameters in older individuals should deepen the understanding of this connection and develop preventive actions.

Utilization and validation of the Global Leadership Initiative on Malnutrition (GLIM): A scoping review

BACKGROUND & AIMS

The diagnosis of malnutrition remains a significant challenge despite various published diagnostic criteria. In 2018, the Global Leadership Initiative on Malnutrition (GLIM) published a set of evidence-based criteria as a framework for malnutrition diagnosis in adults. A scoping review was conducted to understand how the GLIM criteria have been used in published literature and compare the reported validation methods to published validation guidance.

METHODS

Dialog and Dimensions databases were searched by publication date (January 1, 2019, through January 29, 2021). Data were extracted and mapped to the research objectives.

RESULTS

Seventy-nine studies were reviewed; 32% were in patients at least 65 years of age; 67% occurred in hospitals. The majority were cohort studies (61%). Fifty-seven percent employed all 5 GLIM criteria. Regarding phenotypic criteria, 92% used low BMI, and 45% applied anthropometry as a marker for muscle mass, of which 54% used calf circumference. Regarding etiologic criteria, 72% used reduced food intake/assimilation, and 85% applied inflammation/disease burden. Validation of GLIM criteria was described in 77% of publications.

CONCLUSIONS

The GLIM criteria have been studied extensively since their publication. Low BMI was the phenotypic criterion used most often, whereas both reduced food intake/assimilation and inflammation/disease burden were frequently employed as the etiologic criteria. However, how the criteria were combined and how validation was conducted were not clear in most studies. Adequately powered, methodologically sound validation studies using the complete GLIM criteria are needed in various patient populations and disease settings to assess validity for the diagnosis of malnutrition.

Sarcopenia and Mortality Risk of Patients with Sepsis: A Meta-Analysis

Background

The association between sarcopenia at admission and mortality in patients with sepsis has not been comprehensively evaluated. We performed a meta-analysis to systematically evaluate the above association.

Methods

This meta-analysis included relevant observational studies from Medline, Embase, and Web of Science databases. A random-effect model after incorporation of the intrastudy heterogeneity was selected to pool the results. Subgroup analyses were applied to evaluate the influences of study characteristics on relationship.

Results

Ten cohort studies including 2396 patients with sepsis were included, and 1496 (62.4%) of them had sarcopenia at presentation. Pooled results showed that compared to those without sarcopenia, septic patients with sarcopenia had a significantly increased early (in-hospital or 1-month) mortality risk (risk ration (RR): 2.14, 95% confidence interval (CI): 1.60-2.87, P < 0.001; I 2 = 46%). Subgroup analyses showed consistent association between sarcopenia and increased acute mortality risk in septic patients which were not affected by study characteristics such as study design, country of the study, clinical settings, diagnostic criteria for sepsis, age, gender of the patients, and methods for diagnosis of sarcopenia (P for all subgroup analyses >0.05). Further meta-analyses showed that sarcopenia was also associated with increased mortality risk in septic patients at 3-6 months (RR: 2.13, 95% CI: 1.58-2.89, P < 0.001; I 2 = 0%) and at 1 year (RR: 1.57, 95% CI: 1.09-2.24, P = 0.01; I 2 = 29%).

Conclusions

Current evidence suggests that sarcopenia may be a predictor of mortality in patients with sepsis.

Association of sarcopenia with a higher risk of infection in patients with type 2 diabetes

AIMS

This study aimed to determine whether patients with type 2 diabetes and sarcopenia had a higher risk of infection.

STUDY DESIGNS

A cross-sectional study and a follow-up study were performed.

METHOD

A total of 2562 patients were enrolled and assessed for body composition and infection status. They were classified into four groups according to body fat (BF) and muscle mass index (ASMI): obese, sarcopenic, sarcopenic obese, and normal. Among these, 275 patients were followed for a median follow-up period of 1.84 years to evaluate the relationship of changes in skeletal muscle with infection status.

RESULTS

The sarcopenic and sarcopenic obese groups showed a higher risk of infection, an increase by 49.6% (OR = 1.496, 95% CI 1.102-2.031) and 42.4% (OR = 1.424, 95% CI 1.031-1.967) compared with the normal group, and also had a higher risk of respiratory infection, an increase by 56.0% (OR = 1.560, 95% CI 1.084-2.246) and 57.4% (OR = 1.574, 95% CI 1.080-2.293), respectively. Patients with the increased ASMI (OR = 0.079, 95% CI 0.021-0.298) represented a lower risk of infection than those with the decreased ASMI. Even a minor change (OR = 0.125, 95% CI 0.041-0.378) against age was beneficial to lowering the risk of infection. However, no association was found in the changes of body mass index and BF with infection status.

CONCLUSIONS

Sarcopenia, especially in patients with diabetes who are also obese, increases the risk of infection. Maintaining or improving muscle mass is expected to reduce infections.

Lean mass as a risk factor for intensive care unit admission: an observational study

PURPOSE

Intensive care unit (ICU) survivors have reduced physical function likely due to skeletal muscle wasting and weakness acquired during critical illness. However, the contribution of pre-morbid muscle mass has not been elucidated. We aimed to examine the association between pre-ICU muscle mass and ICU admission risk. Secondary outcomes include the relationship between muscle mass and ICU outcomes.

METHODS

ICU admissions between June 1, 1998, and February 1, 2019, were identified among participants of Geelong Osteoporosis Study (GOS), a population-based cohort study. Cox proportional hazard regression models estimated hazard ratios (HR) for ICU admission across T-score strata and continuous values of DXA-derived lean mass measures of skeletal mass index (SMI, lean mass/body mass %) and appendicular lean mass corrected for height (ALM/h2, kg/m2). Multivariable regression was used to determine the relationship between lean mass and ICU outcomes.

RESULTS

One hundred and eighty-six of 3126 participants enrolled in GOS were admitted to the ICU during the follow-up period. In adjusted models, lean mass was not predictive of ICU admission (SMI: HR 0.99 95%CI 0.97-1.01, p = 0.32; ALM/h2: HR 1.11 95%CI 0.94-1.31, p = 0.23), while greater appendicular lean mass was related to reduced 28-day mortality (ALM/h2 adjOR: 0.25, 95%CI 0.10-0.63, p = 0.003, SMI adjOR: 0.91, 95%CI 0.82-1.02, p = 0.09).

CONCLUSION

Lean mass was not associated with ICU admission in this population-based cohort study; however, greater appendicular lean mass was associated with reduced mortality. This suggests pre-ICU muscle status may not predict development of critical illness but is associated with better survival after critical illness occurs.

Impact of Muscle Mass on Survival in Patients with Sepsis: A Systematic Review and Meta-Analysis

INTRODUCTION

The aim of this study is to investigate the association between loss of muscle mass and prognosis of sepsis.

METHODS

Six databases, including PubMed, Embase, Cochrane Library, Web of Science, Scopus, and Ovid, were searched by the deadline of August 18, 2020. A meta-analysis was conducted on the collected data by means of a random-effects model. The quality of each included article was assessed according to the Newcastle-Ottawa Scale.

RESULTS

Out of 1,819 references, 6 articles and 1 conference abstract were included. Sepsis patients with a loss of muscle mass or sarcopenia had higher mortality (risk ratio [RR]: 1.94, 95% confidence intervals [CI]: 1.59-2.37; I-squared = 18.7%, p < 0.001). The RR of mortality within 30 days (RR: 2.31, 95% CI: 1.78-2.99, p < 0.001) was higher than that of mortality over 30 days. Loss of psoas muscle mass, as evaluated by CT, showed the highest RR of sepsis mortality. In addition, based on data on overall survival retrieved from 4 trials, the pooled hazard ratio (HR) for patients with a loss of muscle mass or sarcopenia was 3.04. Subgroup analysis showed that survival time was the main source of heterogeneity for the overall HR. Furthermore, the scanning areas of muscle mass in survival patients were 0.33 cm2/m2 higher than those measured in deceased patients.

CONCLUSION

A loss of muscle mass, as evaluated by CT scan, was associated with a poor outcome in sepsis.

Nutritional risk and clinical outcomes in critically ill adult patients with COVID-19

INTRODUCTION

the COVID-19 pandemic put the world's population at risk. As the relationship between nutritional risk and clinical outcomes in critically ill patients with COVID-19 is still poorly understood, a multidisciplinary research team of the Argentine Society of Intensive Care (SATI) conducted a multicenter study aimed to define nutritional features, and to evaluate the relationship between nutritional risk and relevant clinical outcomes for COVID-19 patients in an intensive care unit (ICU).

METHODS

a multicenter, prospective, observational study including twelve Argentinian ICUs was conducted between March and October 2020. Inclusion criteria were: adult patients older than 18 years who were admitted to the ICU with a COVID-19 diagnosis were included. Clinical data included comorbidities scores, and nutritional screening tools such as the Subjective Global Assessment (SGA), the Nutritional Risk Screening (NRS) 2002, and the modified NUTRIC score (mNUTRIC SCORE) were used. In addition, clinical outcomes including overall mortality, mechanical ventilation (MV) days, and ICU and hospital length of stay (LOS) were recorded.

RESULTS

a total of 285 ICU patients met our inclusion criteria. Mean age was 61.24 (SD = 14.6) years; APACHE-II, 14.2 (SD = 6.6); Charlson Comorbidity Index (CCI), 2.3 (SD = 2.3). Most patients were admitted from the emergency room to the ICU. Hypertension, obesity, and diabetes were the most common comorbidities. Nutritional assessment showed that 36.9 % were SGA B+C, and 46 % were obese. Mean ICU LOS was 22.2 (SD = 19.5), and hospital LOS was 28.1 (SD = 21.9) days. Of all patients, 90.2 % underwent MV, and MV days were 20.6 (SD = 15.6). The univariate and multivariate analyses showed that risk factors for COVID-19 mortality were (odds ratio [95 % confidence interval]): SGA score of B or C: 2.13 [1.11-4.06], and NRS 2002 ≥ 3: 2.25 [1.01-5.01].

CONCLUSIONS

in the present study, nutritional status (SGA) and NRS 2002 were major mortality risk factors for CODIV-19 patients in the ICU.

Branched-Chain Amino Acids Can Predict Mortality in ICU Sepsis Patients

Sepsis biomarkers and potential therapeutic targets are urgently needed. With proton nuclear magnetic resonance (¹H NMR) spectroscopy, several metabolites can be assessed simultaneously. Fifty-three adult medical ICU sepsis patients and 25 ICU controls without sepsis were prospectively enrolled. ¹H NMR differences between groups and associations with 28-day and ICU mortality were investigated. In multivariate metabolomic analyses, we found separate clustering of ICU controls and sepsis patients, as well as septic shock survivors and non-survivors. Lipoproteins were significantly different between sepsis and control patients. Levels of the branched-chain amino acids (BCAA) valine (median 43.3 [29.0–53.7] vs. 64.3 [47.7–72.3] normalized signal intensity units; p = 0.005), leucine (57.0 [38.4–71.0] vs. 73.0 [54.3–86.3]; p = 0.034) and isoleucine (15.2 [10.9–21.6] vs. 17.9 [16.1–24.4]; p = 0.048) were lower in patients with septic shock compared to those without. Similarly, BCAA were lower in ICU non-survivors compared to survivors, and BCAA were good discriminators for ICU and 28-day mortality. In uni- and multivariable logistic regression analyses, higher BCAA levels were associated with decreased ICU- and 28-day mortality. In conclusion, metabolomics using ¹H NMR spectroscopy showed encouraging potential for personalized medicine in sepsis. BCAA was significantly lower in sepsis non-survivors and may be used as early biomarkers for outcome prediction.

Computed tomography-defined low skeletal muscle mass as a prognostic marker for short-term mortality in critically ill patients: A systematic review and meta-analysis

OBJECTIVE

Low skeletal muscle mass (LSMM) can be assessed by imaging modalities and is associated with several clinically relevant factors in critically ill patients. Our aim was to establish the effect of computed tomography (CT)-defined LSMM on short-term mortality in critically ill patients based on a large patient sample.

METHODS

The MedLine library and the Cochrane and SCOPUS databases were screened for associations between CT-defined LSMM and short-term mortality in critically ill patients up to May 2021. The primary endpoint of the systematic review was the odds ratio of sarcopenia on mortality. In total, nine studies were selected as suitable for the analysis and included into the present analysis.

RESULTS

The studies included a total of 1563 critically ill patients with different underlying diagnoses. The pooled overall prevalence of LSMM was 50.9%. The pooled odds ratio for the effect of sarcopenia on short-term mortality was 2.78 (95% confidence interval, 2.05-3.75).

CONCLUSIONS

CT-defined LSMM is highly prevalent in critically ill patients, has a relevant effect on short-term mortality, and should be included as a relevant prognostic biomarker in clinical routines.

Anthropometric analysis of body habitus and outcomes in critically ill COVID-19 patients

Aims

This study aimed to determine whether anthropometric markers of thoracic skeletal muscle and abdominal visceral fat tissue correlate with outcome parameters in critically ill COVID-19 patients.

Methods

We retrospectively analysed thoracic CT-scans of 67 patients in four ICUs at a university hospital. Thoracic skeletal muscle (total cross-sectional area (CSA); pectoralis muscle area (PMA)) and abdominal visceral fat tissue (VAT) were quantified using a semi-automated method. Point-biserial-correlation-coefficient, Spearman-correlation-coefficient, Wilcoxon rank-sum test and logistic regression were used to assess the correlation and test for differences between anthropometric parameters and death, ventilator- and ICU-free days and initial inflammatory laboratory values.

Results

Deceased patients had lower CSA and PMA values, but higher VAT values (p < 0.001). Male patients with higher CSA values had more ventilator-free days (p = 0.047) and ICU-free days (p = 0.017). Higher VAT/CSA and VAT/PMA values were associated with higher mortality (p < 0.001), but were negatively correlated with ICU length of stay in female patients only (p < 0.016). There was no association between anthropometric parameters and initial inflammatory biomarker levels. Logistic regression revealed no significant independent predictor for death.

Conclusion

Our study suggests that pathologic body composition assessed by planimetric measurements using thoracic CT-scans is associated with worse outcome in critically ill COVID-19 patients.

Sarcopenia as a predictor of mortality among the critically ill in an intensive care unit: a systematic review and meta-analysis

BACKGROUND

The evidence of sarcopenia based on CT-scan as an important prognostic factor for critically ill patients has not seen consistent results. To determine the impact of sarcopenia on mortality in critically ill patients, we performed a systematic review and meta-analysis to quantify the association between sarcopenia and mortality.

METHODS

We searched studies from the literature of PubMed, EMBASE, and Cochrane Library from database inception to June 15, 2020. All observational studies exploring the relationship between sarcopenia based on CT-scan and mortality in critically ill patients were included. The search and data analysis were independently conducted by two investigators. A meta-analysis was performed using STATA Version 14.0 software using a fixed-effects model.

RESULTS

Fourteen studies with a total of 3,249 participants were included in our meta-analysis. The pooled prevalence of sarcopenia among critically ill patients was 41 % (95 % CI:33-49 %). Critically ill patients with sarcopenia in the intensive care unit have an increased risk of mortality compared to critically ill patients without sarcopenia (OR = 2.28, 95 %CI: 1.83-2.83; P < 0.001; I2 = 22.1 %). In addition, a subgroup analysis found that sarcopenia was associated with high risk of mortality when defining sarcopenia by total psoas muscle area (TPA, OR = 3.12,95 %CI:1.71-5.70), skeletal muscle index (SMI, OR = 2.16,95 %CI:1.60-2.90), skeletal muscle area (SMA, OR = 2.29, 95 %CI:1.37-3.83), and masseter muscle(OR = 2.08, 95 %CI:1.15-3.77). Furthermore, critically ill patients with sarcopenia have an increased risk of mortality regardless of mortality types such as in-hospital mortality (OR = 1.99, 95 %CI:1.45-2.73), 30-day mortality(OR = 2.08, 95 %CI:1.36-3.19), and 1-year mortality (OR = 3.23, 95 %CI:2.08 -5.00).

CONCLUSIONS

Sarcopenia increases the risk of mortality in critical illness. Identifying the risk factors of sarcopenia should be routine in clinical assessments and offering corresponding interventions may help medical staff achieve good patient outcomes in ICU departments.

Metabolism of Proteins and Amino Acids in Critical Illness: From Physiological Alterations to Relevant Clinical Practice

The clinical impact of nutrition therapy in critically ill patients has been known for years, and relevant guidelines regarding nutrition therapy have emphasized the importance of proteins. During critical illness, such as sepsis or the state following major surgery, major trauma, or major burn injury, patients suffer from a high degree of stress/inflammation, and during this time, metabolism deviates from homeostasis. The increased degradation of endogenous proteins in response to stress hormones is among the most important events in the acute phase of critical illness. Currently published evidence suggests that adequate protein supplementation might improve the clinical outcomes of critically ill patients. The role of sufficient protein supplementation may even surpass that of caloric supplementation. In this review, we focus on relevant physiological alterations in critical illness, the effects of critical illness on protein metabolism, nutrition therapy in clinical practice, and the function of specific amino acids.

Deterioration of mitochondrial function in the human intercostal muscles differs among individuals with sarcopenia, obesity, and sarcopenic obesity

BACKGROUND & AIMS

Sarcopenic obesity (SO) increases the risk of mortality more than sarcopenia or obesity alone. Sarcopenia weakens the peripheral and respiratory muscles, leading to respiratory complications. It also induces mitochondrial dysfunction in the peripheral muscle; however, whether mitochondrial dysfunction in respiratory muscles differs among individuals with obesity, sarcopenia, and SO remains unknown. We evaluated the deterioration of respiratory muscle strength and mitochondrial function among normal, sarcopenia, obesity, and SO subjects.

METHODS

Twenty-five patients who underwent lung resections were enrolled between April 2017 and January 2021, and their intercostal muscles were harvested. Based on their L3 muscle index and visceral fat area, the patients were divided into four groups (normal, obesity, sarcopenia, and SO). The clinical data, mRNA expression, and protein expressions associated with mitochondrial biogenesis/fusion/fission in the intercostal muscles were compared among the four groups.

RESULTS

The respiratory muscle strength was evaluated using peak expiratory flow rate (PEFR). The PEFR values of the four groups were not significantly different. The levels of pAkt/Akt and mTOR (a marker of protein synthesis) were not significantly different among the four groups; however, those in the SO group were substantially lower than those in the sarcopenia or obesity groups. The levels of Atrogen-1 and MuRF1 (a marker of protein degradation) were not significantly different among the four groups; however, those in the SO group were substantially higher than those in the sarcopenia or obesity groups. Expression of PGC1-α (a marker of mitochondrial biogenesis) in the SO group was significantly lower than that in the normal group. MFN1 and MFN2 (marker of mitochondrial fusion) levels were significantly lower in the SO group than those in the normal group. DRP1 (a marker of mitochondrial fission) level in the SO group was substantially lower than that in the normal group. The expression of TNF-α (a pro-inflammatory cytokine) in the SO group was substantially lower than that in the normal group.

CONCLUSION

Our results suggest that the deterioration of protein synthesis and degradation of mitochondrial function in the respiratory muscles was most prominent in the SO before the weakening of the respiratory muscles. The deterioration mechanism may differentially regulate obesity, sarcopenia, and SO.

Edema in critically ill patients leads to overestimation of skeletal muscle mass measurements using computed tomography scans

OBJECTIVES

Changes in muscle mass and quality are important targets for nutritional intervention in critical illness. Effects of such interventions may be assessed using sequential computed tomography (CT) scans. However, fluid and lipid infiltration potentially affects muscle area measurements. The aim of this study was to evaluate changes in muscle mass and quality in critical illness with special emphasis on the influence of edema on this assessment.

METHODS

Changes in skeletal muscle area index (SMI) and radiation attenuation (RA) at the level of vertebra L3 were analyzed using sequential CT scans of 77 patients with abdominal sepsis. Additionally, the relation between these changes and disease severity using the maximum Sequential Organ Failure Assessment (SOFA) score and change in edema were studied.

RESULTS

SMI declined on average 0.35%/d (±1.22%; P = 0.013). However, SMI increased in 41.6% of the study population. Increasing edema formation was significantly associated with increased SMI and with a higher SOFA score. Muscle RA decreased during critical illness, but was not significantly associated with changes in SMI or changes in edema.

CONCLUSION

In critically ill patients, edema affects skeletal muscle area measurements, which leads to an overestimation of skeletal muscle area. A higher SOFA score was associated with edema formation. Because both edema and fat infiltration may affect muscle RA, the separate effects of these on muscle quality are difficult to distinguish. When using abdominal CT scans to changes in muscle mass and quality in critically ill patients, researchers must be aware and careful with the interpretation of the results.

Diagnosis of obesity based on body composition-associated health risks-Time for a change in paradigm

Traditional diagnosis and understanding of the pathophysiology of obesity are based on excessive fat storage due to a chronically positive energy balance characterized by body mass index (BMI). Quantitative and qualitative analysis of lean and adipose tissue compartments by body composition analysis reveals that characterization of obesity as "overfat" does not facilitate a comprehensive understanding of obesity-associated health risk. Instead of being related to fat mass, body composition characteristics underlying BMI-associated prognosis may depend (i) on accelerated growth by a gain in lean mass or fat-free mass (FFM) in children with early BMI rebound or adolescents with early puberty; (ii) on a low muscle mass in aging, associated chronic disease, or severe illness; and (iii) on impaired adipose tissue expandability with respect to cardiometabolic risk. It is therefore time to call the adipocentric paradigm of obesity into question and to avoid the use of BMI and body fat percentage. By contrast, obesity should be seen in face of a limited FFM/muscle mass together with a limited capacity of fat storage.

Low psoas muscle area is associated with postoperative complications in Crohn's disease

BACKGROUND AND AIMS

Crohn's disease (CD) is associated with increased postoperative morbidity. Sarcopenia correlates with increased morbidity and mortality in various medical conditions. We assessed correlations of the lean body mass marker and psoas muscle area (PMA), with postoperative outcomes in CD patients undergoing gastrointestinal surgery.

METHODS

We included patients with CD who underwent gastrointestinal surgery between June 2009 and October 2018 and had CT/MRI scans within 8 weeks preoperatively. PMA was measured bilaterally on perioperative imaging.

RESULTS

Of 121 patients, the mean age was 35.98 ± 15.07 years; 51.2% were male. The mean BMI was 21.56 ± 4 kg/m2. The mean PMA was 95.12 ± 263.2cm². Patients with postoperative complications (N = 31, 26%) had significantly lower PMA compared with patients with a normal postoperative recovery (8.5 ± 2.26 cm2 vs. 9.85 ± 2.68 cm2, P = 0.02). A similar finding was noted comparing patients with anastomotic leaks to those without anastomotic leaks (7.48 ± 0.1 cm2 vs. 9.6 ± 2.51 cm2, P = 0.04). PMA correlated with the maximum degree of complications per patient, according to the Clavien-Dindo classification (Spearman's coefficient = -0.26, P = 0.004). Patients with major postoperative complications (Clavien-Dindo ≥ 3) had lower mean PMA (8.12 ± 2.75 cm2 vs. 9.71 ± 2.57 cm2, P = 0.03). Associations were similar when stratifying by gender and operation urgency. On multivariate analysis, PMA (HR = 0.72/cm2, P = 0.02), operation urgency (HR = 3.84, P < 0.01), and higher white blood cell count (HR = 1.14, P = 0.02) were independent predictive factors for postoperative complications.

CONCLUSION

PMA is an easily measured radiographic parameter associated with postoperative complications in patients with CD undergoing bowel resection.

Sarcopenia is poor risk for unfavorable short- and long-term outcomes in stage I non-small cell lung cancer

Background

Sarcopenia characterized by skeletal muscle loss may influence postoperative outcomes through physical decline and weakened immunity. We aimed to investigate clinical significance of sarcopenia in resected early-stage non-small cell lung cancer (NSCLC).

Methods

We retrospectively reviewed 315 consecutive patients with pathologic stage I NSCLC who had undergone lobectomy with systematic nodal dissection. Sarcopenia was defined as the lowest quartile of psoas muscle area on the 3rd vertebra on the high-resolution computed tomography (HRCT) image. Clinicopathological variables were used to investigate the correlation to postoperative complications as well as overall and recurrence-free survival.

Results

Upon multivariable analysis, male sex [odds ratio (OR) =5.780, 95% confidence interval (CI): 2.681–12.500, P<0.001], and sarcopenia (OR =21.00, 95% CI: 10.30–42.80, P<0.001) were independently associated with postoperative complications. The sarcopenia group showed significantly lower 5-over all survival (84.4% vs. 69.1%, P<0.001) and recurrence-free survival (77.2% vs. 62.0%, P<0.001) comparing with the non-sarcopenia group. In a multivariable analysis, sarcopenia was an independent prognostic factor [hazard ratio (HR) =1.978, 95% CI: 1.177–3.326, P=0.010] together with age ≥70 years (HR =1.956, 95% CI: 1.141–3.351, P=0.015) and non-adenocarcinoma histology (HR =1.958, 95% CI: 1.159–3.301, P=0.016).

Conclusions

This is the first study which demonstrates that preoperative sarcopenia is significantly associated with unfavorable postoperative complications as well as long-term survival in pathologic stage I NSCLC. This readily available factor on HRCT may provide valuable information to consider possible choice of surgical procedure and perioperative management.

Sarcopenia is a useful risk stratification tool to prognosticate splenic abscess patients in the emergency department

BACKGROUND/PURPOSE

Splenic abscess is a life-threatening surgical emergency which requires early diagnosis and intervention to maximize patient outcomes. This can be achieved through accurate risk stratification in the emergency department (ED). Sarcopenia refers to an age-related loss of skeletal muscle mass and strength that is accompanied by major physiologic and clinical ramifications, and often signifies decreased physiologic reserves. It is associated with poor clinical outcomes in sepsis, acute respiratory failure, oncological surgery, and liver transplantation. This study evaluates the utility of sarcopenia as a radiological stratification tool to predict in-hospital mortality of splenic abscess patients in the ED. This will assist emergency physicians, internists and surgeons in rapid risk stratification, assessing treatment options, and communicating with family members.

METHODS

99 adult patients at four training and research hospitals who had undergone an abdominal contrast computed tomography scan in the ED with the final diagnosis of splenic abscess from January 2004 to November 2017 were recruited. Evaluation for sarcopenia was performed via calculating the psoas cross-sectional area at the level of the third lumbar vertebra and normalising for height, before checking it against pre-defined values. Univariate analyses were used to evaluate the differences between survivors and non-survivors. Sensitivity, specificity, and predictive values of the presence of sarcopenia in predicting in-hospital mortality were calculated. Kaplan-Meier methods, log-rank test, and Cox proportional hazards model were also performed to examine survival between groups with sarcopenia versus non-sarcopenia.

RESULTS

Splenic abscess patients with sarcopenia were 7.56 times more at risk of in-hospital mortality than those without sarcopenia (multivariate-adjusted HR: 7.56; 95% CI: 1.55-36.93). Presence of sarcopenia was found to have 84.62% sensitivity and 96.49% negative predictive value in predicting mortality.

CONCLUSION

Sarcopenia is associated with poor prognoses of in-hospital mortality in patients with splenic abscess presenting to the ED. We recommend its use in the ED to rapidly risk stratify and predict outcome to guide treatment strategies.

Skeletal Muscle Composition Predicts Outcome in Critically Ill Patients

Supplemental Digital Content is available in the text.

Parameters of patients’ body composition have been suggested as prognostic markers in several clinical conditions including cancer and liver transplantation, but only limited data on its value in critical illness exist to date. In this study, we aimed at evaluating a potential prognostic value of the skeletal muscle mass and skeletal muscle myosteatosis of critically ill patients at admission to the ICU.

A retrospective observational study of sarcopenia and outcomes in critically ill patients

Frailty assessment in patients admitted to intensive care is often limited using traditional clinical frailty assessment tools. Opportunistic use of contemporary computed tomography (CT) can provide an objective estimate of low skeletal muscle mass (sarcopenia) as a proxy for frailty. The aim of this study was to establish the prevalence of sarcopenia in an Australian intensive care unit (ICU) population and to examine the relationship between sarcopenia and clinical outcomes. We undertook a single centre retrospective study of 1085 adult patients admitted to a single ICU over 12 months. Patients with a contemporary CT scan including the L3 vertebral body were included. Patients were categorised as sarcopenic or non-sarcopenic using previously published data. A total of 279 patients with a mean age of 67 years had an eligible CT scan; 163 (58%) were male. Higher 30-day mortality was associated with the use of CRRT (continuous renal replacement therapy) during the ICU admission (OR 6.84, P < 0.001) and also associated with lower cross-sectional muscle area (odds ratio (OR) 0.98, P = 0.004). Sarcopenia was found to be highly prevalent in this particular Australian ICU population (68%) and associated with older age (68 versus 55 years, P < 0.001), lower body mass index (27 versus 32 kg m-2, P < 0.001), more comorbidities (3 versus 2, P = 0.009), and longer stays in hospital (279 versus 223 h, P = 0.043). As a continuous predictor, lumbar muscle mass was associated with 30-day mortality with and without adjusting for other covariates.

Older Sepsis Survivors Suffer Persistent Disability Burden and Poor Long-Term Survival

OBJECTIVES

Sepsis has been called a "disease of the elderly," and as in-hospital mortality has decreased, more sepsis survivors are progressing into poorly characterized long-term outcomes. The purpose of this study was to describe the current epidemiology of sepsis in older adults compared with middle-aged and young adults.

DESIGN

Prospective longitudinal study with young (≤45 years), middle-aged (46-64 years), and older (≥65 years) patient groups.

SETTING

University tertiary medical center.

PARTICIPANTS

A total of 328 adult surgical intensive care unit (ICU) sepsis patients.

MEASUREMENTS

Patients were characterized by (1) baseline demographics and predisposition, (2) septic event, (3) hospital outcomes and discharge disposition, (4) 12-month mortality, and (5) Zubrod Performance Status, physical function (Short Physical Performance Battery and handgrip strength), and cognitive function (Hopkins Verbal Learning Test, Controlled Oral Word Association, and Mini-Mental Status Examination) at 3-, 6-, and 12-month follow-up. Loss to follow-up was due to death (in 68), consent withdrawal (in 32), and illness and scheduling difficulties: month 3 (in 51), month 6 (in 29), and month 12 (in 20).

RESULTS

Compared with young and middle-aged patients, older patients had (1) significantly more comorbidities at presentation (eg, chronic renal disease 6% vs 12% vs 21%), intra-abdominal infections (14% vs 25% vs 37%), septic shock (12% vs 25% vs 36%), and organ dysfunctions; (2) higher 30-day mortality (6% vs 4% vs 17%) and fewer ICU-free days (median = 25 vs 23 vs 20); (3) more progression into chronic critical illness (22% vs 34% vs 42%) with higher poor disposition discharge to non-home destinations (19% vs 40% vs 62%); (4) worse 12-month mortality (11% vs 14% vs 33%); and (5) poorer Zubrod Performance Status and objectively measured physical and cognitive functions with only slight improvement over 12-month follow-up.

CONCLUSION

Compared with younger patients, older sepsis survivors suffer both a higher persistent disability burden and 12-month mortality.

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.

Phenotypes of Sarcopenic Obesity: Exploring the Effects on Peri-Muscular Fat, the Obesity Paradox, Hormone-Related Responses and the Clinical Implications

Sarcopenic obesity combines the words sarcopenia and obesity. This definition of obesity should be better differentiated between visceral and subcutaneous fat phenotypes. For this reason, this review lays the foundation for defining the subcutaneous and the visceral fat into the context of sarcopenia. Thus, the review aims to explore the missing links on pathogenesis of visceral fat and its relationship on age: defining the peri-muscular fat as a new entity and the subcutaneous fat as a first factor that leads to the obesity paradox. Last but not least, this review underlines and motivates the mechanisms of the hormonal responses and anti-inflammatory adipokines responsible for the clinical implications of sarcopenic visceral obesity, describing factor by factor the multiple axis between the visceral fat-sarcopenia and all mortality outcomes linked to cancer, diabetes, cardiovascular diseases, cirrhosis, polycystic ovary, disability and postoperative complications.

Protein Requirements in Critical Illness: Do We Really Know Why to Give So Much?

The protein and energy requirements of critically ill patients treated in intensive care units (ICUs) have been actively discussed recently. Currently published clinical recommendations and reviews suggest significant increases of protein provision to 2-2.5 g/kg/d in some populations of ICU patients. However, a detailed analysis of the main sources of these recommendations reveals a number of serious contradictions, as well as an absence of obvious evidence supporting the allotment of high doses of protein. We went through these recommendations and reviewed cited articles and other studies, and we have separated our arguments against excessive protein provision into sections.

Comparing the performance of SOFA, TPA combined with SOFA and APACHE-II for predicting ICU mortality in critically ill surgical patients: A secondary analysis

INTRODUCTION

Total psoas muscle area (TPA) can indicate the status of the entire human body's skeletal muscle mass. It has been reported that lower TPA can increase the risk of mortality in critically ill patients. The aim of our study was to evaluate the relationship between TPA and ICU mortality and to compare the performance of Sequential Organ Failure Assessment (SOFA), TPA combined with SOFA and Acute Physiology, Chronic Health Evaluation (APACHE-II) for predicting ICU mortality in critically ill surgical patients.

METHODS

This study was a retrospective observational cohort study with a total of 96 critically ill surgical patients, ages 21-96 years old. Main outcome measures included difficult-to-wean (DTW), operation methods, ICU mortality, ICU stay, APACHE II, sepsis and SOFA. CT-scan assessed the TPA. It is acknowledged that the entire study was completed by Hao-Wei Kou et al. and the data were uploaded from plosone.com. The authors used this data only for secondary analysis.

RESULTS

The results showed that TPA is a protective factor for ICU mortality (OR: 0.99 95% [0.99, 1.00], P = 0.0269). In addition, when we defined sarcopenia-based TPA, our study showed that sarcopenia increased the risk of ICU mortality (OR:3.73 (1.27, 10.98) P = 0.0167. Furthermore, discrimination of ICU mortality was significantly higher using SOFA (AUROC, 0.7810 [99% CI, 0.6658-0.8962]) than either TPA (AUROC, 0.7023 [99% CI, 0.5552-0.8494]) or APACHE II score (AUROC, 0.7447 [99% CI, 0.6289-0.8604]). Additionally, when we combined TPA with SOFA score, the ROC of TPA + SOFA (AUROC, 0.8647 [99% CI, 0.7881-0.9412]) was the highest when compared to the other three models.

CONCLUSION

The relationship between TPA and ICU mortality is negative in critically ill surgical patients. In addition, the combination of TPA and SOFA was the best tool among the three scoring systems in providing significant discriminative ability when predicting ICU mortality in critically ill surgical patients.

Open Abdomen in Obese Patients: Pay Attention! New Evidences from IROA, the International Register of Open Abdomen

BACKGROUND

Open abdomen is the cornerstone of damage control strategies in acute care and trauma surgery. The role of BMI has not been well investigated. The aim of the study was to assess the role of BMI in determining outcomes after open abdomen.

METHODS

This is an analysis of patients recorded into the International Register of Open Abdomen; patients were classified in two groups according to BMI using a cutoff of 30 kg/m2. The primary outcome was in-hospital mortality; secondary outcomes were primary fascia closure rate, length of treatment, complication rate, entero-atmospheric fistula rate and length of ICU stay.

RESULTS

A total of 591 patients were enrolled from 57 centers, and obese patients were 127 (21.5%). There was no difference in mortality between the two groups; complications developed during the open treatment were higher in obese patients (63.8% vs. 53.4%, p = 0.038) while post-closure complications rate was similar. Obese patients had a significantly longer duration of the open treatment (9.1 ± 11.5 days vs. 6.3 ± 7.5 days; p = 0,002) and lower primary fascia closure rate (75.5% vs. 89.5%; p < 0,001). No differences in fistula rate were found. There was a linear correlation between the duration of open abdomen and the BMI (Pearson's linear correlation coefficient = 0,201; p < 0,001).

CONCLUSIONS

Open abdomen in obese patients seems to be safe as in non-obese patients with similar mortality; however, in obese patients the length of open abdomen is significantly higher with higher complication rate, longer ICU length of stay and lower primary fascia closure rate.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov, Identifier: NCT02382770.

Muscle wasting associated co-morbidities, rather than sarcopenia are risk factors for hospital mortality in critical illness

BACKGROUND

Low skeletal muscle mass on intensive care unit admission is related to increased mortality. It is however unknown whether this association is influenced by co-morbidities that are associated with skeletal muscle loss. The aim of this study was to investigate whether sarcopenia is an independent risk factor for hospital mortality in critical illness in the presence of co-morbidities associated with muscle wasting.

METHODS

Data of 155 patients with abdominal sepsis were retrospectively analyzed. Skeletal muscle area was assessed using CT-scans at the level of vertebra L3. Demographic and clinical data were retrieved from electronic patient files. Sarcopenia was defined as a muscle area index below the 5th percentile of the general population. Uni- and multivariable analyses were performed to assess the association between sarcopenia and hospital mortality, correcting for age and comorbidities.

RESULTS

The prevalence of sarcopenia was higher in patients that did not survive until hospital discharge. However, it appeared that this relation was confounded by the presence of chronic renal insufficiency and cancer. These were independent risk factors for hospital mortality, whereas sarcopenia was not.

CONCLUSION

In critically ill patients with abdominal sepsis, muscle wasting associated co-morbidities rather than sarcopenia were risk factors for hospital mortality.

Progressive loss of muscle mass could be an adverse prognostic factor of 28-day mortality in septic shock patients

A decrease in skeletal muscle mass has been shown to increase hospital mortality. Nevertheless, little is known about the association between progressive muscle loss over time and clinical outcomes. We aimed to evaluate whether progressive loss of muscle mass in septic shock patients was associated with mortality. We reviewed prospectively enrolled registry of septic shock which had 817 consecutive patients. Of these, 175 patients who had computed tomography (CT) at a time of admission as well as 3-6 months prior to admission were included. Between these two CTs, the change in total abdominal muscle area index (TAMAI) was evaluated for progressive muscle loss. The change in TAMAI was higher in the non-survivors (-7.6 cm²/m², 19.0% decrease) than the survivors (-4.0 cm²/m², 10.5% decrease) with statistical significance (p = 0.002). Multiple logistic regression showed that the patients who had more than a 6.4 cm²/m² (16.7%) reduction of TAMAI had a 4.42-fold higher risk for mortality at 28 days (OR, 4.42; 95% CI, 1.41-13.81, p = 0.011). Our study suggested that progressive loss of muscle mass might be a useful prognostic factor for septic shock patients. This implication will need to be further explored in future prospective studies.

Impact of Body Composition Status on 90-Day Mortality in Cancer Patients with Septic Shock: Sex Differences in the Skeletal Muscle Index

Abnormalities in body composition are associated with poor prognosis in cancer patients. We investigated the association between body composition and 90-day mortality in cancer patients who developed septic shock. We included consecutive septic shock patients with active cancer from 2010 to 2017. The muscle area at the level of the third lumbar vertebra was measured by computed tomography upon emergency department admission and adjusted by height squared, yielding the Skeletal Muscle Index (SMI). Hazard ratios (HRs) and 95% confidence intervals (CIs) for 90-day mortality were estimated using a Cox proportional hazards model. Among 478 patients, the prevalence of muscle depletion was 87.7%. Among markers of body composition, the SMI only differed significantly between non-survivors and survivors (mean, 35.48 vs. 33.32 cm²/m²; P = 0.002) and was independently associated with lower 90-day mortality (adjusted HR, 0.970; P = 0.001). The multivariable-adjusted HRs (95% CI) for 90-day mortality comparing quartiles 2, 3, and 4 of the SMI to the lowest quartile were 0.646 (0.916–1.307), 0.620 (0.424–0.909), and 0.529 (0.355–0.788), respectively. The associations were evident in male patients, but not in female patients. The SMI was independently associated with 90-day mortality in cancer patients with septic shock. The graded association between the SMI and 90-day mortality was observed in male patients.