Ultrasonic Elastography of the Rectus Femoris, a Potential Tool to Predict Sarcopenia in Patients With Chronic Obstructive Pulmonary Disease

Applicability of the Instrumented Pendulum Test for Assessing Limb Viscoelastic Properties in Neurological and Internal Diseases: A Narrative Review

BACKGROUND

The pendulum test was first introduced by Wartenberg as a clinical tool for neurological examination in patients with hypertonia. It was later instrumented to measure the kinematic parameters of gravity-imposed knee movements in patients with spasticity. More recently, the instrumented pendulum test has enabled the quantification of stiffness, viscosity, and damping in both the lower and upper limbs across various neurological and internal diseases.

OBJECTIVE

To highlight the utility of the instrumented pendulum test as a valuable tool for the quantification of stiffness, viscosity, and damping of knee and elbow joints within a clinical setting.

DESIGN

Narrative review.

METHODS

A comprehensive search was conducted using PubMed/MEDLINE, focusing on the terms "pendulum test" combined with "viscosity", "stiffness", and "damping".

RESULTS

The instrumented pendulum test effectively quantifies stiffness, viscosity, and damping of the knee and elbow across various conditions, including rheumatic diseases, chronic obstructive pulmonary disease, hypertonia, and hypotonia. Studies have also demonstrated correlations between these non-neural parameters and factors such as age and disease severity.

CONCLUSIONS

Findings suggest that the instrumented pendulum test could serve as a valuable tool in clinical decision-making for targeted pharmacological treatments, such as botulinum toxin-A or hyaluronidase injections for spasticity, as well as interventions for myofascial system disorders.

Diagnostic performance of various radiological modalities in the detection of sarcopenia within Asian populations: a systematic review

PURPOSE

Diagnosing sarcopenia necessitates the measurement of skeletal muscle mass. However, guidelines lack a standardized imaging modality with thresholds validated among Asians. This systematic review compared ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and bioelectrical impedance analysis (BIA)/body composition monitoring in the detection of sarcopenia within Asian populations.

METHODS

PubMed and Embase were systematically searched for studies analyzing ultrasonography, CT, MRI, and BIA in diagnosing sarcopenia among Asians. Study quality was assessed using the Newcastle-Ottawa scale.

RESULTS

Pooled findings from 21,598 patients across 25 studies were examined. In receiver operating characteristic analysis, ultrasound displayed a pooled mean area under the curve (AUC) of 0.767 (95% confidence interval [CI], 0.709-0.806), with mean sensitivity of 81.1% (95% CI, 0.744-0.846) and specificity of 73.1% (95% CI, 0.648-0.774), for detecting sarcopenia in Asian populations. CT exhibited an AUC of 0.720 (sensitivity, 54.0%; specificity, 92.0%). MRI demonstrated an AUC of 0.839 (sensitivity, 67.0%; specificity, 66.0%). BIA displayed an AUC of 0.905 (95% CI, 0.842-0.968), 80.7% sensitivity (95% CI, 0.129-0.679), and 82.4% specificity (95% CI, 0.191-0.633).

CONCLUSIONS

Various modalities aid in diagnosing sarcopenia, and selection should be individualized. Although only BIA and dual-energy x-ray absorptiometry are recommended by the Asian Working Group for Sarcopenia and the European Working Group on Sarcopenia in Older People, ultrasound imaging may hold diagnostic value for sarcopenia in the Asian population. In certain groups, diagnostic use of CT and MRI is warranted. Future research can standardize and validate modality-specific thresholds and protocols within Asian populations.

Comparison of Shear-Wave Elastography USG and CT: Composition Analysis of Rectus Femoris Muscle in Healthy Adults and Chronic Kidney Disease Patients

PURPOSE

This study aimed to compare shear-wave elastography (SWE) USG and composition analysis of CT on the right mid-rectus femoris muscle (RF) in both healthy adults and chronic kidney disease (CKD) patients.

METHODS

Sixty-three healthy adults and 22 CKD patients were included. One musculoskeletal radiologist performed right RF SWE USG, while two radiologists measured shear-wave velocity (SWV) from the same SWE images. CT scan was performed, and muscle composition was measured using imageJ, categorized into four HU-based compositions. Interobserver agreement for SWV between two readers was evaluated. Correlations between SWV and CT compositions were analyzed using Pearson's or Spearman's correlation.

RESULTS

SWV of healthy group was significantly higher than CKD group by each reader (p = 0.030 and 0.038). The percentage of low-density muscle was higher in CKD group than healthy group (p < 0.001), and the percentage of normal density muscle was higher in healthy group than CKD (p < 0.001) by each reader. Interobserver agreement of SWV by the two readers was almost perfect in both groups (k = 0.957-0.984, 0.959-0.993). There was a statistically significant correlation between SWV and the percentage of normal density muscle on CT in both healthy adults and CKD patient groups (Reader 1, r = 0.318-0.480, p = 0.001 and 0.024; Reader 2, r = 0.511-0.518, p < 0.001 and p = 0.013).

CONCLUSIONS

SWV demonstrated a significant correlation with the percentage of normal density muscle on CT in both healthy adults and CKD patients by each reader. SWE provides a radiation-free approach that may offer an objective method for evaluating muscle quality, potentially making it an option for muscle monitoring.

Application value of two-dimensional ultrasound and shear-wave elastography parameters in evaluating sarcopenia with essential hypertension

Background

Patients with essential hypertension have a high risk of muscle mass and strength decline. Ultrasound is a promising method for assessing sarcopenia. This study aimed to analyze the correlation between ultrasound and shear-wave elastography (SWE) features, and muscle mass, muscle strength, and physical performance, and to assess the clinical applicability of ultrasound in the diagnosis of sarcopenia in patients with essential hypertension.

Methods

In total, 134 patients with essential hypertension were enrolled in this cross-sectional study. The appendicular skeletal muscle mass index (ASMI), handgrip strength, and 6-meter walking speed of all the patients were measured. The patients were classified into the sarcopenia group and the non-sarcopenia group. The ultrasound-derived muscle thickness (MT), cross-sectional area (CSA), and SWE of the rectus femoris muscle (RFM) were measured in both the relaxed and contracted states. In addition, ultrasound features, such as the muscle fascicle length (Fl), pennation angle (PA), MT, and SWE of the gastrocnemius medialis muscle (GMM), were measured in the relaxed state. Correlations between the clinical indicators, and the ultrasound and SWE features were analyzed. The clinical indicators, and the ultrasound and SWE features were then compared between the sarcopenia and non-sarcopenia groups to determine the independent predictors. Based on these predictors, diagnostic models were established by logistic regression analysis.

Results

Both the ASMI and grip strength were positively correlated with the ultrasound-derived MT and CSA of the RFM in the relaxed and contracted states, and positively correlated with the MT, Fl, PA, and SWE of the GMM in the relaxed state (all P<0.05). The 6-meter walking speed was positively correlated with the ultrasound-derived MT and CSA of the RFM in the relaxed and contracted states, and positively correlated with the Fl and SWE of the GMM in the relaxed state (all P<0.05). Compared with the non-sarcopenia patients, the sarcopenia patients had a decrease in the ultrasound-derived MT and CSA of the RFM in the relaxed and contracted states, and the MT, Fl and SWE of the GMM in the relaxed state (all P<0.05). Based on these results, the cut-off value of the prediction model was 0.443, and it had a diagnostic sensitivity of 84.5% and a specificity of 90.8%.

Conclusions

Two-dimensional ultrasound combined with the SWE model can be used to diagnose sarcopenia in patients with essential hypertension. The model has high sensitivity and specificity, and can more accurately detect sarcopenia in patients with essential hypertension.

Ultrasound for body composition assessment: a narrative review

Ultrasound has become an increasingly valuable tool for the assessment of body composition, offering several applications and indications in clinical practice. Ultrasound allows bedside evaluation of muscle mass, fat compartments, and extravascular water, providing a cost-effective, portable, and accessible alternative to traditional methods, such as Dual-energy X-ray Absorptiometry (DEXA), Bioelectrical Impedance Analysis (BIA), Computed Tomography (CT), and Magnetic Resonance Imaging (MRI). It is particularly useful in evaluating conditions, such as malnutrition, sarcopenia, and sarcopenic obesity, which require poor muscle mass to establish a diagnosis. The potential uses of ultrasound in body composition assessment include measurement of muscle thickness, cross-sectional area, pennation angle, and echo-intensity, which are indicative of muscle health. Additionally, ultrasound can be used to evaluate various fat compartments, including visceral, subcutaneous, and ectopic fat, which are important for understanding metabolic health and cardiovascular risk. However, the widespread adoption of ultrasound is challenged by the lack of standardized measurements and the absence of ultrasound measures in the validated diagnostic criteria. This article reviews the current applications of ultrasound in body composition assessment, highlighting the recent advancements and the correlation between ultrasound parameters and clinical outcomes. It discusses the advantages of ultrasound while also addressing its limitations, such as the need for standardized protocols and cut-off points. By providing a comprehensive update based on recent publications, this article aims to enhance the clinical utility of ultrasound in assessing and monitoring body composition and pave the way for future research in this field.

Ultrasonic surface acoustic wave elastography: A review of basic theories, technical developments, and medical applications

Physiological and pathological changes in tissues often cause changes in tissue mechanical properties, making tissue elastography an effective modality in medical imaging. Among the existing elastography methods, ultrasound elastography is of great interest due to the inherent advantages of ultrasound imaging technology, such as low cost, portability, safety, and wide availability. However, most current ultrasound elastography methods are based on the bulk shear wave; they can image deep tissues but cannot image superficial tissues. To address this challenge, ultrasonic elastography methods based on surface acoustic waves have been proposed. In this paper, we present a comprehensive review of ultrasound-based surface acoustic wave elastography techniques, including their theoretical foundations, technical implementations, and existing medical applications. The goal is to provide a concise summary of the state-of-the-art of this field, hoping to offer a reliable reference for the further development of these techniques and foster the expansion of their medical applications.

Sarcopenia prediction using shear-wave elastography, grayscale ultrasonography, and clinical information with machine learning fusion techniques: feature-level fusion vs. score-level fusion

This study aimed to develop and evaluate a sarcopenia prediction model by fusing numerical features from shear-wave elastography (SWE) and gray-scale ultrasonography (GSU) examinations, using the rectus femoris muscle (RF) and categorical/numerical features related to clinical information. Both cohorts (development, 70 healthy subjects; evaluation, 81 patients) underwent ultrasonography (SWE and GSU) and computed tomography. Sarcopenia was determined using skeletal muscle index calculated from the computed tomography. Clinical and ultrasonography measurements were used to predict sarcopenia based on a linear regression model with the least absolute shrinkage and selection operator (LASSO) regularization. Furthermore, clinical and ultrasonography features were combined at the feature and score levels to improve sarcopenia prediction performance. The accuracies of LASSO were 70.57 ± 5.00-81.54 ± 4.83 (clinical) and 69.00 ± 4.52-69.73 ± 5.47 (ultrasonography). Feature-level fusion of clinical and ultrasonography (accuracy, 70.29 ± 6.63 and 83.55 ± 4.32) showed similar performance with clinical features. Score-level fusion by AdaBoost showed the best performance (accuracy, 73.43 ± 6.57-83.17 ± 5.51) in the development and evaluation cohorts, respectively. This study might suggest the potential of machine learning fusion techniques to enhance the accuracy of sarcopenia prediction models and improve clinical decision-making in patients with sarcopenia.

Sonographic methods to predict type 2 diabetes patients with sarcopenia: B mode ultrasound and shear wave elastography

BACKGROUND

Type 2 diabetes accelerates the loss of muscle mass and strength. Sarcopenia is also one of the chronic complications of diabetes.

OBJECTIVE

To investigate the clinical value of B mode ultrasound (BMUS) and shear wave elastography (SWE) for predicting type 2 diabetic sarcopenia.

METHODS

We recorded Skeletal Muscle Mass Index (ASMI), grip strength, muscle thickness (MT), pinna angle (PA), fascicle length (FL), and the difference of Young's modulus in the relaxed states and tense states (ΔSWE). The correlations between clinical indicators and ultrasound characteristics were compared. A diagnostic model of sarcopenia was developed to assess the independent correlates and evaluate the diagnostic efficacy of sarcopenia.

RESULTS

ASMI was significantly and positively correlated with MT and ΔSWE (r = 0.826, 0.765, P < 0.01), and grip strength was significantly and positively correlated with MT and ΔSWE (r = 0.797, 0.818, P < 0.01). MT was the most significant predictor of sarcopenia (OR = 4.576, P < 0.001), and the cut-off value of MT was 11.4 mm (AUC: 0.952).

CONCLUSION

BMUS and SWE can quantitatively assess muscle mass and strength, and are effective methods to predict the occurrence of sarcopenia in elderly patients with type 2 diabetes.

Revisiting Skeletal Muscle Dysfunction and Exercise in Chronic Obstructive Pulmonary Disease: Emerging Significance of Myokines

Skeletal muscle dysfunction (SMD) is the most significant extrapulmonary complication and an independent prognostic indicator in patients with chronic obstructive pulmonary disease (COPD). Myokines, such as interleukin (IL)-6, IL-15, myostatin, irisin, and insulin-like growth factor (IGF)-1, play important roles in skeletal muscle mitochondrial function, protein synthesis and breakdown balance, and regeneration of skeletal muscles in COPD. As the main component of pulmonary rehabilitation, exercise can improve muscle strength, muscle endurance, and exercise capacity in patients with COPD, as well as improve the prognosis of SMD and COPD by regulating the expression levels of myokines. The mechanisms by which exercise regulates myokine levels are related to microRNAs. IGF-1 expression is upregulated by decreasing the expression of miR-1 or miR-29b. Myostatin downregulation and irisin upregulation are associated with increased miR-27a expression and decreased miR-696 expression, respectively. These findings suggest that myokines are potential targets for the prevention and treatment of SMD in COPD. A comprehensive analysis of the role and regulatory mechanisms of myokines can facilitate the development of new exercise-based therapeutic approaches for patients with COPD.

Muscle ultrasound and its application to point-of-care ultrasonography: a narrative review

Technological advances of hand-held ultrasound devices and educational programmes for their use, such as point-of-care ultrasonography (POCUS) training, have contributed to the increasing application of these devices in clinical practice. With the greater impact of frailty and sarcopenia in aging societies, attention is being focused on the use of ultrasound for skeletal muscle assessment. In this narrative review, we discuss how ultrasound can be applied to skeletal muscle assessment, especially that of the quadriceps muscle, in clinical practice. Muscle thickness by ultrasound has been shown to have good reliability and validity for the evaluation of muscle size, and echo intensity has been used to evaluate muscle quality. Muscle ultrasound has not only been useful to diagnose sarcopenia in various settings, but has also been validated to predict health-related outcomes such as death and functional disability. Recommended methods for muscle ultrasound was published recently, and the results of future studies are expected to be comparable. Although several challenging issues with muscle ultrasound remain, if it could be incorporated into educational programmes such as POCUS training, more clinicians may be able to use ultrasound for skeletal muscle assessment in the future.KEY MESSAGESThe evolution of hand-held ultrasound devices enables physicians to perform ultrasound at the bedside as part of regular medical examinations.Muscle ultrasound is considered an effective tool for evaluating muscle size and quality, and has been studied in various settings.More clinicians may be able to evaluate skeletal muscle assessment with the development of educational programmes on muscle ultrasound in the future.

Ultrasound Assessment of the Gastrocnemius Muscle as a Potential Tool for Identifying Sarcopenia in Patients with Type 2 Diabetes

Objective

This study aims to examine the clinical significance of ultrasound evaluation of the gastrocnemius muscle (GM) in identifying sarcopenia in patients with type 2 diabetes (T2D).

Methods

One hundred and fifty-three patients with T2D were included in this study. We measured the appendicular skeletal muscle mass index (ASMI), handgrip strength, and 6-meter walking speed. The US-derived muscle thickness (MT), cross-sectional area (CSA), and shear wave ultrasound elastography (SWE) of GM were also measured. We assessed the correlations between clinical indicators and US features. The model for screening sarcopenia was established using stepwise logistic regression. Stepwise linear regression was used to identify a set of variables that jointly estimated ASMI. The model's ability to identify sarcopenia and low muscle mass was assessed by receiver operating characteristic (ROC) curve analysis.

Results

The prevalence of sarcopenia in this study was 24.2%. The CSA, MT and SWE values of the patients with sarcopenia were lower than those of patients without sarcopenia (all p < 0.05). ASMI was positively correlated with CSA (r = 0.56, p < 0.001) and MT (r = 0.39, p < 0.001). Handgrip strength was positively correlated with CSA (r = 0.45, p < 0.001), MT (r = 0.25, p < 0.001), and SWE (r = 0.26, p = 0.002). A diagnostic model for sarcopenia was established with a sensitivity of 81.1%, specificity of 75.0%, and an area under the curve (AUC) of 0.800. The estimated ASMI equation was developed and found to have a positive correlation with actual ASMI (r = 0.70, p < 0.001). It was also effective in diagnosing low muscle mass, with an AUC of 0.787 for males and 0.783 for females.

Conclusion

Ultrasonographic assessment of the gastrocnemius muscle was found to be a useful and convenient method for detecting sarcopenia in patients with T2D.

Value of conventional ultrasound and shear wave elastography in the assessment of muscle mass and function in elderly people with type 2 diabetes

OBJECTIVES

We assessed muscle mass and function using ultrasound (US) and shear wave elastography (SWE) for sarcopenia in elderly patients with type 2 diabetes.

METHODS

There were 84 patients with type 2 diabetes enrolled in this study; of these, 30 had sarcopenia and 54 did not. We measured appendicular skeletal muscle mass index (ASMI), handgrip strength, calf circumference, 6-m walking speed, and 5-time chair stand test. All patients were in the supine position with their knees in straight and bent poses in turn. The US-derived thickness (Tstraight, Tbent), cross-sectional area (CSAstraight, CSAbent), and SWE (SWEstraight, SWEbent) of the rectus femoris muscle (RFM) were measured and the differences (ΔT, ΔCSA, ΔSWE) were calculated. We assessed the correlations of clinical indicators with US and SWE features. We then compared the clinical indicators and US and SWE features between patients with and without sarcopenia to determine independent predictors. Diagnostic models were established based on these independent predictors.

RESULTS

The ASMI was correlated with Tbent (r = 0.57, p < 0.001) and CSAbent (r = 0.50, p < 0.001). Handgrip strength was correlated with Tbent (r = 0.53, p < 0.001) and CSAbent (r = 0.51, p < 0.001). Between patients with and without sarcopenia, the indicators of age, ΔCSA, and ΔSWE were statically different (all p ≤ 0.001). Based on these results, a diagnostic model for sarcopenia was established with 83.3% sensitivity, 83.3% specificity, and 83.3% accuracy.

CONCLUSIONS

In elderly people with type 2 diabetes, sarcopenia patients had smaller muscle CSA and less stiffness than non-sarcopenia patients. US and SWE might be useful to screen them.

KEY POINTS

• Sarcopenia is common in elderly people with type 2 diabetes. • Ultrasound and shear wave elastography might be useful methods for quantitatively assessing muscle mass and strength. • Ultrasound and shear wave elastography might be useful methods for screening sarcopenia in elderly patients with type 2 diabetes.

Comparison of the asymmetries in muscle mass, biomechanical property and muscle activation asymmetry of quadriceps femoris between patients with unilateral and bilateral knee osteoarthritis

Background: More and more attention has been paid to the research of muscle mass and muscle quality of quadriceps femoris (QF) in knee osteoarthritis (KOA). This study aimed to explore the asymmetric changes of muscle mass, biomechanical property and muscle activation in the inter-limbs QF of KOA patients, and tried to provide a novel insight for the evaluation, prevention and treatment of KOA. Methods: A total of 56 Participants with unilateral or bilateral KOA were included in this study: 30 patients with unilateral pain and 26 patients with bilateral pain were assigned to the bilateral group (BG) and unilateral group (UG), respectively. The symptom severity of bilateral lower limbs was evaluated by visual analogue scale, and the relatively serious leg (RSL) and relatively moderate leg (RML) were classified. The thickness of rectus femoris (RF), vastus intermedius (VI), vastus medialis (VM) and vastus lateralis (VL) were measured by ultrasound. The Shear wave elastography (SWE) techniqie was used to measure the shear modulus of RF, VM and VL. Surface electromyography (sEMG) was used to assess the root mean square (RMS) of the RF, VM, and VL during straight leg raising in a sitting position and squatting task. We calculated the asymmetry indexes of inter-limbs for the corresponding indices of the measured muscles. Result: Thickness of RF, VI and VL of RSL was lower than those on RML (p < 0.05), and thickness of VM was lower more significant (p < 0.01). Thickness of RF, VI and VL of RSL was also lower than those of RML in BG (p < 0.05), however, there was no significant difference in VM thickness (p > 0.05). There were no significant difference in Asymmetry indexes of all measured muscle thickness between the two groups (p > 0.05). The Shear modulus of RF, VM, and VL in the RML of UG and BG was higher than those in the RSL (p < 0.05). In sitting and straight leg raising task, the RMS of RF, VM and VL in RML were higher than those in RSL, UG and BG both showed this trend (p < 0.05). About squatting task, in UG, the RMS of the three muscles in RML of patients were also higher than those in the RSL (p < 0.05). However, the difference was not significant in BG (p > 0.05). In the straight leg raising task, the asymmetry indexes of RMS in RF, VM, and VL of both the two groups were positively correlated with VAS scores (p < 0.05). Conclusion: The muscle thickness, shear modulus and muscle activation electromyography of QF in RML were higher than those of RSL in unilateral KOA patients. The VM of RML in bilateral KOA patients may show muscle thickness degeneration earlier, which is closer to the VM of RSL. The shear modulus of RF, VM, and VL were higher on the RML side during the single-leg task, but there may be passive compensation for muscle activation in both lower limbs during the bipedal task. In conclusion, there is a general asymmetry of QF muscle mass, biomechanics Characteristic and performance in patients with KOA, which may provide new ideas for the assessment, treatment and rehabilitation of the disease.

Novel Tools to Assess Muscle Sarcopenic Process in ICU Patients: Are They Worthwhile?

Critical illness induces hypercatabolic response with severe loss of lean body mass, this being a key symptom in patients with prolonged ICU stay and is associated with acquired muscle weakness, long-term mechanical ventilation, fatigue, delayed recovery, and poor quality of life after ICU stay [...].

Nutritional State and COPD: Effects on Dyspnoea and Exercise Tolerance

Chronic Obstructive Pulmonary Disease (COPD) is a disease that is spreading worldwide and is responsible for a huge number of deaths annually. It is characterized by progressive and often irreversible airflow obstruction, with a heterogeneous clinical manifestation based on disease severity. Along with pulmonary impairment, COPD patients display different grades of malnutrition that can be linked to a worsening of respiratory function and to a negative prognosis. Nutritional impairment seems to be related to a reduced exercise tolerance and to dyspnoea becoming a major determinant in patient-perceived quality of life. Many strategies have been proposed to limit the effects of malnutrition on disease progression, but there are still limited data available to determine which of them is the best option to manage COPD patients. The purpose of this review is to highlight the main aspects of COPD-related malnutrition and to underline the importance of poor nutritional state on muscle energetics, exercise tolerance and dyspnoea.

Shear Wave Elastography for Detecting Calf Muscle Stiffness: An Effective Tool for Assessing Sarcopenia

OBJECTIVES

To explore the feasibility of shear wave elastography for evaluating sarcopenia.

METHODS

The shear wave velocities (SWV) of the tibialis anterior, medial gastrocnemius, and soleus were measured in 130 subjects in the Second Affiliated Hospital of Fujian Medical University from January 2021 to June 2022. Consistency was evaluated in 20 cases using the intraclass correlation coefficient. According to the 2019 Asian Working Group for Sarcopenia（AWGS） diagnostic criteria, the patients were divided into a healthy and a sarcopenia group. The differences in SWV between the two groups were compared, and their correlation between calf muscles and muscle mass, grip strength, and pace were analyzed. The diagnostic cutoff value of calf muscle SWV for sarcopenia was obtained using receiver operating characteristic (ROC) curves, and the diagnostic efficacy of different ROC curves was compared.

RESULTS

The SWV inter-group and intra-group correlation coefficients of the three lower limbs muscles were all greater than 0.85. Moreover, the corresponding SWV in the sarcopenia group were significantly smaller than those in the healthy control group (P < .05). Further, SWV were positively correlated with the appendicular skeletal muscle mass index (ASMI), grip strength, and gait speed. Finally, the SWV of the anterior tibialis and medial gastrocnemius muscles were 3.02 and 2.26 m/s, respectively, and their diagnostic efficacy for sarcopenia did not differ significantly (Z = 0.190, P = .8497).

CONCLUSION

SWE can be used to detect the hardness of the anterior tibialis and medial gastrocnemius, calculate their muscle mass as an effective tool to evaluate sarcopenia.

Diagnostic test accuracy of ultrasound for sarcopenia diagnosis: A systematic review and meta-analysis

Muscle ultrasound is an emerging tool for diagnosing sarcopenia. This review aims to summarize the current knowledge on the diagnostic test accuracy of ultrasound for the diagnosis of sarcopenia. We collected data from Ovid Medline, Embase and the Cochrane Central Register of Controlled Trials. Diagnostic test accuracy studies using muscle ultrasound to detect sarcopenia were included. Bivariate random-effects models based on sensitivity and specificity pairs were used to calculate the pooled estimates of sensitivity, specificity and the area under the curves (AUCs) of summary receiver operating characteristic (SROC), if possible. We screened 7332 publications and included 17 studies with 2143 participants (mean age range: 52.6-82.8 years). All included studies had a high risk of bias. The study populations, reference standards and ultrasound measurement methods varied across the studies. Lower extremity muscles were commonly studied, whereas muscle thickness (MT) was the most widely measured parameter, followed by the cross-sectional area (CSA). The MTs of the gastrocnemius, rectus femoris, tibialis anterior, soleus, rectus abdominis and geniohyoid muscles showed a moderate diagnostic accuracy for sarcopenia (SROC-AUC 0.83, 8 studies; SROC-AUC 0.78, 5 studies; AUC 0.82, 1 study; AUC 0.76-0.78, 2 studies; AUC 0.76, 1 study; and AUC 0.79, 1 study, respectively), whereas the MTs of vastus intermedius, quadriceps femoris and transversus abdominis muscles showed a low diagnostic accuracy (AUC 0.67-0.71, 3 studies; SROC-AUC 0.64, 4 studies; and AUC 0.68, 1 study, respectively). The CSA of rectus femoris, biceps brachii muscles and gastrocnemius fascicle length also showed a moderate diagnostic accuracy (AUC 0.70-0.90, 3 studies; 0.81, 1 study; and 0.78-0.80, 1 study, respectively), whereas the echo intensity (EI) of rectus femoris, vastus intermedius, quadriceps femoris and biceps brachii muscles showed a low diagnostic accuracy (AUC 0.52-0.67, 2 studies; 0.48-0.50, 1 study; 0.43-0.49, 1 study; and 0.69, 1 study, respectively). The combination of CSA and EI of biceps brachii or rectus femoris muscles was better than either CSA or EI alone for diagnosing sarcopenia. Muscle ultrasound shows a low-to-moderate diagnostic test accuracy for sarcopenia diagnosis depending on different ultrasound parameters, measured muscles, reference standards and study populations. The combination of muscle quality indicators (e.g., EI) and muscle quantity indicators (e.g., MT) might provide better diagnostic test accuracy.

Phase angle in assessment and monitoring treatment of individuals with respiratory disease

Phase angle (PhA) represents a raw variable measured with bioelectrical impedance analysis (BIA) that is used to assess malnutrition in many diseases, including respiratory diseases, mainly chronic obstructive pulmonary disease (COPD). COPD patients with reduced PhA are older, more hypoxic and hypercapnic; patients with more severe COPD have reduced cell mass, evident skeletal muscle depletion, and worsening gas exchange. Malnourished patients with stable COPD in long-term oxygen therapy (LTOT) have more intense dyspnea at rest, greater weight loss over the past 12 months, and more exacerbations per year. Multiple regression analysis highlighted the significance of PhA° in the estimation of muscle strength: hand grip strength (HGS) and in that of respiratory muscles: maximal inspiratory pressure / max. expiratory pressure ratio (MIP/MEP). Furthermore, the relationship between PhA° and all-cause mortality in COPD patients was confirmed with the Cox regression model, Kaplan-Meier test, and log-rank tests. The role of malnutrition in idiopathic pulmonary fibrosis (IPF) is confirmed by the PhA° measurements which, regardless of body weight, is associated with the reduction in muscle mass of these patients, reduces their strength and exercise capacity, and greatly influences the prognosis. In conclusion PhA is a novel biomarker of morbidity and mortality in patients with severe respiratory diseases.

Predictors of Sarcopenia in Outpatients with Post-Critical SARS-CoV2 Disease. Nutritional Ultrasound of Rectus Femoris Muscle, a Potential Tool

Background and Objectives: The loss of muscle mass in post-critical COVID-19 outpatients is difficult to assess due to the limitations of techniques and the high prevalence of obesity. Ultrasound is an emerging technique for evaluating body composition. The aim is to evaluate sarcopenia and its risk factors, determining ultrasound usefulness as a potential tool for this purpose according to established techniques, such as the bioimpedance vector analysis (BIVA), handgrip strength, and timed up-and-go test. Methods: This is a transversal study of 30 post-critical COVID-19 outpatients. We evaluated nutritional status by ultrasound (Rectus Femoris-cross-sectional-area (RF-CSA), thickness, and subcutaneous-adipose-tissue), BIVA, handgrip strength, timed up-and-go test, and clinical variables during admission. Results: According to The European Society for Clinical Nutrition and Metabolism and the European Association for the Study of Obesity (ESPEN&EASO) Consensus for Sarcopenic and Obesity, in terms of excess fat mass and decreased lean mass, the prevalence of class-1 sarcopenic obesity was 23.4% (n = 7), and class-2 sarcopenic obesity was 33.3% (n = 10) in our study. A total of 46.7% (n = 14) of patients had a handgrip strength below the 10th percentile, and 30% (n = 9) achieved a time greater than 10s in the timed up-and-go test. There were strong correlations between the different techniques that evaluated the morphological (BIVA, Ultrasound) and functional measurements of muscle. Intensive care unit stay, mechanical ventilation, and age all conditioned the presence of sarcopenia in COVID-19 outpatients (R2 = 0.488, p = 0.002). Predictive models for sarcopenic diagnosis based on a skeletal muscle index estimation were established by RF-CSA (R2 0.792, standard error of estimate (SEE) 1.10, p < 0.001), muscle-thickness (R2 0.774, SEE 1.14, p < 0.001), and handgrip strength (R2 0.856, SEE 0.92, p < 0.001). RF-CSA/weight of 5.3 cm2/kg × 100 was the cut-off value for predicting sarcopenia in post-critical COVID-19 outpatients, with 88.2 sensitivity and 69.2% specificity. Conclusion: More than half of the post-critical COVID-19 survivors had sarcopenic obesity and functional impairment of handgrip strength. Intensive care unit stay, age, and mechanical ventilation all predict sarcopenia. An ultrasound, when applied to the assessment of body composition in post-critical COVID-19 patients, provided the possibility of assessing sarcopenia in this population.

Updated Perspectives on the Role of Biomechanics in COPD: Considerations for the Clinician

Patients with chronic obstructive pulmonary disease (COPD) demonstrate extra-pulmonary functional decline such as an increased prevalence of falls. Biomechanics offers insight into functional decline by examining mechanics of abnormal movement patterns. This review discusses biomechanics of functional outcomes, muscle mechanics, and breathing mechanics in patients with COPD as well as future directions and clinical perspectives. Patients with COPD demonstrate changes in their postural sway during quiet standing compared to controls, and these deficits are exacerbated when sensory information (eg, eyes closed) is manipulated. If standing balance is disrupted with a perturbation, patients with COPD are slower to return to baseline and their muscle activity is differential from controls. When walking, patients with COPD appear to adopt a gait pattern that may increase stability (eg, shorter and wider steps, decreased gait speed) in addition to altered gait variability. Biomechanical muscle mechanics (ie, tension, extensibility, elasticity, and irritability) alterations with COPD are not well documented, with relatively few articles investigating these properties. On the other hand, dyssynchronous motion of the abdomen and rib cage while breathing is well documented in patients with COPD. Newer biomechanical technologies have allowed for estimation of regional, compartmental, lung volumes during activity such as exercise, as well as respiratory muscle activation during breathing. Future directions of biomechanical analyses in COPD are trending toward wearable sensors, big data, and cloud computing. Each of these offers unique opportunities as well as challenges. Advanced analytics of sensor data can offer insight into the health of a system by quantifying complexity or fluctuations in patterns of movement, as healthy systems demonstrate flexibility and are thus adaptable to changing conditions. Biomechanics may offer clinical utility in prediction of 30-day readmissions, identifying disease severity, and patient monitoring. Biomechanics is complementary to other assessments, capturing what patients do, as well as their capability.

SWEmean of Quadriceps, a Potential Index of Complication Evaluation to Patients with Chronic Obstructive Pulmonary Disease

Purpose

To develop a potential quadriceps' index of complication evaluation for patients with chronic obstructive pulmonary disease (COPD) which is simple, convenient, and quantifiable.

Patients and Methods

We conducted a prospective study of 59 patients with COPD and 56 healthy controls recruited by the Chengdu First People's Hospital. Grayscale ultrasound (US) of the rectus femoris was performed to measure thickness (RF_thick) and cross-sectional area (RF_csa). Shear wave elastography was used to determine the mean elasticity index (SWE_mean) of the rectus femoris (SWE_RFmean), vastus lateralis (SWE_VLmean) and vastus medialis (SWE_VMmean). Clinical features included dyspnea index score (modified British Medical Research Council (MMRC) score), COPD Assessment Test (CAT), the Five-Repetition Sit-to-Stand Test (5STS) and the Six-Minute Walk Test (6MWT). We compared the differences between US parameters and SWEmean in healthy controls and COPD patients. We also described the correlation between US parameters, SWE_mean and clinical features of patients with COPD.

Results

The intra-observer repeatability for the performance of using SWE to measure quadriceps stiffness was excellent (intraclass correlation coefficient (ICC)>0.75, p < 0.001). There was a statistically significant difference in the SWE_mean of the quadriceps (p < 0.001), but no significant difference in terms of RF_thic and RF_csa (p > 0.05) between healthy controls and COPD patients. The SWE_RFmean was positively correlated with the 6MWT (r = 0.959, p < 0.001), and negatively related to the mMRC (r=-0.825, p < 0.001), CAT (r=-0.993, p < 0.001) and 5STS (r=-0.936, p < 0.001). However, the RF_thic, RF_csa, SWE_VLmean and SWE_VMmean were not correlated with clinical features (p > 0.05).

Conclusion

As a supplement to US, SWE reflects changes of stiffness in the quadriceps of COPD patients, and can expanding the dimension of US for assessing the quadriceps. Furthermore, SWE_mean was associated with clinical features, and represents a potential index with which to reflect the clinical features of COPD patients.

Resistin as a Systemic Inflammation-Related Biomarker for Sarcopenia in Patients With Chronic Obstructive Pulmonary Disease

Background

Sarcopenia is common in patients with chronic obstructive pulmonary disease (COPD) and is mainly caused by systemic inflammation. Resistin acts as a proinflammatory cytokine and is involved in the activation of multiple inflammatory signaling pathways. The aim of this study was to determine the relationship between resistin levels and systemic inflammation and to assess the clinical value of circulating resistin for sarcopenia in patients with COPD.

Methods

In this prospective observational study, we enrolled 235 patients with COPD who were divided into development and validation sets. The definition of sarcopenia followed the guidelines from the Asian Working Group for Sarcopenia. Serum concentrations of resistin and TNF-α were measured using an enzyme-linked immunosorbent assay (ELISA).

Results

In this study, higher serum resistin levels were significantly associated with lower skeletal muscle mass and muscular strength. The serum resistin levels in patients with sarcopenia were significantly higher than those in patients without sarcopenia. The serum resistin level had positive correlations with the serum TNF-α level (r = 0.250, p = 0.007). The predictive efficacy of the serum resistin level (AUC: 0.828) for sarcopenia was superior to that of the serum TNF-α level (AUC: 0.621). The cutoff point (7.138 ng/ml) for the serum resistin level was validated in the validation set (AUC: 0.818).

Conclusions

Serum resistin levels were associated with systemic inflammation and can be used accurately and easily to predict sarcopenia in patients with COPD.

Growth Differentiation Factor-15 as a Biomarker for Sarcopenia in Patients With Chronic Obstructive Pulmonary Disease

Purpose

Sarcopenia is an important factor contributing to comorbidities in patients with chronic obstructive pulmonary disease (COPD) and is an independent risk factor for increased mortality. The diagnostic process for sarcopenia requires specific equipment and specialized training and is difficult procedurally. A previous study found that GDF15 levels are associated with skeletal muscle mass and function in patients with COPD. However, whether circulating GDF15 levels can be used for the prediction of sarcopenia in patients with COPD is unknown.

Methods

This study included 235 patients with stable COPD who were divided into a development set (n = 117) and a validation set (n = 118), and we followed the definition of sarcopenia as defined by the guidelines from the Asian Working Group for Sarcopenia. Serum concentrations of GDF15 were measured using an enzyme-linked immunosorbent assay (ELISA), and construction of a nomogram and decision curve analysis were performed using the R package “rms.”

Results

In this study, serum GDF15 levels were negatively associated with skeletal muscle mass (r = –0.204, p = 0.031), handgrip strength (r = –0.274, p = 0.004), quadriceps strength (r = –0.269, p = 0.029), and the thickness (r = –0.338, p < 0.001) and area (r = –0.335, p < 0.001) of the rectus femoris muscle in patients with COPD. Furthermore, the serum levels of GDF15 in patients with sarcopenia were significantly higher than those in controls. Importantly, serum levels of GDF15 could effectively predict sarcopenia in patients with COPD based on the development set (AUC = 0.827) and validation set (AUC = 0.801). Finally, a nomogram model based on serum GDF15 levels and clinical features showed good predictive ability (AUC > 0.89) in the development and validation sets.

Conclusion

Serum GDF15 levels could be used to accurately and easily evaluate sarcopenia in patients with COPD.