Usefulness of Muscle Ultrasonography in the Nutritional Assessment of Adult Patients with Cystic Fibrosis

Non-invasive evaluation of steatosis and fibrosis in the liver in adults patients living with cystic fibrosis

BACKGROUND & AIMS

Cystic fibrosis hepatobiliary involvement is a heterogeneous and systemic entity. The primary objective was to determine the prevalence of steatosis, by magnetic resonance-proton density fat fraction (MR-PDFF), and liver fibrosis, by magnetic resonance elastography (MRE), in a cohort of adults with cystic fibrosis. The secondary objective was to determine the diagnostic yield of widely available non-invasive liver markers for steatosis and fibrosis, and vibration controlled transitional elastography (VCTE) releasing Control Attenuation Parameter (CAP) (dB/m) and stiffness (kPa), with the aim of proposing a diagnostic algorithm.

METHODS

We conducted a cross-sectional study including 101 adult patients with cystic fibrosis seen in a multidisciplinary unit. The study encompassed a clinical evaluation, morpho-functional assessment, VCTE, non-invasive liver markers and MR-PDFF and MRE. Diagnostic accuracy was assessed using ROC curves and 2 × 2 tables.

RESULTS

MR-PDFF detected hepatic steatosis in 18 of 101 (17.8 %) patients, while MRE detected significant liver fibrosis in 15 of 101 (14.9 %). The VCTE cut-off with the best diagnostic yield, determined by the Youden index, was 222 dB/m for the presence of steatosis (AUC 0.864 (95 % CI 0.768-0.961; p < 0.001) and the VCTE cut-off was 6.65 kPa for liver fibrosis (AUC 0.951(95 % CI 0.81-1; p = 0.053). A screening algorithm for hepatic steatosis was developed using the fatty liver index (FLI) and CAP, with a negative predictive value of 83.3 %. For liver fibrosis, it was outperformed by the Hepamet Fibrosis Score (HFS) and VCTE, with a negative predictive value of 100 %.

CONCLUSIONS

The prevalence of hepatic steatosis and liver fibrosis was 17.8 % and 14.9 %, respectively. VCTE alone or in combination with FLI for steatosis or HFS for fibrosis demonstrated high diagnostic accuracy. This approach effectively allows for the exclusion of steatosis and fibrosis, thereby reducing the need for MR-PDFF and MRE studies.

Rectus femoris cross sectional area and timed up and go test potential useful of as a predictor of sarcopenia and mortality in idiopathic pulmonary fibrosis

Introduction

Idiopathic pulmonary fibrosis (IPF) is a progressive lung disease often complicated by sarcopenia, significantly impacting patient outcomes. This study investigates the prevalence and clinical implications of sarcopenia in IPF patients using morphofunctional assessment methods.

Materials and methods

Eighty-four IPF patients (predominantly male) were evaluated for sarcopenia using the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) criteria. Assessments included bioelectrical impedance vectorial analysis (Nutrilab, Akern), handgrip strength (HGS), Timed Up and Go test (TUG), and nutritional ultrasound (NU) measurements of rectus femoris and abdominal adipose tissue. Statistical analysis was performed (version 2.3.28 for macOS) to obtain sarcopenia cut-off points for the different techniques, and then the predictive capacity of these values for survival was analyzed using a Kaplan-Meier curve.

Results

Sarcopenia was prevalent in 20.2% of the cohort. Sarcopenic patients exhibited significantly lower forced vital capacity (FVC) (2,142 mL vs. 2745.6 mL, p < 0.05), higher GAP stages (p < 0.05), and worse quality of life (SGRQ impact scores: 45.2 vs. 27.5, p < 0.05). The identified cutoff values were 2.94 cm2 for RFCSA, 9.19 s for TUG, and 1.08 cm for the RF-Y-axis and body cell mass (BCM) cutoff of 25.4 kg. Kaplan-Meier analysis indicated a higher hazard ratio (HR) for mortality in sarcopenic patients. Specifically, RFCSA sarcopenia patients had a 2.37 times higher risk of events (HR = 2.37, 95% CI: 1.02-5.48, p = 0.045), and TUG sarcopenia presented a 4.89 times higher risk of adverse events (HR = 4.89, 95% CI: 1.43-16.70, p = 0.011).

Conclusion

Sarcopenia is prevalent in IPF patients and is associated with greater disease severity and reduced quality of life. RFCSA, BCM, and TUG are good predictors of sarcopenia and 12-month mortality, improving the prognostic value of classical diagnostics based on EWGSOP2 criteria. Despite limitations such as a predominantly male sample and cross-sectional design, the findings emphasize the importance of early detection and targeted interventions. Future research should focus on longitudinal studies to better understand sarcopenia progression in IPF and evaluate the efficacy of various therapeutic approaches.

Multiparametric Approach to the Colorectal Cancer Phenotypes Integrating Morphofunctional Assessment and Computer Tomography

(1) Background: Accurate body composition assessment in CCR patients is crucial due to the high prevalence of malnutrition, sarcopenia, and cachexia affecting survival. This study evaluates the correlation between body composition assessed by CT imaging as a reference technique, BIVA, nutritional ultrasound, and handgrip strength in CCR patients. (2) Methods: This retrospective study included CCR patients assessed by the Endocrinology and Nutrition Services of Virgen de la Victoria in Malaga and Vall d'Hebron in Barcelona from October 2018 to July 2023. Assessments included anthropometry, BIVA, NU, HGS, and AI-assisted CT analysis at the L3 level for body composition. Pearson's analysis determined the correlation of CT-derived variables with BIVA, NU, and HGS. (3) Results: A total of 267 CCR patients (mean age 68.2 ± 10.9 years, 61.8% men) were studied. Significant gender differences were found in body composition and strength. CT-SMI showed strong correlations with body cell mass (r = 0.65), rectus femoris cross-sectional area (r = 0.56), and handgrip strength (r = 0.55), with a Cronbach's alpha of 0.789. CT-based adipose tissue measurements showed significant correlations with fat mass (r = 0.56), BMI (r = 0.78), A-SAT (r = 0.49), and L-SAT (r = 0.66). Regression analysis indicated a high predictive power for CT-SMI, explaining approximately 80% of its variance (R2 = 0.796). (4) Conclusions: Comprehensive screening of colorectal cancer patients through BIVA, NU, HGS, and CT optimizes the results of the evaluation. These methods complement each other in assessing muscle mass, fat distribution, and nutritional status in CCR. When CT is unavailable or bedside assessment is needed, HGS, BIVA, and NU provide an accurate assessment of body composition.

Impact of early high protein intake in critically ill patients: a randomized controlled trial

BACKGROUND

Conflicting findings regarding the impact of High protein intake during the early phase in critically ill patients have been reported. Therefore, we aimed to assess the influence of higher early protein intake on the prognosis of critically ill patients.

METHODS

This randomized controlled trial involved 173 critically ill patients who stayed in the Intensive Care Unit/Emergency ICU (ICU/EICU) for at least 7 days. The Low group (n = 87) and High group (n = 86) received protein supplementation of 0.8 g/kg.d and 1.5 g/kg.d, respectively, within 1-3 days of enteral nutrition (EN) initiation, with both groups transitioning to 1.5 g/kg.d on the 4th day. The serum prealbumin (PA), blood urea nitrogen/creatinine, and rectus femoris muscle thickness and cross-sectional area of all patients was measured on the 1th, 3rd, 5th, 7th day, and the day of ICU/EICU discharge.

RESULTS

Patients in both Low and High groups showed no significant differences in age, APACHE II scores, or other demographic and baseline characteristics. There were also no significant differences in the primary outcome (28-day mortality rate) and secondary outcomes (incidence rate of refeeding syndrome and EN tolerance score) between the two groups. However, the Low group exhibited a significantly higher 28-day mortality rate (HR = 2.462, 95% CI: 1.021-5.936, P = 0.045) compared to High group, as determined by Cox proportional hazards models incorporating the time factor. The High group exhibited significantly shorter durations of mechanical ventilation and ICU stay compared to the Low group. Serum PA levels were higher, and rectus femoris muscle atrophy rates were lower in the High group. Furthermore, for septic patients, high protein intake significantly reduced the 28-day mortality rate despite a small sample size (n = 34).

CONCLUSIONS

Our study indicates that increasing early protein intake to 1.5 g/kg.d may be safe and help improve the nutritional status and prognosis of critically ill patients.

TRIAL REGISTRATION

This study was registered with the Chinese Clinical Trial Registry (ChiCTR2000039997, https://www.chictr.org.cn/ ).

Protocol for a prospective cohort study on the feasibility of application of nutritional ultrasound in the diagnosis and follow-up of patients with nutritional risk at hospital discharge: study on body composition and function (DRECO)

INTRODUCTION

Nutritional ultrasound (US) is an emerging technique in clinical nutrition for the morphological and structural study of muscle mass. Currently, all definitions of malnutrition include the measurement of muscle mass; however, there is no single way to assess it. It is necessary to develop new techniques to identify muscle involvement in malnutrition that are valid, standardised, reliable, accurate and profitable.

OBJECTIVE

To value the new muscle US techniques aimed to measure muscle and functional status, to make a more accurate diagnosis and a better prediction of complications and morbidity and mortality in patients at nutritional risk.

PRIMARY OUTCOME

to assess the feasibility of US or muscle US techniques in both nutritional diagnosis and follow-up in a nutritional intervention programme.

METHODS AND ANALYSIS

Disease-Related caloric-protein malnutrition EChOgraphy (DRECO) is a prospective, multicentre (25 Spanish hospitals), uncontrolled clinical study in standard clinical practice to value the usefulness of nutritional US (muscle US) in the nutritional diagnosis and follow-up, over 3-6 months, after standard nutritional clinical practice intervention and physical activity, to control their disease-related malnutrition. 1000 patients are expected to be included in.

DISCUSSION

This study will standardise nutritional US measures. It will validate and define specific cut-off values for nutritional US and correlate it with already well-known nutritional tools such as Subjective Global Assessment or Global Leadership Initiative on Malnutrition criteria. Thus, muscle US will become not only a tool to diagnose malnutrition, but it will also be integrated in the daily practice to evaluate nutritional interventions.

ETHICS AND DISSEMINATION

All DRECO study materials have been approved by each of the IRB/IEC of all the sites enrolled (either approval of the own IRB/IEC or validating the approval of the IRB/IEC of another hospital). The study has been registered with ClinicalTrials.gov, on 27 June 2022. The results from this study will be presented at scientific conferences and in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT05433831.

Rectus Femoris Cross-Sectional Area and Phase Angle asPredictors of 12-Month Mortality in Idiopathic Pulmonary Fibrosis Patients

BACKGROUND

The value of the phase angle (PhA), measured via bioelectrical impedance analysis (BIA), could be considered a good marker of the cell mass and the cell damage of a patient; however, there are new techniques, such as muscle ultrasonography, that allow the quantity and quality of muscle to be assessed in a minimally invasive way. The aim of this study is to determine the prognostic value of morphofunctional techniques in the prognosis of mortality in patients with idiopathic pulmonary fibrosis (IPF).

METHODS

This multicenter, cross-sectional study included 86 patients with idiopathic pulmonary fibrosis with a mean age of 71 years, 82.7% of whom were male. The nutritional risk of the patients was assessed by means of questionnaires, such as the Subjective Global Assessment (SGA), and non-invasive functional techniques, including BIA, nutritional ultrasound, and hand grip strength (HGS). Statistical analysis of the sample was performed using JAMOVI version 2.3.22.

RESULTS

Correlations were made between the RF-CSA techniques with PhA (r = 0.48, p < 0.001), BCM (r = 0.70, p < 0.001), SMI (r = 0.64, p < 0.001), and HGS (r = 0.54, p < 0.001). The cut-off points for 12-month mortality were PhA = 4.5° (AUC = 0.722, sensitivity of 72.7% and specificity of 66.6%), BCM = 28.8 kg (AUC = 0.609, sensitivity of 32.4% and specificity of 100.0%), RF-CSA = 3.00 cm2 (AUC = 0.857, sensitivity of 64.4% and specificity of 100.0%), 6MMW = 420 m (AUC = 0.830, sensitivity of 63.27% and specificity of 100.0%), and TUG = 7.2 s (AUC = 0.771, sensitivity of 100.0% and specificity of 56.67%). In addition, a multivariate analysis was performed with RF-CSA, HR = 8.11 (1.39-47.16, p = 0.020), and PhA of 6.35 (1.29-31.15, p = 0.023), taking into account age, sex, and BMI to determine mortality. Finally, a Kaplan-Meier survival analysis was conducted with low or normal values for classical parameters (GAP and T6MM) and new parameters (PhA, BCM, RF-CSA, and TUG).

CONCLUSION

RF-CSA and PhA were shown to be good prognostic markers of 12-month mortality and could, therefore, be useful screening tools to complement the nutritional assessment of IPF patients.

Guidance and standard operating procedures for functional exercise testing in cystic fibrosis

Regular exercise testing is recommended for all people with cystic fibrosis (PwCF). A range of validated tests, which integrate both strength and aerobic function, are available and increasingly being used. Together, these tests offer the ability for comprehensive exercise evaluation. Extensive research and expert consensus over recent years has enabled the adaptation and standardisation of a range of exercise tests to aid the understanding of the pathophysiology related to exercise limitation in PwCF and has led to the development of novel exercise tests which may be applied to PwCF. This article provides expert, opinion-based clinical practice guidance, along with test instructions, for a selection of commonly used valid tests which have documented clinimetric properties for PwCF. Importantly, this document also highlights previously used tests that are no longer suggested for PwCF and areas where research is mandated. This collaboration, on behalf of the European Cystic Fibrosis Society Exercise Working Group, represents expert consensus by a multidisciplinary panel of physiotherapists, exercise scientists and clinicians and aims to improve global standardisation of functional exercise testing of PwCF. In short, the standardised use of a small selection of tests performed to a high standard is advocated.

Nutritional Ultrasonography, a Method to Evaluate Muscle Mass and Quality in Morphofunctional Assessment of Disease Related Malnutrition

Nutritional ultrasonography is an emerging technique for measuring muscle mass and quality. The study aimed to evaluate the relationship between the parameters of body mass and quality of ultrasonography with other parameters of morphofunctional assessment in patients with disease-related malnutrition (DRM).

METHODS

A cross-sectional study was developed on 144 patients diagnosed with DRM according to the Global Leadership Initiative on Malnutrition (GLIM) criteria. Morphofunctional evaluation was assessed with anthropometric variables, handgrip strength and bioelectrical impedanciometry (BIA). Nutritional ultrasonography of quadriceps rectus femoris (QRF) was made (muscle mass (Muscle Area of Rectus Femoris index (MARFI)), Y axis and muscle quality (X-Y index and echogenicity).

RESULTS

The mean age of patients was 61.4 (17.34) years. The prevalence of sarcopenia in the sample was 33.3%. Patients with sarcopenia (S) had lower values of MARFI [(S: 1.09 (0.39) cm2/m2; NoS: 1.27 (0.45); p = 0.02), Y axis (S: 0.88 (0.27); NoS: 1.19 (0.60); p < 0.01) and X-Y index (S: 1.52 (0.61); NoS: 1.30 (0.53); p < 0.01)]. There was a correlation between BIA parameters (phase angle) and muscle mass ultrasonographic variables (MARFI) (r = 0.35; p < 0.01); there was an inverse correlation between muscle quality ultrasonographic variables (echogenicity) and handgrip strength (r = -0.36; p < 0.01). In the multivariate analysis adjusted by age, the highest quartile of the X-Y index had more risk of death OR: 4.54 CI95% (1.11-18.47).

CONCLUSIONS

In patients with DRM and sarcopenia, standardized muscle mass and muscle quality parameters determined by ultrasonography of QRF are worse than in patients without sarcopenia. Muscle quality parameters had an inverse correlation with electric parameters from BIA and muscle strength. The highest quartile of the X-Y index determined by ultrasonography was associated with increased mortality risk.

Differences in nutritional risk assessment between NRS2002, RFH-NPT and LDUST in cirrhotic patients

Nutritional status is an independent predictor of outcome in cirrhosis patients. Nutritional Risk Screening 2002 (NRS2002), Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT), and Liver Disease Undernutrition Screening Tool (LDUST) were employed to detect cirrhosis with malnutrition risk in this work. Meanwhile, their diagnostic performances were compared to find the best screening method. This work aimed to establish the sarcopenia cut-off value of the transversal psoas thickness index (TPTI), and identify the risk factors for malnutrition. Cirrhosis patients who were admitted to Heibei Gerneral hospital from April 2021 to October 2021 and underwent abdominal CT examination were enrolled. 78 patients were assessed by NRS2002, RFH-NPT, and LDUST. The Global Leadership Initiative for Malnutrition (GLIM) criteria were selected as the gold standard for the diagnosis of malnutrition. Meanwhile the cut-off value of sarcopenia was established based on the TPTI of malnourished patients. Logistic regression analysis was adopted to assess the influencing factors of malnutrition risk and malnutrition. The prevalence of malnutrition was 42.31%. The prevalence of malnutrition risk was 32.1%, 61.5%, and 62.8% with NRS2002, RFH-NPT, and LDUST, respectively. NRS2002 presented the best specificity compared with the other methods, while RFH-NPT showed the highest sensitivity. The optimal gender-specific TPTI cut-off value for diagnosing sarcopenia was determined as TPTI < 14.56 mm/m (male) and TPTI < 8.34 mm/m (female). In the multivariate analysis, ascites was associated with malnutrition risk, while sarcopenia showed a significant risk for malnutrition. NRS2002 and RFH-NPT were superior to LDUST at detecting the malnutrition in cirrhosis patients diagnosed according to GLIM criteria. The gender-specific TPTI cut-off value was TPTI < 14.56 mm/m (male) and TPTI < 8.34 mm/m (female). Malnutrition risk should be screened for patients with ascites as soon as possible. In addition, it was important to evaluate malnutrition in sarcopenia patients in time.