Prognostic value of bioelectrical impedance analysis in head and neck cancer patients undergoing radiotherapy: a VALOR® study.

Introduction: Bioelectrical impedance analysis (BIA) serves as a method to estimate body composition. Parameters such as phase angle (PA), standardized phase angle (SPA), body mass cell (BCM), BCM index (BCMI), and fat-free mass (FFM) might significantly impact the prognosis of head and neck cancer (HNC) patients. The present study aimed to investigate whether bioelectrical parameters can be used to predict survival in the HNC population and establish the optimal cutoff points for predictive accuracy. Methods: A multicenter observational study was performed across 12 tertiary hospitals in Andalusia (a region from the south of Spain). A total of 494 patients diagnosed with HNC between 2020 and 2022 at different stages were included in this study, with a minimum follow-up period of 12 months. The BIA assessment was carried out during the first 2 weeks of radical radiotherapy treatment with chemotherapy or other systemic treatments. A multivariate logistic regression analysis of overall survival, complications, hospital admission, and palliative care and its relationship with BIA nutritional assessment was performed. Results: Significant prognostic factors identified in the multivariable analysis encompassed phase angle (PA), standardized phase angle (SPA), body cell mass (BCM), and BCM index (BCMI). Lower PA and BCM values were significantly associated with adverse clinical outcomes. A BCM threshold above 17 kg/m2 was the most significant predictor for predicting survival within the overall HNC population. The PA values of <5.1° in male and <4.8° in female patients showed the best predictive potential for mortality. Increased PA (as a continuous variable) demonstrated a significantly reduced risk for mortality (OR, 0.64; 95% CI, 0.43-0.94; p < 0.05) and a decreased likelihood of hospital admission (OR, 0.75; 95% CI, 0.52-1.07; p < 0.05). Higher BCM correlated with a lower risk of mortality (OR, 0.88; 95% CI, 0.80-0.96; p < 0.01) and a diminished probability of hospital admission (OR, 0.91; 95% CI, 0.83-0.99; p < 0.05). Conclusion: BIA is a crucial tool in the nutritional assessment of HNC patients. BCM and PA are the main bioelectrical parameters used to predict clinical outcomes in this population. Future studies are needed to validate BIA variables in a large cohort to ensure whether early intensification of nutritional treatment would improve survival.

Ultrasound Muscle Evaluation for Predicting the Prognosis of Patients with Head and Neck Cancer: A Large-Scale and Multicenter Prospective Study.

Head and neck cancer (HNC) is a prevalent and aggressive form of cancer with high mortality rates and significant implications for nutritional status. Accurate assessment of malnutrition in patients with HNC is crucial for optimizing treatment outcomes and improving survival rates. This study aimed to evaluate the use of ultrasound techniques for predicting nutritional status, malnutrition, and cancer outcomes in patients with HNC. A total of 494 patients with HNC were included in this cross-sectional observational study. Various tools and body composition measurements, including muscle mass and adipose tissue ultrasound evaluations, were implemented. Using regression models, we mainly found that high levels of RF-CSA (rectus femoris cross-sectional area) were associated with a decreased risk of malnutrition (as defined with GLIM criteria (OR = 0.81, 95% CI: 0.68-0.98); as defined with PG-SGA (OR = 0.78, 95% CI: 0.62-0.98)) and sarcopenia (OR = 0.64, 95% CI: 0.49-0.82) after being adjusted for age, sex, and BMI. To predict the importance of muscle mass ultrasound variables on the risk of mortality, a nomogram, a random forest, and decision tree models were conducted. RF-CSA was the most important variable under the random forest model. The obtained C-index for the nomogram was 0.704, and the Brier score was 16.8. With an RF-CSA < 2.7 (AUC of 0.653 (0.59-0.77)) as a split, the decision tree model classified up to 68% of patients as possessing a high probability of survival. According to the cut-off value of 2.7 cm2, patients with a low RF-CSA value lower than 2.7 cm2 had worse survival rates (p < 0.001). The findings of this study highlight the importance of implementing ultrasound tools, for accurate diagnoses and monitoring of malnutrition in patients with HNC. Adipose tissue ultrasound measurements were only weakly associated with malnutrition and not with sarcopenia, indicating that muscle mass is a more important indicator of overall health and nutritional status. These results have the potential to improve survival rates and quality of life by enabling early intervention and personalized nutritional management.

Phase angle and rectus femoris cross-sectional area as predictors of severe malnutrition and their relationship with complications in outpatients with post-critical SARS-CoV2 disease.

Background and aims: The diagnosis of malnutrition in post-critical COVID-19 patients is challenging as a result of the high prevalence of obesity, as well as the variability and previously reported inconsistencies across currently available assessment methods. Bioelectrical impedance vector analysis (BIVA) with phase angle (PhA) and nutritional ultrasound (NU®) are emerging techniques that have been proven successful in assessing body composition with high precision in previous studies. Our study aims to determine the performance and usefulness of PhA and rectus femoris cross-sectional area (RF-CSA) measurements in assessing body composition as part of the full routine morphofunctional assessment used in the clinical setting, as well as their capacity to predict severe malnutrition and to assess complications and aggressive therapy requirements during recent intensive care unit (ICU) admission, in a cohort of post-critically ill COVID-19 outpatients. Methods: This prospective observational study included 75 post-critical outpatients who recovered from severe COVID-19 pneumonia after requiring ICU admission. Correlations between all the morphofunctional parameters, complications, and aggressive therapy requirements during admission were analyzed. Multivariate logistic regression analysis and ROC curves were provided to determine the performance of NU® and PhA to predict severe malnutrition. Differences in complications and aggressive therapy requirements using the cutoff points obtained were analyzed. Results: In total, 54.7% of patients were classified by Subjective Global Assessment (SGA) as SGA-B and 45.3% as SGA-C, while 78.7% met the Global Leadership Initiative of Malnutrition (GLIM) criteria. PhA correlates positively with body cell mass/height (BCM/h) (r = 0.74), skeletal muscle index (SMI) (r = 0.29), RF-CSA (r = 0.22), RF-Y axis (r = 0.42), and handgrip strength (HGS) assessed using dynamometry (r = 0.42) and the Barthel scale (r = 0.29) and negatively with ICU stay (r = -0.48), total hospital stay (r = -0.57), need for invasive mechanical ventilation (IMV) (r = -0.39), days of IMV (r = -0.41), need for tracheostomy (r = -0.51), and number of prone maneuvers (r = -0.20). RF-CSA correlates positively with BCM/h (r = 0.41), SMI (r = 0.58), RF-Y axis (r = 0.69), and HGS assessed using dynamometry (r = 0.50) and the Barthel scale (r = 0.15) and negatively with total hospital stay (r = -0.22) and need for IMV (r = -0.28). Cutoff points of PhA < 5.4° and standardized phase angle (SPhA) < -0.79 showed good capacity to predict severe malnutrition according to SGA and revealed differences in ICU stay, total hospital stay, number of prone maneuvers, need for IMV, and need for rehabilitation, with statistical significance (p < 0.05). An RF-CSA/h < 2.52 cm2/m (for men) and <2.21 cm2/m (for women) also showed good performance in predicting severe malnutrition and revealed differences with statistical significance (p < 0.05) in ICU stay and total hospital stay. Conclusion: More than 75% of the post-critical COVID-19 survivors had malnutrition, and approximately half were obese. PhA, SPhA, RF-CSA, and RF-CSA/h, when applied to the assessment of body composition in post-critical COVID-19 patients, showed moderate-to-high correlation with other morphofunctional parameters and good performance to predict severe malnutrition and to assess complications and aggressive therapy requirements during ICU admission. Besides being readily available methods, BIVA and NU® can help improve the morphofunctional assessment of malnutrition in post-critical COVID-19 survivors; however, more studies are needed to assess the performance of these methods in other populations.

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.

Phase angle as a marker of outcome in hospitalized pediatric patients. A systematic review of the evidence (GRADE) with meta-analysis.

Phase angle (PhA) is a valuable tool for evaluating the nutritional and inflammatory status, which can accompany acute and severe disorders. PhA is a cellular health biomarker, whose value is particularly substantial due to the negative consequences of these situations in the pediatric population. Relevant literature was collected with the aim of comprehensively analysing the evidence on the association between an altered PhA can serve as a predictive-marker for mortality and poor-outcomes in at-risk-pediatric patients. Understanding this relationship could have significant implications for identifying high-risk individuals and implementing timely interventions. A systematic review with meta-analysis was conducted in the primary electronic databases from inception until January 2023. Overall, four studies with a total of 740 patients were eligible for our analysis. Evidence demonstrates that PhA is associated with nutritional status, reflecting undernutrition and changes in body composition related to illness. This review suggests that PhA can indeed be used as an indicator of nutritional status and a tool for predicting prognosis, including mortality and poor-outcomes, in hospitalized pediatric patients. A low PhA was associated with a significant mortality risk [RR:1.51;95%CI (1.22-1.88),p = 0.0002;I2 = 0%,(p = 0.99)] and an increased complications risk [OR:8.17;95%CI (2.44-27.4),p = 0.0007;I2 = 44%,(p = 0.18)]. These findings highlight the importance of taking a comprehensive approach to clinical nutrition, integrating multiple evaluation aspects to establish an accurate diagnosis and personalized therapeutic plans. While PhA emerges as a valuable tool for assessing the risk of malnutrition and as a prognostic-indicator for poor-outcomes in pediatric patients. Further future studies are needed to focus on investigating this relationship in larger and diverse population to strengthen the evidence base.

Phase angle and COVID-19: A systematic review with meta-analysis.

Phase angle (PhA) has been identified as a poor prognostic factor in patients with COVID-19. This study aimed to achieve a systematic review, where we discussed the potential role of PhA value as a prognostic marker of adverse clinical outcomes such as mortality and complication in hospitalized with SARS-CoV2 infection and established the strength of recommendations for use. A systematic literature review with meta-analysis was done in the main electronic databases from 2020 to January 2023. The selected articles had to investigate adverse consequences of the COVID-19 population and raw bioimpedance parameters such as PhA and published in peer-reviewed journals. GRADE tools regarded the quality of the methodology. The review protocol was registered in PROSPERO. Only eight studies, 483 studies, were eligible for the analysis. In general, differences in PhA were seen between the comparative study groups. Patients with a low PhA experienced poor outcomes. A low PhA was associated with a significantly increased mortality risk [RR: 2.44; 95% CI (1.20-4.99), p = 0.01; I2 = 79% (p = 0.0008)] and higher complications risk [OR: 3.47, 95% CI (1.16 - 10.37), p = 0.03; I2 = 82% (p = 0.004)] in COVID-19 patients. Our analysis showed four evidence-based recommendations on the prognostic value of PhA with two strong recommendations, one of moderate and another of low-moderate quality, for predicting mortality and complications, respectively. We recommend using PhA as a prognostic marker for mortality and complications in this population. Although the results are promising, future studies must identify the PhA cut-off to guide therapeutic decisions more precisely.Registration code in PROSPERO: CRD42023391044.

Exploratory Assessment of Nutritional Evaluation Tools as Predictors of Complications and Sarcopenia in Patients with Colorectal Cancer.

BACKGROUND: Patients with colorectal cancer (CRC) are largely malnourished, which decreases overall survival and treatment efficacy and increases mortality rates. We hypothesize that angle phase might be associated with the risk of sarcopenia as well as cancer complications in patients with CRC. The inclusion of various nutritional status indicators and clinical cancer outcomes can result in significant variability. Therefore, the objective of this study was to perform an exploratory analysis of nutritional evaluation tools used to assess body composition and muscle quality in patients with CRC, in order to predict cancer complications and survival rate. METHODS: A total of 127 patients with CRC were included in this study. Bioelectrical impedance analysis and body composition were performed, which we used to obtain phase angle (PhA) values. Muscle function was assessed by hand-grip strength (HGS) and muscle quality and adipose tissue depot were performed using ultrasound techniques. RESULTS: This study showed that there were significant differences in body composition between females and males, as well as in muscle quantity and quality. PhA was highly correlated with quadriceps rectus femoris of cross-sectional area (RF-CSA), circumference of quadriceps rectus femoris (RF-CIR), superficial subcutaneous abdominal fat (S-SAT), as well as HGS (p < 0.05). PhA was also correlated with water content in females, and with muscle mass and quality in males (p < 0.05). Specifically, we found that PhA was a good predictor for cancer complications in women and the risk of sarcopenia in men. In the linear model controlled for age and body mass index (BMI), high PhA value was associated with a decreased risk of complications in females (Odds Ratio (OR) = 0.15, 95% CI: 0.03-0.81, p < 0.05). High PhA value was associated with a decreased risk of sarcopenia in males (OR = 0.42, 95% CI: 0.19-0.95, p < 0.05). In addition, Receiving Operating Characteristics (ROC) curve analysis showed that PhA had a good diagnostic accuracy for detecting cancer complications in females (Area under curve (AUC) = 0.894, 95% CI: 0.88-0.89, p < 0.05) and the risk of sarcopenia in males (AUC = 0.959, 95% CI: 0.91-0.92, p < 0.05). CONCLUSIONS: PhA can accurately predict oncological complications in women and sarcopenia in men. These differences are relevant to understanding the nutritional status of patients with CRC and their personalized nutritional treatment.

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.

Phase Angle and Handgrip Strength as a Predictor of Disease-Related Malnutrition in Admitted Patients: 12-Month Mortality.

Background: Phase Angle (PhA) value measured by bioelectrical impedance analysis (BIA) could be considered a good marker of the patient's cell mass and cellular damage. Various studies have shown that the value of PhA is associated with an increased nutritional risk in several pathologies. However, not many studies have focused on the use of PhA as a screening tool in admitted patients. The aim of this study is to evaluate the prognostic value of PhA to determine disease-related malnutrition (DRM) and the risk that this entails for mortality and length of stay (LOS). Methods: 570 patients admitted to the hospital for different causes were included in this retrospective observational study. Patients' nutritional risk was assessed by screening tests such as the Malnutrition Universal Screening tool (MUST) and Subjective Global Assessment (SGA), in addition to non-invasive functional techniques, such as BIA and handgrip strength (HGS), 24−48 h after admission. After performing an SGA as the gold standard to assess malnutrition, PhA and SPhA values were used to determine DRM. Furthermore, both samples: malnutrition status (MS) and non-malnutrition status (NMS) were compared, with SphA-Malnutrition corresponding to a diagnosis of malnutrition. Statistical analysis of the sample was conducted with JAMOVI version 2.2.2. Results: Patients with MS had lower PhA and SPhA than patients with NMS (p < 0.001). The ROC curve analysis (AUC = 0.81) showed a cut-off point for MS for PhA = 5.4° (sensitivity 77.51% and specificity 74.07%) and AUC = 0.776 with a cut-off point for SPhA = −0.3 (sensitivity 81.74% and specificity 63.53%). Handgrip strength (HGS) was also observed to be a good predictor in hospitalized patients. Carrying out a comparative analysis between MS and NMS, length of stay (LOS) was 9.0 days in MS vs. 5.0 days in NMS patients (OR 1.07 (1.04−1.09, p < 0.001)). A low SPhA-malnutrition value (SPhA < −0.3) was significantly associated with a higher mortality hazards ratio (HR 7.87, 95% CI 2.56−24.24, p < 0.001). Conclusion: PhA, SPhA and HGS are shown to be good prognostic markers of DRM, LOS and mortality and could therefore be useful screening tools to complement the nutritional assessment of admitted patients.