Body composition assessment for sarcopenic obesity and 3-year mortality in older adults: A comparison study.

BACKGROUND: There is no universally accepted definition of sarcopenic obesity (SO), and its prevalence is ambiguous. This study aimed to investigate the prevalence of SO in older adults based on different definitions and determine which predicts all-cause mortality. METHODS: This prospective longitudinal follow-up study included outpatients aged ≥60 years. SO was defined by sarcopenia definition based on the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) criteria plus obesity. Three different methods were used to define obesity. Body mass index (BMI) ≥ 30 kg/m2, waist circumference (WC) ≥ 102 cm for men and ≥88.0 cm for women, and body fat percentage (BF%) ≥ 37.3% for men and ≥51.1% for women. Different definitions of SO and their mortality predictions were compared. RESULTS: The median age of the 584 patients in the study was 70.0 (interquartile range, 66.0-76.0) years. The prevalence of sarcopenia was 38.5% (47.5% in men and 35.7% in women). The prevalence of SO based on BMI, WC, and BF% was 15.3%, 16.4%, and 10.5%, respectively. The mortality rate was 6.7%. SO based on BMI (odds ratio [OR], 2.73; 95% CI, 1.12-17.9; P = 0.024) and BF% (OR, 1.43; 95% CI, 1.19-3.02; P = 0.007) were significantly associated with 3-year mortality after adjusting for the confounding variables of age, sex, and number of comorbidities. SO based on WC was not associated with mortality (OR, 0.78; 95% CI, 0.07-1.27; P = 0.104). CONCLUSION: The use of BF% and BMI for defining SO is appropriate in outpatient older adults.

Prognostic significance of the skeletal muscle index and systemic inflammatory index in patients with lymph node-positive breast cancer after radical mastectomy.

BACKGROUND: The role of skeletal muscle index (SMI) and systemic inflammation index (SII) for patients with lymph node-positive breast cancer remain controversial. This retrospective study aims to evaluate the individual and synergistic value of SMI and SII in outcomes prediction in this population. METHODS: Lymph node-positive breast cancer patients who received mastectomy between January 2011 and February 2013 were included in this retrospective study. We used abdominal computed tomography (CT) to measure skeletal muscle mass at the third lumbar (L3) level. The optimal cut-off values of SMI and SII were determined through maximizing the Youden index on the receiver operating characteristic (ROC) curves. Kaplan-Meier method was used to assess the correlation between SMI, SII, and overall survival (OS). The prognostic value of SMI and SII were analyzed with the multivariable Cox proportional hazards model. RESULTS: Of 97 patients included in our study (mean age: 46 [range: 27-73] years; median follow-up: 62.5 months), 71 had low SMI (sarcopenia), 59 had low SII, and 56 had low SMI + SII. Kaplan-Meier survival curves showed that both high SMI (P = 0.021, 5-year OS: 84.0% vs. 94.1%) and high SII (P = 0.043, 5-year OS: 81.0% vs. 97.3%) were associated with worse OS. Additionally, patients with either low SMI or low SII had significantly better OS (P = 0.0059, 5-year OS: 100.0% vs. 84.6%) than those with high SMI + SII. Multivariable analysis confirmed the predictive values of high SMI (P = 0.024, hazard ratio [HR]: 9.87) and high SII (P = 0.048, HR: 6.87) for poor OS. Moreover, high SMI + SII was significantly associated with poor survival (P = 0.016, HR: 16.36). CONCLUSIONS: In this retrospective analysis, both SMI and SII independently predicted the prognosis of patients with lymph node-positive breast cancer. SMI + SII might be a stronger prognostic factor than either alone based on our findings, but should be further verified in a larger study.

Body composition assessment and sarcopenia in patients with biliary tract cancer: A systematic review and meta-analysis.

BACKGROUND: Sarcopenia, as assessed by body composition, can affect morbidity and survival in several gastrointestinal cancer. However, the impact of sarcopenia, referring to both quantity and quality of skeletal muscle, in biliary tract cancer (BTC) is debatable. We aimed to investigate the impact of sarcopenia on morbidity and mortality in patients with BTC. METHODS: Electronic databases and trial registries were searched through July 2021 to perform random-effects meta-analyses. Study selection, data abstraction and quality assessment were independently performed using the Grading of Recommendations, Assessment, Development, and Evaluation approach. RESULTS: Twenty-nine studies (4443 patients) were included; 28 used computed tomography and one used dual-energy X-ray absorptiometry to assess body composition. Eighteen studies reported the impact of pre-operative sarcopenia on postoperative outcomes; namely, sarcopenia increased postoperative complications (risk ratio = 1.23, 95% confidence interval [CI] = 1.07 to 1.41; I2 = 2%), and decreased recurrence-free survival (hazard ratio [HR] = 2.20, 95% CI = 1.75 to 2.75; I2 = 0%) in multivariable analyses. Low muscle quantity (HR = 2.26, 95% CI = 1.75 to 2.92; I2 = 66%) and quality (HR = 1.75, 95% CI = 1.33 to 2.29; I2 = 50%) decreased overall survival in multivariable analyses. The certainty of the evidence was low because of heterogeneity and imprecision. CONCLUSIONS: In sarcopenia, low muscle quantity and quality by body composition conferred an independent risk of morbidity and mortality in patients with BTC. Further studies are needed to confirm these findings and mitigate risk.

Assessment of Sarcopenia in the Intensive Care Unit and 1-Year Mortality in Survivors of Critical Illness.

Skeletal muscle wasting in the intensive care unit (ICU) has been associated with mortality, but it is unclear whether sarcopenia, defined by skeletal muscle mass and function, is useful for detailed risk stratification after ICU discharge. In this cohort study, 72 critically ill patients with an ICU stay of ≥48 h were identified. Skeletal muscle mass was assessed from the muscle thickness (MT) of the patients' quadriceps using ultrasound images before ICU discharge. Skeletal muscle function was assessed from the patients' muscle strength (MS) before ICU discharge according to the Medical Research Council sum score. A diagnosis of sarcopenia in the ICU was made in patients with low MT and low MS. The study endpoint was 1-year mortality. Sarcopenia in the ICU was diagnosed in 26/72 patients (36%). After adjusting for covariates in the Cox regression, sarcopenia in the ICU was significantly associated with 1-year mortality (hazard ratio 3.82; 95% confidence interval, 1.40-10.42). Sarcopenia in the ICU, defined by low skeletal muscle mass and function, was associated with 1-year mortality in survivors of critical illness. Skeletal muscle mass and function assessed at the bedside could be used to identify higher-risk patients in the ICU.

Compound Sarcopenia in Hospitalized Patients with Cirrhosis Worsens Outcomes with Increasing Age.

BACKGROUND: There are limited data on outcomes of older patients with chronic diseases. Skeletal muscle loss of aging (primary sarcopenia) has been extensively studied but the impact of secondary sarcopenia of chronic disease is not as well evaluated. Older patients with chronic diseases have both primary and secondary sarcopenia that we term compound sarcopenia. We evaluated the clinical impact of compound sarcopenia in hospitalized patients with cirrhosis given the increasing number of patients and high prevalence of sarcopenia in these patients. DESIGN: The Nationwide Inpatients Sample (NIS) database (years 2010-2014) was analyzed to study older patients with cirrhosis. Since there is no universal hospital diagnosis code for "muscle loss", we used a comprehensive array of codes for "muscle loss phenotype" in the international classification of diseases-9 (ICD-9). A randomly selected 2% sample of hospitalized general medical population (GMP) and inpatients with cirrhosis were stratified into 3 age groups based on age-related changes in muscle mass. In-hospital mortality, length of stay (LoS), cost of hospitalization (CoH), comorbidities and discharge disposition were analyzed. RESULTS: Of 517,605 hospitalizations for GMP and 106,835 hospitalizations for treatment of cirrhosis or a cirrhosis-related complication, 207,266 (40.4%) GMP and 29,018 (27.7%) patients with cirrhosis were >65 years old, respectively. Muscle loss phenotype in both GMP and inpatients with cirrhosis 51-65 years old and >65 years old was significantly (p < 0.001 for all) associated with higher mortality, LoS, and CoH compared to those ≤50 years old. Patients >65 years old with cirrhosis and muscle loss phenotype had higher mortality (adjusted OR: 1.06, 95% CI [1.04, 1.08] and CoH (adjusted odds ratio (OR): 1.10, 95% confidence interval (CI) [1.04, 1.08])) when compared to >65 years old GMP with muscle loss phenotype. Muscle loss in younger patients with cirrhosis (≤50 years old) was associated with worse outcomes compared to GMP >65 years old. Non-home discharges (nursing, skilled, long-term care) were more frequent with increasing age to a greater extent in patients with cirrhosis with muscle loss phenotype for each age stratum. CONCLUSION: Muscle loss is more frequent in older patients with cirrhosis than younger patients with cirrhosis and older GMP. Younger patients with cirrhosis had clinical outcomes similar to those of older GMP, suggesting an accelerated senescence in cirrhosis. Compound sarcopenia in older patients with cirrhosis is associated with higher inpatient mortality, increased LoS, and CoH compared to GMP with sarcopenia.

Clinical impact of compound sarcopenia in hospitalized older adult patients with heart failure.

OBJECTIVES: Skeletal muscle loss or sarcopenia is a frequent complication in heart failure (HF) and contributes to adverse clinical outcomes. We evaluated if age (primary) and chronic disease (secondary) related sarcopenia, that we refer to as compound sarcopenia, impacts clinical outcomes in hospitalized patients with HF. DESIGN: Cross-sectional study using hospitalized patient data. SETTING: Data from the Agency for Healthcare Research and Quality through the Healthcare Cost and Utilization Project (HCUP). PARTICIPANTS: Hospitalized adult patients with a primary or secondary diagnosis of HF (n = 64,476) and a concurrent random 2% sample of general medical population (GMP; n = 322,217) stratified by age (<50 years of age [y], 51-65y, >65y) from the Nationwide Inpatient Sample (NIS) database (years 2010-2014). MEASUREMENTS: In-hospital mortality, length of stay (LoS), cost of hospitalization per admission (CoH), comorbidities and discharge disposition, with and without muscle loss phenotype, were analyzed. Muscle loss phenotype was defined using a comprehensive code set from international classification of diseases-9 (ICD-9). RESULTS: Muscle loss phenotype was observed in 8673 (13.5%) patients with HF compared to 5213 (1.6%) GMP across all age strata. In patients with HF, muscle loss phenotype was associated with higher mortality, LoS, and CoH. Patients with HF (>65y) and muscle loss phenotype had higher mortality (adjusted OR: 1.81; 95% CI 1.56-2.10), CoH (adjusted OR 1.48; 95% CI 1.44-1.1.52), and LoS (adjusted OR 1.40; 95% CI 1.37-1.43) compared to >65y GMP with muscle loss phenotype. CONCLUSION: Muscle loss phenotype is more commonly associated with increasing age in hospitalized patients with HF. Clinical outcomes were significantly worse in patients with HF aged >65y compared to younger patients with HF and all age strata in GMP with and without a muscle loss phenotype.

SARC-F for screening of sarcopenia among older adults with cancer.

BACKGROUND: Sarcopenia is associated with adverse outcomes among older adults with cancer; however, no easily applied sarcopenia measure exists for use in clinical practice. The use of SARC-F, a 5-item self-reported sarcopenia screening questionnaire, among older adults with cancer remains to be investigated. METHODS: Older adults (aged ≥60 years) with cancer enrolled in the University of Alabama Cancer and Aging Resilience Evaluation Registry were identified. Patients completed the SARC-F questionnaire (with scores ≥4 considered positive for sarcopenia). The authors assessed for differences in geriatric assessment domain impairments, health-related quality of life, and health care utilization between those with and without sarcopenia using multivariate regression, then assessed the association of sarcopenia with survival using Kaplan-Meier methods and a Cox regression model, adjusting for covariates. RESULTS: In total, 256 older adults were identified. The median age was 69 years, 59% of participants were men, and 75% were White. The median SARC-F score was 2 (interquartile range, 0-4), and 33% of participants screened positive. Those with sarcopenia had higher odds of having multiple impairments, including impaired instrumental activities of daily living (adjusted odds ratio [aOR], 18.1; 95% CI, 7.5-43.8) and frailty (aOR, 43.5; 95% CI, 17.7-106.8) as well as reduced physical and mental health-related quality of life (ß coefficient, -13.6 and -11.5, respectively) and increased emergency room visits (aOR, 2.4; 95% CI, 1.3-4.7). Furthermore, sarcopenia was independently associated with inferior overall survival (adjusted hazard ratio, 2.98; 95% CI, 1.1-8.3; P = .04). CONCLUSIONS: One-third of older adults with cancer in this cohort screened positive for sarcopenia using the SARC-F screening questionnaire, and these positive scores are associated with geriatric assessment domain impairments, reduced health-related quality of life, increased emergency room visits, and inferior overall survival.

Does a brief functional assessment in the emergency department predict outcomes of patients admitted with heart failure? The FASTER-HF study.

BACKGROUND: Evaluation of patients with acute decompensated heart failure includes symptom review, biomarker measurement and comorbidity assessment. Early objective evaluation of functional status is generally not performed. AIM: To investigate whether a simple low-impact functional assessment and measurement of sarcopenia would be safe, feasible and predictive of hospital length of stay and all-cause 30-day hospital readmission. METHODS: We administered 3-minute bicycle ergometry and hand grip strength tests at admission and discharge to patients for whom a decision to admit for heart failure management was made in the emergency department. Associations were examined between test results and length of stay and 30-day readmission. Exclusion criteria included acute coronary syndrome, hypoxia, end-stage renal disease, dementia/delirium and inability to sit at bedside. The Kansas City Cardiomyopathy Questionnaire-12, the Patient Health Questionnaire-2 and the visual analogue scale for dyspnoea were administered at admission, the visual analogue scale at discharge and the Kansas City Cardiomyopathy Questionnaire-12 at 30 days. RESULTS: Fifty patients were enrolled: 58% were female; the mean age was 66.2±12.5 years; 24% had heart failure with preserved ejection fraction. Bicycle ergometry variables did not correlate with outcomes. Change in handgrip strength correlated with readmission, but not after adjustment (rpartial=0.14; P=0.35). Total diuretic dose correlated with length of stay; only discharge visual analogue scale and baseline lung disease had significant adjusted correlations with readmission. CONCLUSIONS: Functional assessment in the emergency department of patients admitted for heart failure did not predict outcomes. However, the prognostic value of these assessments for decision-making about disposition (admission or discharge) may still be warranted.

Morphometric and traditional frailty assessment in transcatheter aortic valve implantation.

OBJECTIVES: Frailty is common amongst patients undergoing transcatheter aortic valve implantation (TAVI). The aim of this study was to determine the prognostic relevance of newer objective and traditional measures of frailty after TAVI. METHODS: Consecutive patients were identified from the Leeds Teaching Hospitals Trust TAVI database. Frailty was quantified objectively by measuring the total psoas muscle area (TPMA) on routine computer tomography scans and compared against Canadian Study of Health and Aging Clinical Frailty Score, Katz Index of independence in activities of daily living and Clinician Estimated Poor Mobility. Postintervention morbidity and mortality were examined between these scoring systems. RESULTS: The current study included 420 patients who had undergone TAVI between January 2013 and December 2015. Median clinical follow-up was 4.0 years (interquartile range 2.9-5.0). Standardized measurements of the TPMA were not associated with either postintervention morbidity or mortality. Only the Canadian Study of Health and Aging Clinical Frailty Score was associated with hospital stay (adjusted regression coefficient 0.70, 95% confidence interval 0.04-1.36, P = 0.038) and overall all-cause mortality (adjusted regression coefficient 1.26, 95% confidence interval 1.05-1.50, P = 0.013). There were no significant correlations between TPMA and any of the traditional frailty tools. CONCLUSION: We demonstrate TPMA to be a poor measure of patient frailty when compared with traditional methods of assessment which failed to predict postintervention outcomes. Furthermore, morphometric sarcopaenia correlated poorly with established measures of frailty.

Sarcopenia and myosteatosis in patients undergoing curative radiotherapy for head and neck cancer: Impact on survival, treatment completion, hospital admission and cost.

BACKGROUND: Computed tomography (CT) is the gold standard of body composition analysis at the tissue-organ level. The present study aimed to determine the impact of CT-defined sarcopenia and myosteatosis on outcomes, including overall survival, unplanned hospital admissions and related costs, in patients who had completed treatment of curative intent for head and neck cancer (HNC). METHODS: Retrospective observational study of patients undergoing radiotherapy of curative intent ± other treatment modalities for HNC. Tissue density data derived at the third lumbar vertebra (L3) were evaluated with sarcopenia defined per sex-specific published threshold values for skeletal muscle index, stratified by body mass index and mean skeletal muscle attenuation in HU (Hounsfield units). RESULTS: Pre- or post-treatment images were available for 79/98 patients (80.6%) and 61/98 patients (62.2%), respectively. Sarcopenia was present in 42/79 patients pre-treatment and 36/61 patients post-treatment, whereas myosteatosis was present in 63/79 patients pre-treatment and 48/61 patients post-treatment. In patients with pre- and post-treatment images (n = 60), the median (range) percentage weight change was -8.5% (-29.9 to +11.7). On multivariable analysis, a post-treatment sarcopenia hazard ratio of 3.87 (95% confidence interval = 1.22-12.24, P = 0.021) and a pre-treatment myosteatosis hazard ratio of 8.86 (95% confidence interval = 1.12-69.88, P = 0.038) were independent predictors of reduced overall survival. There was no difference in radiotherapy or chemotherapy treatment completion based on pre-treatment sarcopenia status. The mean (SD) difference unplanned hospital admission cost was $15 846 ($17 707) for patients without sarcopenia versus $47 945 ($82 688) for patients with sarcopenia at any time point (P = 0.077). CONCLUSIONS: As CT-defined sarcopenia and myosteatosis hold clinically meaningful prognostic value, muscle status evaluation is recommended in routine clinical practice.

Importance of combined assessment of skeletal muscle mass and density by computed tomography in predicting clinical outcomes after transcatheter aortic valve replacement.

Skeletal muscle mass (SMM) as calculated by computed tomography (CT) is a predictor of all-cause mortality after transcatheter aortic valve replacement (TAVR), but it remains unclear whether using CT-determined density of skeletal muscle has additive prognostic value. We utilized the Japanese multicenter registry data of 1375 patients who underwent CT prior to TAVR. Sarcopenia status was defined by the CT-derived SMM index (threshold: men, 55.4 cm2/m2; women, 38.9 cm2/m2). The threshold for high and low CT density was based on the median value of the entire cohort (men: 33.4 HU; women: 29.5 HU). Sarcopenia was observed in 802 patients (58.3%) overall. Patients were categorized into non-sarcopenia and high-CT density (n = 298), non-sarcopenia and low-CT density (n = 275), sarcopenia and high-CT density (n = 399), and sarcopenia and low-CT density (n = 403) groups, and procedural outcomes and mortality compared. The cumulative 3-year mortality rates in these groups were 18%, 27%, 24%, and 32%, respectively. Cox-regression multivariate analysis revealed that low-CT density (compared with high-CT density) and sarcopenia and low-CT density (compared with non-sarcopenia and high-CT density as reference) increased mortality after TAVR (hazard ratios [HR]: 1.35 and 1.43, 95% confidence intervals [Cis]: 1.06-1.72 and 1.00-2.08, p = 0.01, and 0.049, respectively). However, sarcopenia alone was not related to an increased risk of mortality (HR 1.30, 95% CI 0.99-1.69, p = 0.52). In conclusion, CT density-based skeletal muscle quality assessment combined with the SMM index improves prediction of adverse outcomes after TAVR.

Sarcopenia supersedes subjective global assessment as a predictor of survival in colorectal cancer.

BACKGROUND: Sarcopenia, the presence of skeletal muscle mass depletion, can be objectively quantified, whereas subjective global assessment (SGA) is a widely utilized subjective instrument to assess nutritional status. Both the presence of sarcopenia and SGA-assessed malnutrition, in isolation, have been shown to be associated with worse overall survival in a wide range of cancers. However, there is no research evaluating the independent prognostic significance of both the presence of sarcopenia and malnutrition as part of the same analysis. We investigated the impact of sarcopenia on overall survival in colorectal cancer specifically controlling for malnutrition. METHODS: We examined a consecutive case series of 112 patients with colorectal cancer first seen at our institution between August 2012 and October 2017. Using computed tomography (CT) imaging, the cross-sectional area of muscles at the L3 vertebral level was measured and then divided by height squared to calculate skeletal muscle index (SMI). Sarcopenia was defined as SMI ≤38.5 cm2/m2 for women and ≤52.4 cm2/m2 for men. SGA assessments were completed within 2 weeks of CT imaging. The association of sarcopenia and malnutrition with overall survival was assessed using univariate and multivariate Cox regression analysis. RESULTS: Median age at presentation was 53.3 years. Sixty-six (58.9%) patients had metastatic disease at diagnosis. Using SMI, 46 (41.1%) patients were sarcopenic, while 66 (58.9%) were non-sarcopenic. Using SGA, 69 (61.6%) patients were assessed as well-nourished, while 43 (38.4%) were malnourished. Of 69 patients classified as well-nourished by SGA, 22 (31.9%) were sarcopenic. Similarly, of 43 patients categorized as malnourished by SGA, 19 (44.2%) were non-sarcopenic. On multivariate analysis, after adjusting for age, gender, tumor stage, BMI, treatment history and SGA, patients with sarcopenia had 3 times greater risk of mortality compared to those without sarcopenia (p = 0.001). The median survival of patients with both sarcopenia and malnutrition (n = 24) was 14.6 months (95% CI: 10.5 to 18.6) compared to the median survival of 25.9 months (95% CI: 7.8 to 44.0) in patients who were either sarcopenic or malnourished but not both (n = 41; p = 0.001). The median survival of patients who were non-sarcopenic and well nourished (n = 48; p = 0.001) was 38.6 months (95% CI: 25.6 to 51.6). CONCLUSIONS: The exploratory study suggests that presence of sarcopenia supersedes the presence of malnutrition as a predictor of survival in colorectal cancer. Co-existence of sarcopenia and malnutrition is associated with worse survival in colorectal cancer compared to just one of those conditions being present. Prospective studies with large sample sizes are needed to confirm these findings.

Limited performance of subjective global assessment compared to computed tomography-determined sarcopenia in predicting adverse clinical outcomes in patients with cirrhosis.

BACKGROUND & AIMS: The subjective global assessment (SGA) is commonly used to assess nutritional status in patients with cirrhosis. Sarcopenia, a major component of malnutrition, is associated with survival in cirrhosis, and can be objectively diagnosed by computing the skeletal muscle index (SMI) using cross-sectional imaging. The aim of this study was to assess the prevalence of sarcopenia between SGA categories in patients with cirrhosis, and to determine their association with decompensation/mortality. METHODS: We included 315 patients (66% males) who were assessed for liver transplantation. All patients had SGA and SMI, and were evaluated for the presence of hepatic encephalopathy (HE) and ascites. RESULTS: Mean age was 54 ± 8 years. SGA categories were 126 SGA A (40%), 155 SGA B (49%), 34 SGA C (11%). Sarcopenia was present in 121 (38%) patients; of these, 82% were SGA A/B. Of SGA A patients, 25 (20%) had sarcopenia. There was a significant but only weak concordance between sarcopenia and SGA B/C (κ = 0.28, p < 0.001), and SGA C (κ = 0.13, p < 0.001). The latter was lost in overweight/obese patients. SGA B/C was associated with HE (OR 2.8, p = 0.01) and ascites (OR 2.3, p = 0.002). Median survival was shorter in patients with sarcopenia (20 [IQR 15.9-24.5] vs. 42 [IQR: 25.8-58.9] months, p < 0.001) and in SGA C patients (9.4 [IQR: 0-26.2] vs. 33 [IQR 20.2-45.7] months, p = 0.01). In univariate analysis both sarcopenia and SGA C were associated with mortality, but sarcopenia was the only factor that remained significant on multivariate analysis. CONCLUSIONS: There was only a weak concordance between SGA and sarcopenia. This concordance was non-significant in patients who were overweight/obese. Sarcopenia was associated with mortality, whereas SGA was not. Sarcopenia by the SMI is a more efficient method to predict adverse outcomes in a timely fashion and has prognostic implications.

Opportunistic Measurement of Skeletal Muscle Size and Muscle Attenuation on Computed Tomography Predicts 1-Year Mortality in Medicare Patients.

BACKGROUND: Opportunistic assessment of sarcopenia on CT examinations is becoming increasingly common. This study aimed to determine relationships between CT-measured skeletal muscle size and attenuation with 1-year risk of mortality in older adults enrolled in a Medicare Shared Savings Program (MSSP). METHODS: Relationships between skeletal muscle metrics and all-cause mortality were determined in 436 participants (52% women, mean age 75 years) who had abdominopelvic CT examinations. On CT images, skeletal muscles were segmented at the level of L3 using two methods: (a) all muscles with a threshold of -29 to +150 Hounsfield units (HU), using a dedicated segmentation software, (b) left psoas muscle using a free-hand region of interest tool on a clinical workstation. Muscle cross-sectional area (CSA) and muscle attenuation were measured. Cox regression models were fit to determine the associations between muscle metrics and mortality, adjusting for age, sex, race, smoking status, cancer diagnosis, and Charlson comorbidity index. RESULTS: Within 1 year of follow-up, 20.6% (90/436) participants died. In the fully-adjusted model, higher muscle index and muscle attenuation were associated with lower risk of mortality. A one-unit standard deviation (SD) increase was associated with a HR = 0.69 (95% CI = 0.49, 0.96; p = .03) for total muscle index, HR = 0.67 (95% CI = 0.49, 0.90; p < .01) for psoas muscle index, HR = 0.54 (95% CI = 0.40, 0.74; p < .01) for total muscle attenuation, and HR = 0.79 (95% CI = 0.66, 0.95; p = .01) for psoas muscle attenuation. CONCLUSION: In older adults, higher skeletal muscle index and muscle attenuation on abdominopelvic CT examinations were associated with better survival, after adjusting for multiple risk factors.

Assessment of Computed Tomography (CT)-Defined Muscle and Adipose Tissue Features in Relation to Short-Term Outcomes After Elective Surgery for Colorectal Cancer: A Multicenter Approach.

BACKGROUND: Sarcopenia, visceral obesity (VO), and reduced muscle radiodensity (myosteatosis) are suggested risk factors for postoperative morbidity in colorectal cancer (CRC), but usually are not concurrently assessed. Published thresholds used to define these features are not CRC-specific and are defined in relation to mortality, not postoperative outcomes. This study aimed to evaluate body composition in relation to length of hospital stay (LOS) and postoperative outcomes. METHODS: Pre-surgical computed tomography (CT) images were assessed for total area and radiodensity of skeletal muscle and visceral adipose tissue in a pooled Canadian and UK cohort (n = 2100). Sex- and age-specific values for these features were calculated. For 1139 of 2100 patients, LOS data were available, and sex- and age-specific thresholds for sarcopenia, myosteatosis, and VO were defined on the basis of LOS. Association of CT-defined features with LOS and readmissions was explored using negative binomial and logistic regression models, respectively. RESULTS: In the multivariable analysis, the predictors of LOS (P < 0.001) were age, surgical approach, major complications (incidence rate ratio [IRR] 2.42; 95% confidence interval [CI] 2.18-2.68), study cohort, and three body composition profiles characterized by myosteatosis combined with either sarcopenia (IRR, 1.27; 95% CI 1.12-1.43) or VO (IRR, 1.25; 95% CI 1.10-1.42), and myosteatosis combined with both sarcopenia and VO (IRR, 1.58; 95% CI 1.29-1.93). In the multivariable analysis, risk of readmission was associated with VO alone (odds ratio [OR] 2.66; 95% CI 1.18-6.00); P = 0.018), VO combined with myosteatosis (OR, 2.72; 95% CI 1.36-5.46; P = 0.005), or VO combined with myosteatosis and sarcopenia (OR, 2.98; 95% CI 1.06-5.46; P = 0.038). Importantly, the effect of body composition profiles on LOS and readmission was independent of major complications. CONCLUSION: The findings showed that CT-defined multidimensional body habitus is independently associated with LOS and hospital readmission.

Low skeletal muscle mass is associated with increased hospital costs in patients with cirrhosis listed for liver transplantation-a retrospective study.

Low skeletal muscle mass (sarcopenia) is associated with increased morbidity and mortality in liver transplant candidates. We investigated the association between sarcopenia and hospital costs in patients listed for liver transplantation. Consecutive patients with cirrhosis listed for liver transplantation between 2007 and 2014 in a Eurotransplant centre were identified. The skeletal muscle index (SMI, cm2 /m2 ) was measured on CT performed within 90 days from waiting list placement. The lowest sex-spe cific quartile represented patients with sarcopenia. In total, 224 patients were included. Median time on the waiting list was 170 (IQR 47-306) days, and median MELD score was 16 (IQR 11-20). The median total hospital costs in patients with sarcopenia were €11 294 (IQR 3570-46 469) compared with €6878 (IQR 1305-20 683) in patients without sarcopenia (P = 0.008). In multivariable regression analysis, an incremental increase in SMI was significantly associated with a decrease in total costs (€455 per incremental SMI, 95% CI 11-900, P = 0.045), independent of the total time on the waiting list. In conclusion, sarcopenia is independently associated with increased health-related costs for patients on the waiting list for liver transplantation. Optimizing skeletal muscle mass may therefore lead to a decrease in hospital expenditure, in addition to greater health benefit for the transplant candidate.

Sarcopenia in the prognosis of cirrhosis: Going beyond the MELD score.

Estimating the prognosis of patients with cirrhosis remains challenging, because the natural history of cirrhosis varies according to the cause, presence of portal hypertension, liver synthetic function, and the reversibility of underlying disease. Conventional prognostic scoring systems, including the Child-Turcotte-Pugh score or model for end-stage liver diseases are widely used; however, revised models have been introduced to improve prognostic performance. Although sarcopenia is one of the most common complications related to survival of patients with cirrhosis, the newly proposed prognostic models lack a nutritional status evaluation of patients. This is reflected by the lack of an optimal index for sarcopenia in terms of objectivity, reproducibility, practicality, and prognostic performance, and of a consensus definition for sarcopenia in patients with cirrhosis in whom ascites and edema may interfere with body composition analysis. Quantifying skeletal muscle mass using cross-sectional abdominal imaging is a promising tool for assessing sarcopenia. As radiological imaging provides direct visualization of body composition, it is useful to evaluate sarcopenia in patients with cirrhosis whose body mass index, anthropometric measurements, or biochemical markers are inaccurate on a nutritional assessment. Sarcopenia defined by cross-sectional imaging-based muscular assessment is prevalent and predicts mortality in patients with cirrhosis. Sarcopenia alone or in combination with conventional prognostic systems shows promise for a cirrhosis prognosis. Including an objective assessment of sarcopenia with conventional scores to optimize the outcome prediction for patients with cirrhosis needs further research.

One-year postoperative resource utilization in sarcopenic patients.

BACKGROUND: It is well established that sarcopenic patients are at higher risk of postoperative complications and short-term health care utilization. Less well understood is how these patients fare over the long term after surviving the immediate postoperative period. We explored costs over the first postoperative year among sarcopenic patients. METHODS: We identified 1279 patients in the Michigan Surgical Quality Collaborative database who underwent inpatient elective surgery at a single institution from 2006-2011. Sarcopenia, defined by gender-stratified tertiles of lean psoas area, was determined from preoperative computed tomography scans using validated analytic morphomics. Data were analyzed to assess sarcopenia's relationship to costs, readmissions, discharge location, intensive care unit admissions, hospital length of stay, and mortality. Multivariate models were adjusted for patient demographics and surgical risk factors. RESULTS: Sarcopenia was independently associated with increased adjusted costs at 30, 90, and 180 but not 365 d. The difference in adjusted postsurgical costs between sarcopenic and nonsarcopenic patients was $16,455 at 30 d and $14,093 at 1 y. Sarcopenic patients were more likely to be discharged somewhere other than home (P < 0.001). Sarcopenia was not an independent predictor of increased readmission rates in the postsurgical year. CONCLUSIONS: The effects of sarcopenia on health care costs are concentrated in the immediate postoperative period. It may be appropriate to allocate additional resources to sarcopenic patients in the perioperative setting to reduce the incidence of negative postoperative outcomes.