ASPEN-AND-ESPEN: A postacute-care comparison of the basic definition of malnutrition from the American Society of Parenteral and Enteral Nutrition and Academy of Nutrition and Dietetics with the European Society for Clinical Nutrition and Metabolism definition.

BACKGROUND: The aim of this study was to assess the prevalence of malnutrition by applying the ASPEN/AND definition and the ESPEN consensus definition in a postacute-care population, and secondly, to determine the metrological properties of the set of six clinical characteristics that constitute the ASPEN/AND basic diagnosis, compared to the ESPEN consensus, based mostly on objective anthropometric measurements. METHODS: Prospective study of 84 consecutive deconditioned older inpatients (85.4 ± 6.2; 59.5% women) admitted for rehabilitation in postacute care. ASPEN/AND diagnosis of malnutrition was considered in presence of at least two of the following: low energy intake, fluid accumulation, diminished handgrip strength, and loss of weight, muscle mass, or subcutaneous fat. Sensitivity, specificity, positive and negative predictive values, accuracy, likelihood ratios, and kappa statistics were calculated for ASPEN/AND criteria and compared with ESPEN consensus. RESULTS: The prevalence of malnutrition by ASPEN/AND criteria was 63.1% and by ESPEN consensus, 20.2%; both diagnoses were associated with significantly longer length of stay, but the ESPEN definition was significantly associated with poorer functional outcomes after the rehabilitation program. Compared to ESPEN consensus, ASPEN/AND diagnosis showed fair validity (sensitivity = 94.1%; specificity = 44.8%); kappa statistic was 2.217. CONCLUSIONS: Applying the ASPEN/AND definition obtained a higher prevalence of malnutrition in a postacute-care population than was identified by the ESPEN definition. ASPEN/AND criteria had fair validity and agreement compared with the ESPEN definition. A simple, evidence-based, unified malnutrition definition might improve geriatric care.

Ultrasound assessment of rectus femoris muscle in rehabilitation patients with chronic obstructive pulmonary disease screened for sarcopenia: correlation of muscle size with quadriceps strength and fat-free mass.

PURPOSE: To determine the relationship of the size of the rectus femoris muscle, assessed by ultrasonography, with parameters of muscle strength and body composition that are commonly used in the case-finding of sarcopenia in rehabilitation patients with chronic obstructive pulmonary disease (COPD). METHODS: Cross-sectional pilot study of 18 men with severe COPD and 17 healthy controls. MAIN OUTCOME VARIABLES: cross-sectional area, thickness, and width of the non-dominant rectus femoris muscle obtained by ultrasound, muscle strength determined by voluntary maximum isometric contraction of the quadriceps muscle, and fat-free mass assessed by bioimpedance analysis. RESULTS: Ultrasounds detected differences in the size of the rectus femoris muscle: cross-sectional area was 4.3 (SD 1.05) cm2 in patients, compared to 5.6 (SD 1.25) cm2 in controls; patients also presented lower quadriceps strength, and fat-free mass index. Cross-sectional area of the rectus femoris muscle showed a moderate correlation with quadriceps strength (R = 0.497, p = 0.036) and fat-free mass (R = 0.584, p = 0.011). In a multivariate linear model adjusted for age, body mass index, fat-free mass and muscle size, muscle strength was 7.44 kg lower (p value = 0.014) in patients, compared to controls. CONCLUSIONS: A causal relationship was observed between the cross-sectional area of the rectus femoris muscle, assessed with ultrasonography, and maximum isometric strength of knee extension in COPD rehabilitation patients. Reduced cross-sectional area was also associated with loss of fat-free mass. Muscle ultrasound and bioimpedance analysis provide complementary and relevant information that could be useful in the case-finding of sarcopenia in COPD patients.

Malnutrition according to ESPEN consensus predicts hospitalizations and long-term mortality in rehabilitation patients with stable chronic obstructive pulmonary disease.

BACKGROUND: Nutritional disorders are frequent in patients with chronic pulmonary obstructive disease (COPD) and have negative health impacts. This study aimed to explore the value of the European Society of Clinical Nutrition and Metabolism (ESPEN) definition of malnutrition (and/or its individual components) to predict hospitalizations and mortality at 2 years, and to determine the prevalence of malnutrition in COPD patients referred to pulmonary rehabilitation. METHODS: The study was a prospective analysis of 118 patients with COPD free of exacerbations and/or hospital admissions in the previous two months. Main outcome variables were mortality, hospital admissions, and length of stay at 2-year follow-up; main covariates were malnutrition assessment according to the ESPEN definition and its components: unintentional weight loss, body mass index, and fat-free mass index (FFMI). Body composition was assessed by bioimpedance analysis. Kaplan-Meier survival curves and linear regression analyses were performed, adjusting for age and airflow obstruction as potential confounders. RESULTS: The observed prevalence of malnutrition was 24.6%. Malnutrition was associated with increased mortality risk (HR = 3.9 [95% CI: 1.4-10.62]). FFMI was independently associated with increased mortality (HR = 17.0 [95% CI: 2.24-129.8]), which persisted after adjustment for age and lung function (adjusted HR = 13.0 [95% CI: 1.67-101.7]). Low age-related body mass index was associated with increased risk of hospital admissions. CONCLUSIONS: Malnutrition according to ESPEN criteria, highly prevalent in patients with stable COPD referred to pulmonary rehabilitation, was associated with 4 times greater mortality risk after 2 years. Low FFMI was associated with a 17-fold increase in mortality risk, suggesting independent predictive value.

Prognostic Value of the ESPEN Consensus and Guidelines for Malnutrition: Prediction of Post-Discharge Clinical Outcomes in Older Inpatients.

INTRODUCTION: Our study aimed to determine whether malnutrition and nutrition-related conditions using the European Society for Clinical Nutrition and Metabolism (ESPEN) consensus were associated with functional status, institutionalization, readmissions, and mortality in older patients at 3-month follow-up. METHODS: A cohort of 102 consecutive deconditioned patients was assessed at 3 months postdischarge from postacute geriatric care. Inclusion criteria were age ≥70 years, scores of Mini-Mental Status Examination ≥21/30, and being admitted for rehabilitation after an acute non-disabling disease. Malnutrition as defined by ESPEN consensus and nutrition-related conditions (such as frailty, sarcopenia, overweight/obesity, nutrient deficiency, and cachexia) was assessed, and related to postdischarge clinical outcomes at 3-month follow-up. RESULTS: Of 95 included patients (84.5 ± 6.5 years; 63.2% women), 31 had unintentional weight loss and 19 fulfilled malnutrition criteria defined by the ESPEN consensus. Nutrition-related conditions were frequent: 94 patients had frailty, 44 sarcopenia, 58 overweight/obesity, and 59 nutrient deficiency. Sarcopenia reduced functional status at 3-month follow-up (median difference: -25.5; 95% confidence interval (CI) -46.4 - -4.3, P = 0.008). Institutionalization was related to unintentional weight loss in univariate analysis (odds ratio (OR) = 3.9; 95%CI 1.3 - 12.4, P = 0.018). Meeting the basic ESPEN definition of malnutrition was related to institutionalization in univariate (OR = 3.4; 95%CI 1.0 to 11.3, P = 0.042) but not multivariate analysis, and was not significantly associated with readmissions or mortality at 3-month follow-up. CONCLUSIONS: Further research is needed on the potential value of the ESPEN consensus and guidelines for malnutrition to identify older patients at risk of worse functional status, institutionalization, readmissions, and mortality at 3-month follow-up postdischarge.

Malnutrition according to ESPEN definition predicts long-term mortality in general older population: Findings from the EPIDOS study-Toulouse cohort.

BACKGROUND: The European Society of Clinical Nutrition and Metabolism (ESPEN) has developed a consensus definition of malnutrition. This study aimed to determine the prevalence of malnutrition according to the ESPEN definition in otherwise healthy community-dwelling older women and to explore its value for predicting long-term mortality in this population. METHODS: This prospective population-based cohort study included 181 women (age ≥75 years) from a subsample of the EPIDémiologie de l'OStéoporose (EPIDOS) study participants from Toulouse. Inclusion criteria were the availability of the data on variables required to apply the ESPEN definition and survival after 7 years of follow-up. Primary outcome was mortality at 12-year follow-up; main covariates were malnutrition assessment according to the ESPEN consensus and its components (unintentional weight loss, BMI, and FFMI). Body composition was assessed by dual-energy X-ray absorptiometry at baseline and at 7-year follow-up. Kaplan-Meier survival curves and adjusted Cox regressions were performed. Analysis was adjusted for age, hypertension, diabetes mellitus, and coronary heart disease as potential confounders. RESULTS: Complete data were available for 179 of the 181 women in the EPIDOS-Toulouse cohort (83.1 ± 2.2 years) and 13 (7.3%) fulfilled the ESPEN definition for malnutrition at 7-year follow-up. Malnutrition was associated with increased risk of mortality (adjusted HR = 4.4 [95%CI: 1.7-11.3]). Among the ESPEN components, only BMI was associated with increased mortality (adjusted HR=0.6 [95%CI: 0.4-0.9]). CONCLUSIONS: Although malnutrition prevalence according to the ESPEN definition was relatively low (7.3%) in this sample of otherwise healthy community-dwelling older French women, malnutrition was associated with 4.4-fold higher mortality risk at 12-year follow-up.

Prospective study of shoulder strength, shoulder range of motion, and lymphedema in breast cancer patients from pre-surgery to 5 years after ALND or SLNB.

OBJECTIVE: Determine the changes in shoulder strength, shoulder range of motion, and arm volume in breast cancer patients treated with sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) METHOD: Sixty-eight SLNB and 44 ALND patients were followed up from pre-surgery to 5 years after surgery. Primary outcomes were the differences between affected and non-affected sides for the following: shoulder strength measured by dynamometry, shoulder range of motion measured by goniometry, and lymphedema measured by volume. As a secondary outcome, health-related quality of life (HRQL) was assessed by the Short Form-36 Health Survey (SF-36) and the Functional Assessment of Cancer Therapy for breast cancer (FACT-B+4) questionnaires. Changes over time were tested for SLNB and ALND using univariate repeated measures analysis of variance. Generalized estimating equation models were constructed to assess the effect of SLNB and ALND over time. RESULTS: After 5 years, the ALND group had significant loss of strength for internal rotators (1.39 kg, p = 0.001) and significant arm volume increase (132.45 mL, p = 0.031). The ALND group had a greater number of patients with clinically relevant internal rotator strength loss (38.7 vs. 13.6%, p = 0.012) and a greater number of lymphedema requiring treatment (33.3 vs. 3.4%, p < 0.001) than the SLNB group. A loss of strength for shoulder external rotators, shoulder range of motion, and HRQL in physical and arm domains persisted at 5 years in both SLNB and ALND groups. CONCLUSION: These results could help understand and plan the prevention, needs, and long-term care of breast cancer patients.

Clinical application of the basic definition of malnutrition proposed by the European Society for Clinical Nutrition and Metabolism (ESPEN): Comparison with classical tools in geriatric care.

BACKGROUND: Malnutrition is a prevalent condition related to adverse outcomes in older people. Our aim was to compare the diagnostic capacity of the malnutrition criteria of the European Society of Parenteral and Enteral Nutrition (ESPEN) with other classical diagnostic tools. METHODS: Cohort study of 102 consecutive in-patients ≥70 years admitted for postacute rehabilitation. Patients were considered malnourished if their Mini-Nutritional Assessment-Short Form (MNA-SF) score was ≤11 and serum albumin <3 mg/dL or MNA-SF ≤ 11, serum albumin <3 mg/dL, and usual clinical signs and symptoms of malnutrition. Sensitivity, specificity, positive and negative predictive values, accuracy likelihood ratios, and kappa values were calculated for both methods: and compared with ESPEN consensus. RESULTS: Of 102 eligible in-patients, 88 fulfilled inclusion criteria and were identified as "at risk" by MNA-SF. Malnutrition diagnosis was confirmed in 11.6% and 10.5% of the patients using classical methods,whereas 19.3% were malnourished according to the ESPEN criteria. Combined with low albumin levels, the diagnosis showed 57.9% sensitivity, 64.5% specificity, 85.9% negative predictive value,0.63 accuracy (fair validity, low range), and kappa index of 0.163 (poor ESPEN agreement). The combination of MNA-SF, low albumin, and clinical malnutrition showed 52.6% sensitivity, 88.3% specificity, 88.3%negative predictive value, and 0.82 accuracy (fair validity, low range), and kappa index of 0.43 (fair ESPEN agreement). CONCLUSIONS: Malnutrition was almost twice as prevalent when diagnosed by the ESPEN consensus, compared to classical assessment methods: Classical methods: showed fair validity and poor agreement with the ESPEN consensus in assessing malnutrition in geriatric postacute care.

Malnutrition in postacute geriatric care: Basic ESPEN diagnosis and etiology based diagnoses analyzed by length of stay, in-hospital mortality, and functional rehabilitation indexes.

OBJECTIVE: To determine the relationships between malnutrition and nutrition-related conditions according to the European Society of Clinical Nutrition and Metabolism (ESPEN) consensus and guidelines and clinical outcomes in postacute rehabilitation. METHODS: Of 102 eligible inpatients, 95 (84.5 years old, 63.2% women) fulfilled inclusion criteria: aged ≥70 years, body mass index <30kg/m2, admission for rehabilitation. Mini-Nutritional Assessment-Short Form (MNA-SF≤11) identified patients "at risk" and ESPEN basic and etiology based definitions were applied. Nutrition-related conditions (sarcopenia, frailty, overweight/obesity, micronutrient abnormalities) were determined. We assessed the relationship between these conditions and the clinical and rehabilitation outcomes (relative functional gain, rehabilitation efficiency) during hospitalization. RESULTS: All patients were "at risk" by MNA-SF criteria and 31 reported unintentional weight loss >5% in the last year or 2-3kg in the last 6 months. Nineteen fulfilled the ESPEN basic definition, of which 10 had disease-related malnutrition with inflammation and 9 without inflammation, and 20 had cachexia. Sarcopenia (n=44), frailty (n=94), overweight/obesity (n=59), and micronutrient abnormalities (n=70) were frequent. Unintentional weight loss impaired all functional outcomes and increased length of stay [OR=6.04 (2.87-9.22); p<0.001]. In multivariate analysis, relationships between rehabilitation impact indices and the ESPEN basic and etiology-based definitions observed in univariate analysis persisted only (and marginally) for relative functional gain [OR=13.24 (0.96-181.95); p=0.005]. Infrequent in-hospital mortality prevented meaningful analysis of this outcome. CONCLUSIONS: ESPEN basic and etiology-based definitions and nutrition related disorders were determined in postacute care. Malnutrition was associated with poor rehabilitation outcomes, mainly due to unintentional weight loss.

Prevalence of malnutrition and sarcopenia in a post-acute care geriatric unit: Applying the new ESPEN definition and EWGSOP criteria.

BACKGROUNDS & AIMS: The European Society of Clinical Nutrition and Metabolism (ESPEN) consensus definition of malnutrition has been applied in hospitalized older diabetics and middle-aged patients, geriatric outpatients, and healthy elderly and young individuals. In a post-acute care setting, our aim was to assess malnutrition (ESPEN definition) and determine its relationship with sarcopenia in older in-patients deconditioned due to an acute process. METHODS: Eighty-eight in-patients aged ≥70 years with body mass index (BMI) <30 kg/m2 were included (84.1 years old; 62% women) and screened for malnutrition risk using biochemical markers and Mini-Nutritional Assessment-Short Form (MNA-SF). The ESPEN definition was applied: 1) BMI <18.5 kg/m2 or 2) unintentional weight loss plus a) low BMI or b) low fat-free mass index (FFMI). European Working Group on Sarcopenia in Older People (EWGSOP) criteria were also applied. RESULTS: Unintentional weight loss occurred in 27 (30.7%) of 88 in-patients considered "at risk" by MNA-SF. Malnutrition prevalence was 4.5%, 7.9%, and 17% using ESPEN definitions 1, 2a, and 2b, respectively; 19.3% were malnourished. Prevalence of sarcopenia was 37.5%, of which 90.9% fulfilled ESPEN malnutrition criteria, a significant association (p = 0.02). No differences in biochemical markers were observed between patients with or without malnutrition or sarcopenia. CONCLUSIONS: ESPEN criteria constitute an appropriate tool to establish a malnutrition diagnosis in post-acute care. Sarcopenia, as defined by EWGSOP, was present in 37.5% of patients, of which 90.9% fulfilled ESPEN criteria; therefore, malnutrition was significantly related to sarcopenia. Additional work is needed to determine further implications of the ESPEN consensus definition.

Inspiratory and expiratory muscle training in subacute stroke: A randomized clinical trial.

OBJECTIVE: To assess the effectiveness, feasibility, and safety of short-term inspiratory and expiratory muscle training (IEMT) in subacute stroke patients. METHODS: Within 2 weeks of stroke onset, 109 patients with a first ischemic stroke event were randomly assigned to the IEMT (n = 56) or sham IEMT (n = 53) study group. The IEMT consisted of 5 sets of 10 repetitions, twice a day, 5 days per week for 3 weeks, at a training workload equivalent to 30% of maximal respiratory pressures. Patients and researchers assessing outcome variables were blinded to the assigned study group. The main outcome was respiratory muscle strength assessed by maximal inspiratory and expiratory pressures (PImax, PEmax). Respiratory complications at 6 months were also recorded. RESULTS: Both groups improved respiratory muscle strength during the study. IEMT was associated with significantly improved %PImax and %PEmax: effect size d = 0.74 (95% confidence interval [CI] 0.28-1.20) and d = 0.56 (95% CI 0.11-1.02), respectively. No significant training effect was observed for peripheral muscle strength. Respiratory complications at 6 months occurred more frequently in the sham group (8 vs 2, p = 0.042), with an absolute risk reduction of 14%. The number needed to treat to prevent one lung infection event over a follow-up of 6 months was 7. No major adverse events or side effects were observed. CONCLUSION: IEMT induces significant improvement in inspiratory and expiratory muscle strength and could potentially offer an additional therapeutic tool aimed to reduce respiratory complications at 6 months in stroke patients. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that short-term training may have the potential to improve respiratory muscle strength in patients with subacute stroke.

Does gait speed contribute to sarcopenia case-finding in a postacute rehabilitation setting?

OBJECTIVE: The European Working Group of Sarcopenia in Older People (EWGSOP) has developed an algorithm based on gait speed measurement to begin sarcopenia case-finding in clinical practice, in which a cut-off point of <0.8m/s identifies risk for sarcopenia in community-dwelling older people. The objective of this study was to assess the application of the EWGSOP algorithm in hospitalised elderly patients with impaired functional capacity. METHODS: One hundred in-patients (aged 84.1 SD 8.5, 62% women) were prospectively studied in a postacute care geriatric unit focused on rehabilitation. Sarcopenia was assessed by corporal composition (electrical bioimpedance), handgrip strength, and physical performance (gait speed). Other measurements were Charlson index, length of stay, and functional gain at discharge and 3-month follow-up. All patients were screened by the EWGSOP algorithm and sarcopenia was confirmed according to diagnostic criteria. RESULTS: Gait speed was <0.8m/s in all cases and 58 patients had low muscle mass, which, according to the EWGSOP-algorithm, would indicate a diagnosis of sarcopenia. No differences were observed in functional capacity between these patients and those with normal muscle mass. When decreased handgrip strength was considered, 47 of these patients met the EWGSOP criteria for severe sarcopenia. In this group, differences in functional capacity were observed at discharge (Barthel 45.2 vs. 56.3, p=0.042) and 3-month follow-up (48.3 vs. 59.8, p=0.047). CONCLUSION: The application of the EWGSOP algorithm in hospitalised, postacute, elderly patients with low gait speed suggested that muscle strength should be considered before confirming or discarding a sarcopenia diagnosis.

Variabilidad de la composición corporal medida con bioimpedanciometría eléctrica según condiciones de realización: influencia del ayuno y del reposo / Variability in bioelectrical impedance assessment of body composition depending on measurement conditions influence of fast and rest

Introducción: La bioimpedanciometría eléctrica (BIA) constituye una de las principales herramientas para evaluar la composición corporal. Aunque se recomienda la realización de la BIA en condiciones de ayuno y 60 minutos de reposo, en la práctica asistencial no siempre es posible garantizar su cumplimiento. Objetivos: Determinar la fiabilidad de los parámetros de composición corporal estimados por BIA bajo diferentes condiciones fisiológicas: ayuno + reposo, ayuno + no-reposo y no-ayuno + no- reposo en voluntarios sanos. Metodología: Estudio transversal en 25 voluntarios sanos entre 18 y 34 años de edad (12 hombres, 13 mujeres). Se realizó una BIA en tres condiciones diferentes: 1) ayuno + reposo de 60 minutos en decúbito supino (gold standard), 2) ayuno + no reposo y 3) no ayuno + no reposo. Los parámetros recogidos fueron: masa magra y masa grasa (Kg) y agua corporal (litros y en porcentaje del peso corporal). Para valorar la concordancia entre las diferentes mediciones, se utilizó el coeficiente de correlación intraclase (CCI) Resultados: En comparación con el gold standard, la diferencia de medias de la masa magra en la condición de ayuno + no-reposo, fue -0.15 (DE 1.44) en los hombres y 0.98 (DE 1.36) en mujeres; la masa grasa disminuyó 0.06 (DE 1.55) en hombres y 0.82 (DE 1.5) en mujeres; el CCI osciló entre 0.826-0.995 en todas las comparaciones. En la condición de no-ayuno + no reposo, la masa magra disminuyó una media 0.05 (DE 0.33) en los hombres y en las mujeres se incrementó 0.62 (DE 0.46); la masa grasa disminuyó 0.57 (DE 0.82) en hombres y 0.46 (DE 0.60) en mujeres; y el CCI osciló entre 0.942 y 0.999, excepto en el agua corporal en hombres que fue de 0.340. Discusión: Las diferencias observadas en los parámetros obtenidos por BIA al comparar la condición gold standard (ayuno + reposo) con las otras condiciones (ayuno + no reposo y no-ayuno + no-reposo), aunque significativas, son de escasa magnitud. En la práctica clínica, la valoración de parámetros de composición corporal permite tomar decisiones a la hora de planificar el tratamiento en pacientes con desacondicionamiento físico. Conclusiones: La fiabilidad de los parámetros obtenidos por BIA entre diferentes condiciones fisiológicas de ayuno y reposo es excelente (CCI >0.75) en adultos sanos entre 19 y 34 años. Si bien las recomendaciones generales sobre el uso de los dispositivos de BIA se deben mantener, las condiciones de realización podrían modificarse en función del contexto asumiendo una diferencia de pequeña magnitud y escasa relevancia clínica (AU)

Background: Bioelectrical Impedance Assessment (BIA) is one of the main tools to measure body composition. BIA is recommended in fasting and after 60 minutes of rest; however, this cannot always be guaranteed in healthcare practice. Objectives: To establish the reliability of the body composition parameters assessed with BIA under different physiological conditions: fast + rest, fast + no-rest and no-fast + no-rest in healthy volunteers. Methods: Transversal study including 25 healthy volunteers aged 18-34 (12 men, 13 women). A BIA was performed under three different conditions: 1) fast + 60 minute rest in cubito supino (gold standard), 2) fast + no rest and 3) no fast + no rest. The collected parameters were: lean mass and fat mass (Kg) and body water (in liters and as body weight percentage). The intraclass correlation coefficient (ICC) was applied for the assessment of concordance within the different measurements. Results: Compared to the gold standard, the difference in lean mass means in the condition of fast + no-rest, was -0.15 (DE 1.44) in men and 0.98 (DE 1.36) in women; fat mass decreased in 0.06 (DE 1.55) in men and 0.82 (DE 1.5) in women; ICC ranged between 0.826-0.995 in all comparisons. In the condition of no-fast + no rest, lean mass decreased an average of 0.05 (DE 0.33) in men and it increased 0.62 (DE 0.46) in women; fat mass decreased 0.57 (DE 0.82) in men and 0.46 (DE 0.60) in women; ad ICC ranged between 0.942 and 0.999, except in body water in men, where it was 0.340. Discussion: Although relevant, the differences observedin parameters from BIA when comparing the gold standard condition (fast + rest) with the other conditions (fast + no-rest and no-fast + no-rest) are of little magnitude. In clinical practice, the assessment of body composition allows to take decisions when planning treatment for patients with a poor physical condition. Conclusions: The reliability of the parameters acquired via BIA within different physiological conditions of fast and rest is excellent (CCI >0.75) in healthy adults aged 19-34. Although general recommendations on theuse of BIA devices must be kept in place, the conditions of the performance could be modified according to the context and assuming a small difference of little clinical relevance (AU)

[Variability in bioelectrical impedance assessment of body composition depending on measurement conditions: influence of fast and rest]. / Variabilidad de la composición corporal medida con bioimpedanciometría eléctrica según condiciones de realización: influencia del ayuno y del reposo.

BACKGROUND: Bioelectrical Impedance Assessment (BIA) is one of the main tools to measure body composition. BIA is recommended in fasting and after 60 minutes of rest; however, this cannot always be guaranteed in healthcare practice. OBJECTIVES: To establish the reliability of the body composition parameters assessed with BIA under different physiological conditions: fast + rest, fast + no-rest and no-fast + no-rest in healthy volunteers. METHODS: Transversal study including 25 healthy volunteers aged 18-34 (12 men, 13 women). A BIA was performed under three different conditions: 1) fast + 60 minute rest in cubito supino (gold standard), 2) fast + no rest and 3) no fast + no rest. The collected parameters were: lean mass and fat mass (Kg) and body water (in liters and as body weight percentage). The intraclass correlation coefficient (ICC) was applied for the assessment of concordance within the different measurements. RESULTS: Compared to the gold standard, the difference in lean mass means in the condition of fast + no-rest, was -0.15 (DE 1.44) in men and 0.98 (DE 1.36) in women; fat mass decreased in 0.06 (DE 1.55) in men and 0.82 (DE 1.5) in women; ICC ranged between 0.826-0.995 in all comparisons. In the condition of no-fast + no rest, lean mass decreased an average of 0.05 (DE 0.33) in men and it increased 0.62 (DE 0.46) in women; fat mass decreased 0.57 (DE 0.82) in men and 0.46 (DE 0.60) in women; ad ICC ranged between 0.942 and 0.999, except in body water in men, where it was 0.340. DISCUSSION: Although relevant, the differences observed in parameters from BIA when comparing the gold standard condition (fast + rest) with the other conditions (fast + no-rest and no-fast + no-rest) are of little magnitude. In clinical practice, the assessment of body composition allows to take decisions when planning treatment for patients with a poor physical condition. CONCLUSIONS: The reliability of the parameters acquired via BIA within different physiological conditions of fast and rest is excellent (CCI >0.75) in healthy adults aged 19-34. Although general recommendations on the use of BIA devices must be kept in place, the conditions of the performance could be modified according to the context and assuming a small difference of little clinical relevance.

Introducción: La bioimpedanciometría eléctrica (BIA) constituye una de las principales herramientas para evaluar la composición corporal. Aunque se recomienda la realización de la BIA en condiciones de ayuno y 60 minutos de reposo, en la práctica asistencial no siempre es posible garantizar su cumplimiento. Objetivos: Determinar la fiabilidad de los parámetros de composición corporal estimados por BIA bajo diferentes condiciones fisiológicas: ayuno + reposo, ayuno + no-reposo y no-ayuno + no- reposo en voluntarios sanos. Metodología: Estudio transversal en 25 voluntarios sanos entre 18 y 34 años de edad (12 hombres, 13 mujeres). Se realizó una BIA en tres condiciones diferentes: 1) ayuno + reposo de 60 minutos en decúbito supino (gold standard), 2) ayuno + no reposo y 3) no ayuno + no reposo. Los parámetros recogidos fueron: masa magra y masa grasa (Kg) y agua corporal (litros y en porcentaje del peso corporal). Para valorar la concordancia entre las diferentes mediciones, se utilizó el coeficiente de correlación intraclase (CCI). Resultados: En comparación con el gold standard, la diferencia de medias de la masa magra en la condición de ayuno + no-reposo, fue -0.15 (DE 1.44) en los hombres y 0.98 (DE 1.36) en mujeres; la masa grasa disminuyó 0.06 (DE 1.55) en hombres y 0.82 (DE 1.5) en mujeres; el CCI osciló entre 0.826-0.995 en todas las comparaciones. En la condición de no-ayuno + no reposo, la masa magra disminuyó una media 0.05 (DE 0.33) en los hombres y en las mujeres se incrementó 0.62 (DE 0.46); la masa grasa disminuyó 0.57 (DE 0.82) en hombres y 0.46 (DE 0.60) en mujeres; y el CCI osciló entre 0.942 y 0.999, excepto en el agua corporal en hombres que fue de 0.340. Discusión: Las diferencias observadas en los parámetros obtenidos por BIA al comparar la condición gold standard (ayuno + reposo) con las otras condiciones (ayuno + no reposo y no-ayuno + no-reposo), aunque significativas, son de escasa magnitud. En la práctica clínica, la valoración de parámetros de composición corporal permite tomar decisiones a la hora de planificar el tratamiento en pacientes con desacondicionamiento físico. Conclusiones: La fiabilidad de los parámetros obtenidos por BIA entre diferentes condiciones fisiológicas de ayuno y reposo es excelente (CCI >0.75) en adultos sanos entre 19 y 34 años. Si bien las recomendaciones generales sobre el uso de los dispositivos de BIA se deben mantener, las condiciones de realización podrían modificarse en función del contexto asumiendo una diferencia de pequeña magnitud y escasa relevancia clínica.

Sarcopenia, physical rehabilitation and functional outcomes of patients in a subacute geriatric care unit.

Sarcopenia is the loss of muscle mass and strength, which in the elderly can result in disability and affect functional outcomes after hospitalization. The aim of this study was to evaluate the functional outcomes and mortality during hospitalization and at three months post-discharge, according to the presence of sarcopenia. Prospective study of 99 patients (38.4% men, aged 84.6) admitted in a subacute geriatric care unit who underwent a rehabilitation intervention. Main outcomes were mortality and functional improvement at discharge and at three-month follow-up. Sarcopenia was assessed by handgrip strength (hydraulic dynamometer) and by body composition bioimpedance. Forty-six (46.5%) patients met diagnostic criteria of sarcopenia. Patients with sarcopenia had a worse prior functional status than those without the condition (Barthel Index: 64.2±22.8 vs 73.3±21.8; p=0.04) but both groups had similar functional decline at admission (Barthel Index: 24±15.1 vs 28.5±15.2; p=0.1) and achieved similar functional improvement at discharge (20.4±18.3 vs 27.4±21; p=0.08). Barthel Index at discharge remained comparatively worse in patients with sarcopenia (44.2±26.6 vs 55.9±26.7; p=0.03). After completing a 3-month at-home rehabilitation program, no changes in functional capacity were observed in patients with sarcopenia; their peers improved their Barthel Index scores (45.5±24.8 vs 61.6±26.6; p=0.007). Mortality rates at 3-month follow-up did not differ between groups. In conclusion, patients with sarcopenia had a worse functional status, similar functional improvement during hospitalization and a lack of recovery after returning home. Further studies are needed to establish long-terms effects on mortality.

Usefulness of the volume-viscosity swallow test for screening dysphagia in subacute stroke patients in rehabilitation income.

BACKGROUND: Swallowing disorders affect up to 35-85% of patients with stroke. Dysphagia complications can lead to malnutrition, dehydration, bronchoaspirative pneumonia and death, and have impact on health care costs. OBJECTIVE: To evaluate the clinical screening capacity of the Volume Viscosity Swallow Test (V-VST) for oropharyngeal dysphagia and aspiration in a homogeneous stroke patient sample. METHODS: Cohort study of 52 stroke patients in a subacute phase. Piecemeal deglutition and oropharyngeal residue were considered signs of impaired efficacy and cough, fall in oxygen saturation and voice changes, signs of impaired safety. Sensitivity, specificity, positive and negative predictive values, accuracy and likelihood ratios were calculated for V-VST results and compared with those of videofluoroscopy (VFS), the gold standard for studies on swallowing disorders. RESULTS: The V-VST is a highly sensitive and specific test to detect aspiration with sensitivity of 88.2% and specificity of 71.4%; negative predictive value was 92.6%; accuracy index was 0.74. Sensitivity and specificity for penetration were 34.3% and 70.6%, respectively; accuracy was 32%. CONCLUSIONS: The V-VST is low in cost, easy to use and very sensitive, meeting the requirements of oropharyngeal dysphagia and aspiration screening test in subacute stroke patients.

Effects of information and training provision in satisfaction of patients and carers in stroke rehabilitation.

BACKGROUND: Active information and training improves patient and carer knowledge of stroke and aspects of patient satisfaction, as well as reduces patient depression. OBJECTIVE: To evaluate the effect of a post-stroke information and carer training intervention provided in the rehabilitation hospital setting on patient and carers' satisfaction. METHODS: Nonrandomized, controlled trial with 241 patients consecutively admitted in a post-stroke rehabilitation unit and their carers. The first 140 underwent a standard rehabilitation program (control group) and the 131 following attended an additional class (intervention group). Satisfaction was assessed with the Satisfaction Pound Scale administered by telephone 6 months after stroke in 74 patients and 85 carers from the control group and in 76 patients and 73 carers from the intervention group. RESULTS: Over 80% of patients in both groups were satisfied with information, care and therapy during hospitalization. The amount of therapy and support at discharge were the issues that arouse greater dissatisfaction. Patient and carers' satisfaction with information, support and accessibility to rehabilitation team after hospital discharge improved after the intervention (p < 0.001). CONCLUSIONS: Systematic active information, training and community support provision for stroke patients and carers improves satisfaction with stroke rehabilitation programs and support received after hospital discharge.

Effectiveness of an interactive virtual telerehabilitation system in patients after total knee arthoplasty: a randomized controlled trial.

OBJECTIVE: To compare the effectiveness of a new interactive virtual telerehabilitation system and a conventional programme following total knee arthroplasty. DESIGN: Randomized, controlled, single-blind clinical trial. PARTICIPANTS: A total of 142 total knee arthroplasty patients. METHODS: Participants were randomly assigned to receive either: (i) conventional out-patient physical therapy; or (ii) interactive virtual telerehabilitation system. The main outcome was function assessed with active range of knee movement. Other variables, such as muscle strength, walk speed, pain and the Western Ontario and McMaster Universities osteoarthritis index, were also collected. Comparisons were made on the basis of data collected routinely before surgery, at the end of the rehabilitation programme, and at 3 months follow-up. Quantitative variables were compared by Mann-Whitney U test. The agreed alpha risk for all hypothesis testing was 0.05. RESULTS: Baseline characteristics between groups were comparable. All participants improved after the 2-week intervention on all outcome variables (p < 0.05). Patients in the interactive virtual telerehabilitation group achieved improvements in the functional variables similar to those achieved in the conventional therapy group. CONCLUSION: A 2-week interactive virtual telerehabilitation programme is at least as effective as conventional therapy. Telerehabilitation is a promising alternative to traditional face-to-face therapies after discharge from total knee arthroplasty, especially for those patients who have difficulty with transportation to rehabilitation centres.

High-intensity vs. sham inspiratory muscle training in patients with chronic heart failure: a prospective randomized trial.

AIMS: The purpose of this study was to evaluate the effectiveness, feasibility, and safety of a 4-week high-intensity inspiratory muscle training (hi-IMT) in patients with chronic heart failure (CHF). METHODS AND RESULTS: A double-blind randomized clinical trial was carried out in 22 patients with CHF. Participants were assigned to the hi-IMT or sham-IMT group. The trainer device was a prototype of the Orygen-Dual Valve. The training workloads were adjusted weekly at the inspiratory pressure which allowed the performance of 10 consecutive maximal repetitions (10RM). Main outcomes were strength and endurance of the respiratory muscles assessed by maximal respiratory pressures (PImax and PEmax) and a 10RM manoeuvre, respectively. Twenty-one patients presented impairment in respiratory muscle strength and endurance. Patients in the hi-IMT group showed a significant improvement in both strength and endurance: inspiratory muscle strength in the intervention group increased 57.2% compared with 25.9% in the control group (P = 0.001). The percentage change in endurance was 72.7% for the hi-IMT group compared with 18.2% in the sham-IMT group (P < 0.001). No adverse effects occurred during the intervention. CONCLUSION: A 4-week hi-IMT with the use of the Orygen-Dual Valve is shown to be an effective, feasible, and safe tool to improve weakness and fatigue of the inspiratory muscles. The key point of this study is to discuss immediate practical implications in terms of respiratory muscle dysfunction postulated as a potential prognostic factor and as an additional therapeutic target. TRIALS REGISTRATION: NCT01606553.