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Factors associated with the concomitant occurrence of low muscle mass and low muscle radiodensity are unclear. This study investigated whether different skeletal muscle phenotypes are associated with functional impairment, serum inflammatory markers, and survival in patients with incurable cancer.Three hundred and twenty-six patients (median age, 60 years; 67.5% female) who had abdominal or pelvic computed tomography (CT) scans up to 30 days before the initial assessment were enrolled in the study. CT images were used for the assessment of skeletal muscle index (SMI) and skeletal muscle radiodensity (SMD). Optimal stratification analysis was used to derive cohort-specific cutoff points to define SMI and SMD groups with a higher risk for mortality (SMI, males45.0 cmPhenotypes with high-risk SMI or high-risk SMD, especially when combined, were associated with low handgrip strength, poor performance status, higher C-reactive protein, and lower serum albumin levels. The phenotypes with high-risk SMD, regardless of low-risk SMI (hazard ratio [HR], 1.74; 95% CI, 1.05-2.88) or high-risk SMI (HR, 1.99; 95% CI, 1.29-3.05) were associated with higher 90 days' mortality risk.In patients with incurable cancer, phenotype groups with high-risk SMI and high-risk SMD, particularly when combined, were associated with worse functional impairment and inflammation. Moreover, high-risk SMD was associated with increased mortality risk.

The study aimed to evaluate the effect of muscle mass, alone and combined with muscle strength, in predicting survival in patients with incurable cancer. Muscle mass was assessed by computed tomography (CT).Low muscle mass and low muscle strength was defined, respectively, by skeletal muscle index (SMI) assessed by CT and handgrip strength (HGS) below the first tertile of the studied sample, as follow: SMI41.3 or34.9 cmA total of 386 patients were included, and the median OS was 43 [interquartile range (IQR): 15-96] days. Considering the appropriate SMI and HGS as the reference group, a significantly lower OS was observed in the group with low SMI + low HGS [54 (IQR: 38-69) versus 22 (IQR: 10-33) days; p 0.001]. Patients with low HGS alone presented lower OS than those of the appropriate group [52 (IQR: 42-61) versus 24 (IQR: 17-30) days; p 0.001], but no differences were observed in the groups with low SMI alone versus appropriate [46 (IQR: 35-56) versus 40 (IQR: 30-49) days; p = 0.365]. The adjusted Cox regression demonstrated that low HGS alone [hazard ratio (HR): 1.51; 95% confidence interval (CI): 1.20-1.91] and low SMI + low HGS group (HR: 1.77; 95% IC: 1.28-2.44) had higher risk of 180-day mortality. Muscle mass combined with muscle strength improved OS prediction compared to these measurements alone in patients with incurable cancer.

ObjectiveTo evaluate current evidence of the effect of specialised nutritional interventions on nutritional status, survival, quality of life and measures of functionality in patients with incurable cancer.MethodsSystematic literature review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed/MEDLINE, EMBASE, Scopus, LILACS and Cochrane Library databases. Clinical studies that evaluated different specialised nutritional interventions, such as nutritional counselling, oral nutritional supplementation (ONS), enteral nutrition (EN) and parenteral nutrition (PN), were eligible. Only studies classified as being of high methodological quality (ie, low or moderate risk of bias) were included.ResultsA total of 22 studies reporting on 2448 patients were deemed eligible. Five types of specialised nutrition were observed: mixed (multimodal nature, ie, dietary counseling, ONS, physical activity and/or drugs) (n=12), ONS (n=5), PN (n=3), EN (n=1) and multidisciplinary team counselling (n=1). Benefits of any kind from the interventions were reported in 14 (63.6%) studies, mainly resulting from mixed intervention. Nutritional status improved in 12 (60.0%) of 20 studies and quality of life improved in eight (50.0%) of 16 studies. Few studies have evaluated the influence of nutritional interventions on survival and measure of functionality, and have not shown improvement in these outcomes.ConclusionDespite the limited evidence, specialised nutritional interventions can yield positive effects for patients with incurable cancer, mainly in their nutritional status and quality of life.

Background: Traditionally, hypermetabolism is described in sickle cell disease (SCD). Despite this, few studies have compared rest energy expenditure (REE) with estimated by predictive equations (EEE) in the assessment of adults with SCD. Aims: To compare REE values determined by indirect calorimetry (IC) with that EEE in adults with SCD. Subjects and Methods: A cross-sectional observational study was performed with 46 individuals over 34 years old in the treatment from two reference centers for SCD located in the city of Rio de Janeiro, Brazil. The dual-energy X-ray absorptiometry (DXA) and IC were used to assess BC and REE, respectively. Blood levels were measured to assess hemolytic and protein markers. Pearson’s correlation test was used in the univariate correlation. The Intraclass Correlation Coefficient (ICC) and the Bland-Altman analysis were used in the comparison between EEE and IC. P-values ≤ 0.05 were considered statistically significant. Results: Most participants were from the female sex, Hb SS genotype (80.4%) and with black color (52.2%). The mean age was 50 years old. Weight (r= 0.469; p=0,001), LM (r = 0.631; p=0.000), BMC (r = 0.508; p=0.000) and CRP(r=0.319; p = 0.002) correlated positively with the REE. There was no linear correlation between makers of hemolysis with REE. The REE was overestimated in the EEE when compared to IC (p

This study aimed to develop and validate a distinct method to evaluate muscle mass phenotype in patients with incurable cancer based on a combination of mid-upper arm muscle area (MUAMA) and handgrip strength (HGS).This prospective cohort study was conducted with patients with incurable cancer who were enrolled at the palliative care unit of a cancer institute. The 1,660 patients were randomized into two data sets: training (70%; n = 1162), used to determine the muscle mass phenotype groups, derived from a combination of MUAMA and HGS cutoff points related to 180-days mortality; and validation (30%; n = 498), used to evaluate the relationship of the proposed muscle phenotype grading system with performance status, body composition, nutrition status, and mortality.The training data set resulted in three distinct groups formed by combining the cutoff points of MUAMA and HGS, with the best muscle mass phenotype being group 1, the group with any impairment of muscle mass being the 2, and the worst muscle mass phenotype being group 3. In the validation data set, lower performance status (both sexes p 0.001), worse skeletal muscle index (both sexes p 0.001), muscle radiodensity (men, p = 0.001; women, p = 0.008), and nutritional status (men, p = 0.003; women, p 0.001) were observed as MUAMA and HGS values diminished. Patients in group 3 presented significantly higher risk of 180-day mortality (both sexes p 0.001).The muscle mass phenotype grading system proved to be able to identify patients with lower performance status, worse body composition measurements and nutritional status, and higher risk of death in 180 days.

Background: Evidence about how inflammatory biomarkers vary during the end-stage cancer trajectory is lacking. This study investigates the longitudinal changes in albumin and C-reactive protein (CRP) levels, and CRP/albumin ratio (CAR) in patients with terminal cancer receiving palliative care in the last three months of life.Methods: This is a retrospective analysis of variables extracted from a prospective cohort study that included admitted patients to the exclusive Palliative Care Unit of the National Cancer Institute in Brazil. Routine blood examination results of albumin and CRP were recorded at 0-15 (T1), 16-30 (T2), 31-45 (T3), 46-60 (T4), 61-75 (T5), and 76-90 (T6) days before death and only patients with at least two measurements were included. Crude and adjusted linear mixed-effects regression models were performed to verify the relationships between the longitudinal trajectories of biomarkers and death. Results: A total of 1,635 patients were included. Median albumin was 3.00g/dL across the whole time-period analyzed (interquartile range, IQR: 2.50-3.60) and decreased with the approach of death, while median CRP was 9.31mg/L (IQR: 4.42-17.30) and CAR was 3.20 (IQR: 1.40-6.60), and both increased. The albumin (slope: 0.01 to 0.02; p p p Conclusions: The longitudinal change levels of inflammatory biomarkers worsen with the approach of death and could be used to predict end-stage in patients with terminal cancer.

BACKGROUND The Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF) is a standardized tool for assessing nutrition risk in patients with cancer. The aim of this study was to propose and validate a cutoff point for the PG-SGA SF related to the prognosis of patients with incurable cancer in exclusive palliative care. METHODS This is a prospective cohort study of patients with incurable cancer at the National Cancer Institute in Brazil. A total sample (n = 2,144) was randomly divided into groups: (1) training (n = 1,072), to determine the most accurate PG-SGA SF cutoff, and (2) validation (n = 1,072), to test the predictive accuracy of this cutoff point. The receiver operating characteristic curve was plotted to determine the best cutoff point of the PG-SGA SF related to death. Concordance statistics (C statistic) were used to test the predictive accuracy of the models. Kaplan-Meier curve and the Cox hazard model were used to verify a prognostic value of the cutoff point. RESULTS PG-SGA SF score ≥15 was found to be the best cutoff based on 90-day mortality with good accuracy discrimination (C statistic ≥ 0.74). Patients whose PG-SGA SF score was ≥15 had a shorter survival of 32 (interquartile range [IQR], 12-75) vs 83 days (IQR, 31-90) (p-value < .001) and higher risk of death (hazard ratio: 2.20; 95% CI, 1.64-2.95). CONCLUSIONS The proposed PG-SGA SF cutoff score is valid and, alongside its usefulness in nutrition triage, could provide prognostic value for patients with incurable cancer.

ObjectivesWe aimed (1) to assess the nutritional status (NS) using different methods, according to the primary tumour site and (2) to evaluate the performance of these methods in patients with incurable cancer from a reference centre in Brazil.MethodsCross-sectional analysis of data from patients admitted to the palliative care unit of a reference cancer centre in Brazil, between July 2016 and March 2020. The primary tumour site was the independent variable and the NS using different methods were the dependent variables. Logistic regressions were performed.ResultsA total of 2,144 patients were included in the study. The most common primary tumour site was the upper gastrointestinal (GI) tract (18.0%), followed by gynaecological (17.6%) and head and neck (HN) (13.5%). Our results showed that patients with tumours of the upper GI tract followed by HN presented significantly higher risk of worse NS. In contrast, breast tumours, bone and connective tissues and melanoma presented inverse association. The gynaecological cancer was variably associated with nutritional impairment, according to the assessment method.ConclusionsPatients with incurable cancer present high prevalence of NS impairment, depending on the tumour site, shown to be elevated in patients with tumour in the upper GI tract.

Introduction: The sickle cell trait is a genetic mutation characterized by the presence of hemoglobin S (HbS) in heterozygosis in which patients are asymptomatic, which makes them suitable for blood donation. Aim: Systematizing data related to the prevalence of the sickle cell trait among blood donors. Materials and methods: A search of the literature was conducted in May 2019 to seek articles published from 1990 and which had available online abstracts, in four electronic databases. Studies were selected with the following characteristics: (1) original work; (2) observational; (3) developed with blood donors; and (4) showing prevalence of sickle cell trait. Two independent reviewers identified the articles for inclusion in this systematic review of the literature (SRL), extracted the pre-determined data and carried out the evaluation of the works’ methodological quality. Results: Eight studies published in the last 12 years in different countries were selected to take part in this SRL. With variable sample size, all presented a cross-sectional methodology. For the detection of the presence of HbS, electrophoresis in alkaline pH was commonly used. The statistical analysis developed involved simple techniques, showing that the prevalence of blood donors with sickle cell trait ranged from 0.4% to 20.8%. The majority of studies was considered of high methodological quality. Conclusion: The prevalence of sickle cell trait among blood donors varies widely, although it may not be moderate, given that the screening of HbS has important clinical significance for the proper use of this blood component. Keywords: Sickle cell trait; Blood donor; Blood transfusion.

The aim of the present study was to evaluate the association between sarcopenia, diagnosed by different muscle mass measurement techniques, with nutritional status and overall survival in patients with advanced cancer under palliative care.To investigate the association of sarcopenia, according to distinct muscle mass measurement methods, with nutritional status and overall survival (OS).This observational and prospective study, including 334 patients, defined sarcopenia as reduced muscle mass and strength. Muscle mass was evaluated adopting 3 different methods, mid-upper arm muscle area (MUAMA), calf circumference (CC) and appendicular skeletal muscle mass (ASMI) described by Baumgartner (1998) and adjusted for height. Strength was defined using a handgrip dynamometer and OS was established based on a 90 days follow-up after inclusion date. Kaplan-Meier curves were conducted for survival analyzes and the association between sarcopenia and OS was evaluated by Cox regression model RESULTS: Prevalence of sarcopenia varied from 27-65% according to the method used to evaluate muscle mass. Malnutrition assessed by different parameters was significantly higher in patients with sarcopenia. Patients considered sarcopenic by MUAMA (43 versus 67 days, p0.001), CC (44 versus 77 days, p0.001) and ASMI (48 versus 75 days, p0.001) had significantly lower OS compared to non-sarcopenic patients. Sarcopenia evaluated by MUAMA (HR, 1.57; 95% CI, 1.12-2.18) and CC (HR, 2.00; 95% CI, 1.45-2.76) showed a higher risk of mortality.Sarcopenia diagnosed by MUAMA and CC could predict mortality and CC proved to be the best prognostic method for estimating OS in patients with advanced cancer in palliative care.

Objectives Previous attempts to classify cancer cachexia (CC) have demonstrated limitations regarding stages and diagnostic criteria. This study aims to develop and validate a new staging system for CC in patients with incurable cancer. Methods This is an analysis of a database from a prospective cohort study of 1325 patients with advanced cancer referred for palliative care between 2016 and 2020. The cohort was randomly divided into two groups: Development (882 patients) and validation (443 patients) sets. A hierarchical cluster analysis was performed to distinguish different stages of CC in the development set. Next, the optimal cutoff points and ideal combinations of the most important factors associated with the CC groups (clusters) were ascertained. Finally, the relationship between the CC stages determined using the new system and body composition, quality of life, and overall survival was verified with the validation set. Results The new system classified CC into three stages: Precachexia (10.8%), cachexia (57.8%), and refractory cachexia (31.4%), based on a combination of percentage weight loss in the past 6 mo ( 26.4 kg/m2), and mid-upper-arm muscle area (≥38.0/≥35.5 or Conclusions This study presents a useful, valid system for CC staging in the clinical setting, and is also capable of predicting outcomes, including quality of life and overall survival.

Handgrip strength (HGS) is a potential predictor of outcomes in cancer setting. However, reference values for this population are lacking. The study aimed to describe reference values and cutoff point for HGS in adults with incurable cancer in Brazil and to verify the association of reference values with prognostic. Secondary analysis of a prospective cohort, conducted with 1,868 patients at the National Cancer Institute in Brazil were analyzed. HGS (kg) data were obtained with a Jamar® hydraulic dynamometer. Description of percentile values of HGS was stratified by sex and age groups. Receiver operating characteristic curve was performed to determine the optimal HGS cutoff point by sex and age according to performance status. Kaplan–Meier curves was used to analyze the probability of survival and Cox’s proportional model used to identify whether HGS predict 180-d mortality. HGS value was significantly higher in male than in female and decreased with increasing age. Sex-specific HGS cutoff values ranged from 32.5 to 24.5 kg in males and 20.5 to 18.5 kg in females (with younger adults stronger than the older ones). When compared to HGS ≥50th, patients with HGS ≤10th percentile had significantly lower survival, as well as patients classified below the HGS cutoff point. In addition, patients with lower HGS percentiles showed increased risk of mortality regardless of sex and age. Reference values can inform the clinical assessment of HGS, which is recognized as an important part of the identification of patients with incurable cancer with reduced physical function and short survival.

This study aimed to evaluate the prognostic value of nutritional and inflammatory status in patients with advanced cancer receiving palliative care.The systemic inflammatory response was assessed using the modified Glasgow Prognostic Score (mGPS), and nutritional status was evaluated according to the Patient-Generated Subjective Global Assessment (PG-SGA) in 172 patients evaluated on their first visit in the Palliative Care Unit at the National Cancer Institute in Brazil. The receiver operating characteristic (ROC) curve was used to define the best cutoff point for the death-related PG-SGA score in 90 d. Kaplan-Meier curves were conducted for survival analyses, and logistic regression analyses were performed using the Cox proportional hazards model.According to the PG-SGA, 83.6% of the patients (n = 143) were malnourished (B + C) and 34.8% (n = 53) had mGPS ≥1. The best cutoff of the PG-SGA score for death was ≥19 points (area under the curve, 0.69; P = 0.041). Patients with scores ≥19, mGPS ≥1, albumin3.5 g/dL, and C-reactive protein ≥10 mg/L had a significantly lower overall survival. According to the multivariate analysis, albumin3.5 g/dL (hazard ratio [HR], 2.04; 95% confidence interval [CI], 1.16-3.58), mGPS ≥1 (HR, 1.46; 95% CI, 1.09-2.22), and PG-SGA score ≥19 (HR, 1.66; 95% CI, 1.08-2.55) were independent prognostic factors for overall survival.The severity of the systemic inflammation and the poor nutritional status predict survival and were considered independent prognostic factors. Thus they can be useful tools for nutritional evaluation in palliative care.

Phase angle (PA) is a ratio between the reactance and resistance obtained by bioelectric impedance analysis and has been interpreted as a cell membrane integrity indicator and a predictor of total body cell mass. A low PA may suggest deterioration of the cell membrane, which in advanced cancer patients may result in a reduced overall survival (OS). This systematic review sought to investigate the current evidence regarding whether there is an association between PA and OS in patients with advanced cancer (ie, metastatic disease). The search was conducted on electronic databases in August 2017. A total of 34 articles were identified in the initial literature search. Nine studies reporting on 1496 patients were deemed eligible according to our inclusion criteria. PA data were analyzed as continuous variables or according to different cutoffs, under a frequency of 50 Khz. Low PA was associated with worse nutrition status evaluated by body mass index, serum albumin level, transferrin, and fat-free mass. The median OS of the included papers varied from 25.5-330 days, and all studies analyzed showed a significant association between PA and OS, in that patients with low PA had worse OS. Future studies are necessary to justify the use of PA in therapeutic decisions for this population and to evaluate whether nutrition status can influence the association between PA and survival.

Nutritional impairment is common in cancer patients and adversely affects quality of life (QoL). The aim of this study was to investigate the association between nutritional status and QoL in incurable cancer patients in palliative care. A prospective cohort with incurable cancer patients referred to the specialized Palliative Care Unit of the National Cancer Institute in Brazil was conducted. The nutritional risk (NR) was assessed using the Patient-Generated Subjective Global Assessment short form (PG-SGA SF), and cancer cachexia (CC) was defined according to the international consensus. QoL was evaluated using the Quality of Life Questionnaire Core 15 Palliative (QLQ-C15-PAL). Multivariate linear regressions analyses were performed to assess the relationship between the nutritional status and QoL scores. A total of 1039 consecutive patients were included. A high prevalence of NR (85.4%) and CC (78.7%) were observed. The patients with worse nutritional status presented significantly poorer physical, emotional, symptoms domains scales, and overall QoL. CC were significantly associated with QoL scores for dyspnea (p = 0.013), insomnia (p = 0.046), and appetite loss (p = 0.015), while NR were associated with all the QoL domains scales covered in QLQ-C15-PAL. Our findings support that impaired nutritional status was associated with poor QoL in incurable cancer patients. NR assessed by PG-SGA SF better reflects physical, emotional, symptom burden, and overall QoL scores. Thus, this tool may contribute in identifying patients at risk of deterioration QoL.

Current data suggest that low skeletal muscle mass provides prognostic information in patients with cancer and may even be considered a biomarker in research and clinical evaluations. The aim of this systematic review was to explore whether low muscle mass is associated with overall survival (OS) in patients with incurable cancer. A systematic search was conducted for published literature using PubMed/MEDLINE, Scopus, LILACS, and the Cochrane Library, with no restrictions on language or publication date, to examine whether low muscle mass is associated with OS in patients with incurable cancer. Eligible studies included low muscle mass evaluated using gold standard techniques (dual energy x-ray absorptiometry or computed tomography). The studies quality assessment was performed using the Newcastle-Ottawa Scale. Thirteen studies were included. The studies reported on 1959 patients between 54.3 (median) and 72.9 (mean) y of age; pancreatic cancer was the most common type of tumor. According to the survival curves and most of the multivariate analyses, there was no statistically significant association between loss of muscle mass and reduced OS. Four studies reported that overweight or obese patients with muscle mass depletion had significantly shorter OS. These results indicate that there is insufficient evidence to associate low muscle mass with OS in patients with incurable cancer. Further studies deploying other muscle measurement methods suggest that use of low muscle mass cutoff alone is still necessary in the pursuit of OS prediction in this population.

Introdução: O ângulo de fase (AF) pode estar relacionado ao estado nutricional em indivíduos com câncer. Objetivo: Investigar a correlação entre o AF e o estado nutricional em pacientes com câncer avançado. Método: Estudo transversal com indivíduos de ambos os sexos, idade >20 anos, em seu primeiro atendimento na unidade de cuidados paliativos do Instituto Nacional de CâncerJosé Alencar Gomes da Silva (INCA). O AF foi avaliado por meio da impedância bioelétrica, sendo considerados como baixos os valores

Summary Background & aims It is a challenge in clinical practice to identify and classify cancer cachexia. Currently, it has been extensively discussed if the presence of alterations in inflammatory biomarkers implies the presence of cachexia. This study aimed to evaluate the clinical relevance of cachexia classification through modified Glasgow Prognostic Score (mGPS) in advanced cancer patients in palliative care. Methods Observational prospective cohort study conducted at a Palliative Care Unit in Brazil. Cachexia classification was performed according to mGPS (based on albumin and C-reactive protein) in four different stages: no cachexia (NCa), undernourished (Un), pre cachexia (PCa), and refractory cachexia (RCa). Logistic regression models were used to test the association between cachexia stages and clinical, nutritional and functional domains. Kaplan–Meier curve and Cox multivariate model were used to analyze overall survival (OS). Results A total of 1166 patients were included in the study. According to the cachexia framework 37.5% were NCa, 32.3% Un, 3.9% PCa and 26.4% RCa. Significant differences were observed among cachexia stages for most of the outcome measures. This classification was able to predict mortality in 90 days [Un (HR, 1.55; 95% CI, 1.25; 1.93); PCa (HR, 2.00; 95% CI, 1.34; 2.98); RCa (HR, 2.45; 95% CI, 1.34; 2.98)]. Conclusion Cachexia stages were associated with significant differences in poor clinical outcomes and were also capable of predicting OS. This framework based on simple and objective criteria can be used as part of the routine to characterize the presence and stages of cachexia in advanced cancer patients.

Objectives Cancer cachexia (CC) is a multifactorial syndrome that is associated with worse outcomes. Several criteria for its diagnosis have been suggested, but notable disparities exist. This study compared different diagnostic criteria for CC in patients with incurable cancer who are in palliative care. Methods A prospective cohort study was conducted at the National Cancer Institute in Brazil. Patients were classified by three CC diagnostic criteria, and comparisons between clinical, nutritional, and functional variables were verified according to the CC stage identified. Kaplan-Meier survival curves and Cox regression were used for the survival analysis. Concordance statistics were used to test the prognostic predictive accuracy of the criteria. Results The prevalence of cachexia in the 1384 patients included in the study varied from 13.8% to 53.9% according to the classification criteria used. All criteria distinguished noncachectic patients from other categories according to the majority of the domains studied. However, the results were inconsistent in distinguishing patients with intermediate cachexia (mainly precachexia) from noncachectic and cachectic patients. Patients with cachexia or refractory cachexia faced a higher risk of 90-d mortality. The criteria described by Vigano et al. were found to be better at distinguishing the stages of CC regarding overall survival (hazard ratio increases according to CC severity: 1.87 to 2.87; concordance statistic: 0.74). Conclusions Our results demonstrate the disparities in existing CC diagnostic criteria and their inability to discriminate intermediate stages. Vigano et al.’s criteria is/was the most effective in predicting the prognosis. The development of new diagnostic criteria to improve CC classification requires future exploration.

Introdução: A sarcopenia pode comprometer a qualidade de vida de indivíduos com câncer. Objetivo: Avaliar a prevalência de sarcopenia e sua associação com estado nutricional e qualidade de vida em pacientes com câncer avançado em cuidados paliativos. Método: Estudo transversal com indivíduos com câncer em fase avançada, ambos os sexos, idade >20 anos, em seu primeiro atendimento na unidade de Cuidados Paliativos do Instituto Nacional de Câncer José Alencar Gomes da Silva. Variáveis analisadas: antropometria, força de preensão manual (FPM), Karnofsky performance status, qualidade de vida (QLQ-C15-PAL), avaliação subjetiva global produzida pelo paciente e exames laboratoriais. Para a classificação da sarcopenia, foram consideradas baixa massa muscular [circunferência muscular do braço (CMB) adequação