Total Psoas Area and Psoas Density Assessment in COVID-19 Patients Using CT Imaging – Could Muscle Mass Alteration During Intensive Care Hospitalization be Determined?

Study design	Cohort, observational, retrospective and monocentric
Setting	Anaesthesia and Intensive Care Unit, Târgu Mureș Emergency County Clinical Hospital, Romania Period of recruitment: August 2020 – December 2022 Exposure: COVID-19 Follow-up: two psoas CT scans Data collection: electronic medical and imagistic records
Participants	Eligibility criteria: ≥ 18 years of age admitted in the ICU for at least 24 hours, positively tested for SARS-COV2 by real-time polymerase chain reaction (RT-PCR), and who had two eligible CT scans for psoas analysis
Variables	Main outcomes: analysis of the changes in psoas area and psoas HU in critically ill Predictors: length of stay in hospital, length of stay in ICU, mechanical ventilation Diagnostic criteria: psoas analysis by CT scan
Data sources/measurement	Data sources: Picture Archiving and Communicating System and RadiAnt DICOM Viewer Measurement: Psoas muscle area and density (HU) were measured at the level of the third lumbar vertebrae
Study size	Inclusion of critically ill patients who were hospitalized in the ICU for more than 24h, adults, that had two eligible CT scans for psoas assessment
Statistical methods	To conduct the statistical analysis, SPSS, version 27 (SPSS Inc. Chicago, IL, USA) was utilized. Continuous data are presented as medians (minimum-maximum) or means (±standard deviation) and categorical data as proportions. The Kolmogorov–Smirnov test was used to assess the normal distribution of continuous numerical variables. The Mann-Whitney U test was used for non-Gaussian variables, and Student’s t-test was used for the Gaussian continuous variables. Inter-variability is performed by Bland and Altman methods. Receiver operating characteristics curve analysis was performed. Area under the curve values were displayed including a 95% confidence interval. For correlations, Spearman’s coefficients were used. A p-value of less than 0.05 was considered statistically significant.

CT psoas muscle evaluation at the third lumbar vertebrae. A. Cross-sectional area evaluation showing muscle area. B. Evaluation of muscle density in Hounsfiled unit.

Table 2.

Patients’ characteristics

Demographics	All patients (n=22)
Male sex (n, %)	8 (36.4%)
Age (years, mean±SD)	71.09±10.57
ICU admission diagnostics
ARF (n, %)	11 (50%)
Other (n, %)	11 (50%)
Severity scores
qCSI (mean±SD)	8.73±2.27
CHOSEN score (median (min-max))	13 (1–44)
modified CHOSEN score (mean±SD)	19.33±9.81
Hospital stay characteristics
LOS in Hospital (days) (median (min-max))	18 (10–91)
LOS in ICU (days) (median (min-max))	11 (2–91)
Time period between CTpsoas1 and CT psos2 (days) (medain (min-max))	10 (3–19)
ICU admission oxygenation
Facial mask (n, %)	9 (40.9%)
NIV-CPAP (n, %)	2 (9.1%)
IMV (n, %)	11 (50%)
ICU stay oxygenation
Need for NIV-CPAP (n, %)	5 (22.7%)
Need for IMV (n, %)	18 (81.8%)
IMV <24 hours	3 (13.6%)
IMV 24–96 hours	2 (9.1%)
IMV >96 hours	13 (59.1%)
Admission laboratory report
WBC (mean±SD)	12.307±8.421
Neutrophils (mean±SD)	10.381±7.924
Lymphocytes (mean±SD)	0.958±0.783
Platelets (median (min-max))	262.500 (90.000–1081.000)
NLR (median (min-max))	10.537 (3.758–66.631)
PLR (median (min-max))	382.907 (59.644–1184.2100)
SII (median (min-max))	2361.589 (474.000–42981.947)
CRP (median (min-max))	106.810 (5.660–353.300)
Creatinine (median (min-max))	1.025 (0.140–8.160)
Glucose (mean±SD)	149.136±73.879

[i] ICU: Intensive Care Unit; ARF: acute respiratory failure; qCSI: quick COVID-19 Severity Index; CHOSEN score: COVID Home Safely Now; LOS: length of stay; NIV-CPAP: non-invasive ventilation-continuous positive airway pressure; IMV: invasive mechanical ventilation; WBC: white blood cells (normal range 3.6–10 10³ /μL); Neutrophils (normal range 1.4–6.5 10³ /μL); Lymphocytes (normal range 1.2–3.4 10³ / μL); Platelets (normal range 150–450 10³ /μL) NLR: neutrophil to lymphocyte ratio; PLR: platelet to lymphocyte ration; SII: systemic immune-inflammation index = neutrophil x platelet/lymphocyte; CRP: C reactive protein (normal range 0–5 mg/L); Creatinine (mg/dL, normal range 0.7–1.20 mg/dL).Glucose (g/dL, ≥180g/dL high serum glucose), SD: standard deviation

Box-plot comparing right and left changes in psoas muscle area (A) and psoas muscle HU (B).

Table 3.

Assessment of total psoas area and psoas HU in the first and second CT scan

CT scan parameter	Investigator A Mean±SD	Investigator B Mean±SD	Mean Difference	p difference A and B
Right TPA1(cm²)	8.01±2.70	7.72±2.97	−0.29	0.73
Right TPA2(cm²)	8.39±3.19	7.08±2.92	−1.31	0.15
Left TPA1(cm²)	8.71±3.80	8.41±3.42	−0.29	0.78
Left TPA2(cm²)	8.19±3.20	7.70±3.27	−0.48	0.61
Right psoasHU1	35.95±10.86	39.34±10.27	3.38	0.28
Right psoasHU2	30.55±13.00	36.40±10.65	5.83	0.10
Left psoasHU1	38.49±10.35	41.86±10.99	3.37	0.29
Left poasHU2	34.68±11.99	37.86±9.69	3.18	0.33

[i] CT: computed tomography; TPA1: total psoas area in the first CT scan; TPA2: total psoas area in the second CT scan; HU: Hounsfield units in the first CT scan; HU2: Hounsfield units in the second CT scan; SD: standard deviation

Table 4.

Dynamic changes in total psoas area and psoas HU in two CT scan evaluations

CT scan parameter	CT1 (A+B) Mean±SD	CT2 (A+B) Mean±SD	Difference Mean	p difference 1^st and 2^nd
Right TPA(cm²)	7.82±2.76	7.70±2.90	−0.12	0.88
Left TPA(cm²)	8.52±3.56	7.92±3.20	−0.59	0.56
Right psoas HU	37.4±10.21	33.16±10.31	−4.24	0.17
Left psoas HU	39.9±10.06	35.93±9.33	−3.99	0.17

[i] CT1: mean results of investigator A and investigator B for the first CT scan; CT2: mean results of investigator A and investigator B for the second CT scan; TPA: total psoas area; HU: Hounsfield units; SD: standard deviation

AUC-ROC for psoas area and IMV. A. IMV <24 hours. B. IMV 24-96 hours. C. IMC >96 hours.

AUC-ROC for psoas HU and IMV. A. IMV <24 hours. B. IMV 24-96 hours. C. IMC >96 hours.

Right and left psoas analysis (area - A and HU - B) linked to the patients outcome

Table 5.

AUC-ROC for the Psoas area and IMV duration

IMV duration (hours)	Psoas area (cm²)	Criterion	AUC-ROC	95% CI	p	Sn	95% CI	Sp	95% CI
<24	Right	>−0.654	0.583	0.362–0.783	0.53	100.00	29.2–100.0	40.00	19.1–63.9
Left	≤−1.205	0.667	0.442–0.847	0.39	66.67	9.4–99.2	80.00	56.3–94.3
24–96	Right	>0.275	0.929	0.741–0.994	0.0001	100.00	15.8–100.0	85.71	63.7–97.0
Left	>0.307	0.833	0.621–0.954	0.0001	100.00	15.8–100.0	80.95	58.1–94.6
>96	Right	≤−0.654	0.600	0.377–0.796	0.43	53.85	25.1–80.8	90.00	55.5–99.7
Left	>0.599	0.508	0.294–0.720	0.951	23.08	5.0–53.8	100.00	69.2–100.0

[i] AUC-ROC: Area Under the Curve Receiver Operating Characteristics: Sn: Sensitivity; Sp: Specificity; CI: Confidence Interval; IMV: invasive mechanical ventilation

Table 6.

AUC-ROC for psoas HU and IMV duration

IMV duration (hours)	Psoas (HU)	Criterion	AUC-ROC	95% CI	P	Sn	95% CI	Sp	95% CI
<24	Right	>−0.01	0.850	0.640–0.963	0.0001	100.00	29.2–100.0	75.00	50.9–91.3
Left	>−7.515	0.683	0.458–0.859	0.29	100.00	29.2–100.0	40.00	19.1–63.9
24–96	Right	≤−2.675	0.595	0.373–0.792	0.53	100.00	15.8–100.0	47.62	25.7–70.2
Left	>−5.505	0.548	0.329–0.754	0.70	100.00	15.8–100.0	47.62	25.7–70.2
>96	Right	≤−4.12	0.715	0.491–0.882	0.049	69.23	38.6–90.9	70.00	34.8–93.3
Left	≤−4.27	0.623	0.399–0.814	0.31	69.23	38.6–90.9	60.00	26.2–87.8

[i] AUC-ROC: Area Under the Curve Receiver Operating Characteristics: Sn: Sensitivity; Sp: Specificity; CI: Confidence Interval; IMV: invasive mechanical ventilation; HU: Hounsfield units

Table 7.

AUC-ROC for the negative outcome (deceased patients)

CT scan parameter	Criterion	AUC-ROC	95% CI	P	Sn	95% CI	Sp	95% CI
Right psoas area	>−0.45	0.571	0.351–0.773	0.610	56.2	29.9–80.2	71.4	29.0–96.3
Right psoas HU	>−12.59	0.571	0.350–0.773	0.633	81.2	54.4–96.0	42.9	9.9–81.6
Left psoas area	>−0.319	0.509	0.295–0.721	0.944	43.7	19.8–70.1	85.7	42.1–99.6
Left psoas HU	>−10.35	0.643	0.418–0.829	0.362	93.7	69.8–99.8	57.1	18.4–90.1

[i] CT: computed tomography; HU: Hounsfield units; AUC-ROC: Area Under the Curve Receiver Operating Characteristics: Sn: Sensitivity; Sp: Specificity; CI: Confidence Interval

Table 8.

LOS in hospital and LOS ICU correlations with psoas area and HU

CT scan (mean A+B)	LOS	Right psoas (cm²)		Right psoas (HU)		Left psoas (cm²)		Left psoas (HU)
Correlation coefficient	P	Correlation coefficient	p	Correlation coefficient	p	Correlation coefficient	p
CT scan1	Hospital	0.015	0.94	0.202	0.36	−0.054	0.810	0.362	0.09
ICU	−0.349	0.11	0.417	0.02	−0.322	0.11	0.666	0.01
CT scan2	Hospital	−0.087	0.70	−0.198	0.37	−0.069	0.76	−0.007	0.97
ICU	−0.307	0.16	0.007	0.97	−0.263	0.23	0.250	0.26

[i] CT: computed tomography; LOS: length of stay; ICU: intensive care unit; HU: Hounsfield units

References

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DOI: https://doi.org/10.2478/jccm-2023-0026 | Journal eISSN: 2393-1817 | Journal ISSN: 2393-1809

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Language: English

Page range: 218 - 229

Submitted on: Jun 19, 2023

Accepted on: Sep 19, 2023

Published on: Nov 14, 2023

Published by: University of Medicine, Pharmacy, Science and Technology of Targu Mures

In partnership with: Paradigm Publishing Services

Publication frequency: 4 issues per year

Keywords:

CT scan,

Related subjects:

Internal medicine, other,

Surgery,

Surgery, other,

Anaesthesiology,

Emergency medicine and intensive-care medicine

© 2023 Oana Elena Branea, Anca Gabriela Vlad, Mihai Pui, Diana Andreea Becica, Mihai Emanuel Becica, AnaMaria Romina Budeanu, Razvan Gabriel Budeanu, Florin Stoica, Alexandra Elena Lazar, published by University of Medicine, Pharmacy, Science and Technology of Targu Mures
This work is licensed under the Creative Commons Attribution 4.0 License.

Volume 9 (2023): Issue 4 (October 2023)

Total Psoas Area and Psoas Density Assessment in COVID-19 Patients Using CT Imaging – Could Muscle Mass Alteration During Intensive Care Hospitalization be Determined?

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