126 CHAPTER 7 included an increased sum of three muscle sites (MD 0.5cm, CI [0.12; 0.88], SMD 0.47; thigh muscle area (MD 1.0cm2, CI [0.27; 1.73], SMD 0.50), and forearm muscle thickness (MD 0.4cm, CI [0.26; 0.55], SMD 0.99). Higher protein resulted in significantly less quadriceps muscle layer loss (MD 0.22, CI [0.06; 0.38]).54 No statistically significant differences were seen in the change in femoral muscle loss, mid-upper arm circumference, and biceps muscle thickness or leg circumference on day 7. 7.3.7 Effects of protein provision on nutritional delivery The majority of the studies reported nutritional data, of which in five studies protein and energy delivery was a primary or secondary outcome measure (Appendix 2; table S4). 46,47,50,54,58 Nutritional data were reported using the delivery of protein or kcal at a particular time point (between day 7-28), or the mean delivery between two timepoints. Of these studies, statistically significant differences in protein delivery after intervention were demonstrated in four studies.46,47,54,58 Required protein targets and prescriptions were addressed differently (e.g., based on clinicians’ estimation, clinical guidelines, or measured Figure 4. Forest plot of the effects of protein provision on muscle health (standardised mean difference) (SMD> 0 favours intervention. Abbreviations: BD: baseline difference. PI: Post-interventionCI: confidence interval. CT: Computed Tomography scan. FML: femoral muscle loss. MT: muscle thickness. MUAC: mid-upper arm circumference. SD: standard deviation. SMD: standardised mean difference. Total: number of participants. QMLT: quadriceps muscle layer thickness (midpoint and two-third landmarks, mean of 4 linear thicknesses were calculated for each leg separately). US: Ultrasound technology. Notes: Fetterplace (2018): MD=0.22cm, robust SE 0.08. missing at baseline and discharge in n=6 (23%) in intervention and n=7 (27%) in the comparator group. Ferrie(2016): study results showed p-values for muscle health measures, conducted with analysis of covariance to assess the effect study days 0, 3, and 7, with covariate adjustment including each baseline measure. Missing values were replaced using imputation but results were reported without the replaced value. A total of n=47(39%) and n=7(6%) missing variables for US measurements and leg circumference respectively, with n=25(42%)/n=22(37%) and n=4(57%)/n=3(43%) in intervention/comparator group. Wandrag: 50% of measurements completed. Study Nakamura 2021 FML change % (BD; day 1-10) Ferrie 2016 Forearm MT, cm (PI; day 7) Ferrie 2016 Biceps MT, cm (PI; day 7) Ferrie 2016 Thigh muscle area, cm2 (PI; day 7) Ferrie 2016 Sum 3 muscle sites, cm (PI; day 7) Fetterplace 2018 Change in MUAC, cm (BD; ICU.adm-disch. Ferrie 2016 Leg circumference, cm (PI; day 7) Total 338 25 59 59 59 59 18 59 Mean 14.0 3.2 2.5 6.8 8.4 -1.7 35.9 SD 8.8 0.4 0.6 2.1 1.0 1.5 4.3 Intervention Total 351 31 60 60 60 60 20 60 Mean 17.5 2.8 2.4 5.8 7.9 -2.0 35.9 SD 7.7 0.4 0.4 1.9 1.1 1.2 4.4 Comparator -1 -0.5 0 0.5 1 Standardised Mean Di erence The effects of protein provision on muscle health, SMD>0 favours intervention SMD -0.42 0.99 0.20 0.50 0.47 0.22 0.00 95%-CI [-0.95; 0.11] [ 0.61; 1.38] [-0.17; 0.56] [ 0.13; 0.86] [ 0.11; 0.84] [-0.42; 0.86] [-0.36; 0.36]
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