Enteral nutrition and refeeding syndrome in a patient with anorexia nervosa and COVID-19

Introduction: the evidence on the health problem-related prevalence of COVID-19 is an emergency. Case report: we present the case of a 28-year-old woman who had had a behavioral eating disorder (BED) since age 12. Her body mass index (BMI) was 13.6 kg/m2. She was hospitalized for a respiratory condition (bronchospasm) due to COVID-19, with supplementary oxygen at two liters. During her stay, she refused food and was started on standard enteral nutrition via a naso-gastric tube. She developed refeeding syndrome (RFS), which was managed with electrolytes, and her enteral diet was changed to a low-carbohydrate high-protein diet. She received psychological therapy through video calls, recovered, and was discharged to home. Discussion: refeeding complications increase when a high caloric rate is begun. The standard enteral formula has 54% carbohydrates, which contributes to the risk of developing RFS. The consequences of BED and COVID-19 are unknown, and it is likely to become more evident over time. (Acta Med Colomb 2022; 48. DOI:https://doi.org/10.36104/amc.2023.2626).

YAP regulates the liver size during the fasting-refeeding transition in mice

Liver is the central hub regulating energy metabolism during feeding-fasting transition. Evidence suggests that fasting and refeeding induce dynamic changes in liver size, but the underlying mechanisms remain unclear. Yes-associated protein (YAP) is a key regulator of organ size. This study aims to explore the role of YAP in fasting- and refeeding-induced changes in liver size. Here, fasting significantly reduced liver size, which was recovered to the normal level after refeeding. Moreover, hepatocyte size was decreased and hepatocyte proliferation was inhibited after fasting. Conversely, refeeding promoted hepatocyte enlargement and proliferation compared to fasted state. Mechanistically, fasting or refeeding regulated the expression of YAP and its downstream targets, as well as the proliferation-related protein cyclin D1 (CCND1). Furthermore, fasting significantly reduced the liver size in AAV-control mice, which was mitigated in AAV Yap (5SA) mice. Yap overexpression also prevented the effect of fasting on hepatocyte size and proliferation. Besides, the recovery of liver size after refeeding was delayed in AAV Yap shRNA mice. Yap knockdown attenuated refeeding-induced hepatocyte enlargement and proliferation. In summary, this study demonstrated that YAP plays an important role in dynamic changes of liver size during fasting-refeeding transition, which provides new evidence for YAP in regulating liver size under energy stress.

Analysis on 17 refeeding syndrome cases based on literature review of case reports / 中华临床营养杂志

Objective:To discuss the onset and development pattern and characteristics of refeeding syndrome (RFS) induced by nutrition support and to provide reference for rational drug use in parenteral nutrition management.Methods:Case reports of RFS from CNKI, Wanfang, VIP database and Pubmed from 2000 to 2020 were retrieved. The clinical data were collected and statistically analyzed.Results:A total of 17 reports, including 17 cases, were included in the analysis. Patients were 6 males(35.29%) and 11 females (64.71%). The distribution of age was from 29 weeks in a premature neonate to 87 years old. 12 cases (70.59%) of RFS occurred within 3 days after starting the nutrition support. The most common clinical manifestation were cardiovascular system symptoms (88.23%), with dyspnea as the most reported symptom (41.17%). 15 patients (88.23%) recovered after appropriate intervention and 2 patients died(11.76%).Conclusions:Refeeding syndrome is a potentially fatal condition. The risk of RFS should be assessed before initiating nutrition support. Patients at risk of RFS must be monitored closely at the early stage of nutritional support.

Eating Disorders in Adolescents - Physical and Psychiatric Perspectives

@#Eating disorder (ED) referrals of school age children and adolescents, by their parents and school teachers, have become more common. Also, they are now presenting at an earlier age to the primary health care and school systems, with physical, medical and psychological symptoms. Nevertheless, there is an average of six months to two years between the onset of symptoms to formal assessment and treatment by specialist team. There are also more cases presenting to ED specialist clinic services, especially pre-pubertal children, with early onset and presentation before 14 years old. Mid and late adolescent presentations (after 14 years old) continue to make up more than two third of the cases. More than 60 percent of cases seen in specialist clinics are of the restrictive type anorexia nervosa, and often associated with persistent and excessive exercise. Thirty percent of cases presented are Bulimia nervosa, which tend to be episodic. Majority of single episode bulimia cases do not present themselves early to medical services but take on open source self-directed management. For patients with bulimia who comply to treatment program and recover after 6-12 months of therapy, they can also experience high relapse rate as they often discontinue their follow up. Avoidant-restrictive food intake disorder is more closely related to pre-pubertal onset eating disorder with arrested sexual maturity and growth failure, if left untreated. Psychiatric co-morbidities arising from body image disturbance, overdrive high achievement needs, prior exposure to adverse childhood experiences (ACE), dysfunctional family or peer relationships, include anxiety, avoidance behavior, obsessive rumination, depression, suicidal ideation and attempt. Death can arise from acute presentation and chronic state of ED, when associated with medical complications from refeeding syndrome, severe malnourishment, accidents and suicide. Early identification and assessment by family physicians would significantly improve the prognosis and mitigate against long term chronicity when share care with ED specialist services.

Research progress on risk predictors of refeeding syndrome in intensive care unit patients / 中华危重病急救医学

Refeeding syndrome (RFS) is a potentially fatal complication of clinical nutritional therapy. Patients in intensive care unit (ICU) consuming nutrients under high stress and high metabolism are more likely to develop RFS, which is closely related to the poor prognosis and higher mortality. However, due to the lack of characteristic clinical manifestations of RFS and the incomplete evaluation of risk factors, there are few reports on the related research of RFS risk prediction model, and it is easily ignored by clinicians. The key to prevention and treatment is to clarify the risk factors of RFS in ICU patients, early identify high-risk patients and initiate intervention. In this paper, the diagnostic criteria, current domestic and abroad situation, risk prediction indexes and preventive therapy of RFS are reviewed. It provides a reference for constructing an RFS risk prediction model that is in line with our national conditions, in order to improve the ability of medical staff to early identify RFS and improve the survival rate of ICU patients.

Prevalência de hipofosfatemia e risco de síndrome de realimentação em idosos internados em uma unidade de terapia intensiva / Prevalence of hypophosphatemia and risk of refeeding syndrome in elderly patients admitted to an intensive care unit

Introdução: A presença de hipofosfatemia é fortemente relacionada à ocorrência de síndrome de realimentação em pacientes críticos, na qual um dos principais grupos de risco é a população idosa. Objetivos: Avaliar a prevalência de hipofosfatemia e o risco de síndrome de realimentação em idosos internados em uma unidade de terapia intensiva. Métodos: Estudo observacional prospectivo, realizado numa unidade de terapia intensiva com pacientes idosos de ambos os sexos e em uso de terapia nutricional enteral. Foram coletados dados demográficos, clínicos e exames bioquímicos, e realizadas triagem e avaliação nutricional. As necessidades nutricionais foram calculadas e adotou-se o ponto de corte de 90% para estabelecer a adequação da oferta calórica. Para avaliar o risco e a ocorrência de síndrome de realimentação, foram utilizados os critérios propostos pelo grupo NICE. A análise estatística foi realizada com o auxílio do programa SPSS 13.0, com um intervalo de confiança (IC) de 95%. Resultados: Foram estudados 44 pacientes, dos quais 34,1% estavam em magreza; 86,4% dos pacientes iniciaram a terapia nutricional enteral em até 48 horas, com 43,2% de adequação calórica em até 72 horas. A hipofosfatemia foi encontrada em 9,1% dos pacientes na admissão e em 29,5% após o início da dieta. Com isso, 88,6% dos pacientes apresentaram algum risco para desenvolver síndrome de realimentação e 40,9% deles manifestaram a síndrome. Conclusão: Foi identificada elevada prevalência de hipofosfatemia após o início da terapia nutricional. Além disso, o risco de desenvolver síndrome de realimentação foi elevado e sua manifestação se assemelha aos dados encontrados na literatura. (AU)

Introduction: The presence of hypophosphatemia is strongly related to the occurrence of refeeding syndrome in critically ill patients, in which one of the main risk groups is the elderly population. Objectives: To assess the prevalence of hypophosphatemia and the risk of refeeding syndrome in elderly patients admitted to an intensive care unit. Methods: Prospective observational study carried out in an intensive care unit with elderly patients of both genders using enteral nutritional therapy. Demographic, clinical and biochemical data were collected, and nutritional screening and assessment were performed. The energy and nutrient requirements were calculated and a cutoff point of 90% was adopted to establish the adequacy of the caloric supply. To assess the risk and occurrence of refeeding syndrome, the criteria proposed by the NICE group were used. Statistical analyses were performed using the SPSS 13.0 program, with a 95% confidence interval (CI). Results: 44 patients were studied, of which 34.1% were malnourished; 86.4% of patients started enteral nutritional therapy within 48 hours, with 43.2% of caloric adequacy within 72 hours. Hypophosphatemia was found in 9.1% of patients on admission and in 29.5% after starting the diet. Thus, 88.6% of patients had some risk of developing the refeeding syndrome and 40.9% of them manifested the syndrome. Conclusion: A high prevalence of hypophosphatemia was identified after starting nutritional therapy. In addition, the risk of developing refeeding syndrome was high and its manifestation is similar to data found in the literature. (AU)

Hypophosphatemia and risk of refeeding syndrome in critically ill patients before and after nutritional therapy

Summary OBJECTIVE: To investigate the prevalence of hypophosphatemia as a marker of refeeding syndrome (RFS) before and after the start of nutritional therapy (NT) in critically ill patients. METHODS: Retrospective cohort study including 917 adult patients admitted at the intensive care unit (ICU) of a tertiary hospital in Cuiabá-MT/Brasil. We assessed the frequency of hypophosphatemia (phosphorus <2.5mg/dl) as a risk marker for RFS. Serum phosphorus levels were measured and compared at admission (P1) and after the start of NT (P2). RESULTS: We observed a significant increase (36.3%) of hypophosphatemia and, consequently, a greater risk of RFS from P1 to P2 (25.6 vs 34.9%; p<0.001). After the start of NT, malnourished patients had a greater fall of serum phosphorus. Patients receiving NT had an approximately 1.5 times greater risk of developing RFS (OR= 1.44 95%CI 1.10-1,89; p= 0.01) when compared to those who received an oral diet. Parenteral nutrition was more associated with hypophosphatemia than either enteral nutrition (p=0,001) or parenteral nutrition supplemented with enteral nutrition (p=0,002). CONCLUSION: The frequency of critically ill patients with hypophosphatemia and at risk for RFS on admission is high and this risk increases after the start of NT, especially in malnourished patients and those receiving parenteral nutrition.

RESUMO OBJETIVO: Determinar a frequência de hipofosfatemia como marcador da síndrome de realimentação (SR) antes e após o início da TN em pacientes críticos. MÉTODOS: Coorte retrospectiva realizada com 917 pacientes adultos de um hospital terciário em Cuiabá-MT. Foi determinada a frequência de hipofosfatemia (fósforo <2,5 mg/dl) como marcador de risco de SR, para valores de fósforo sérico da admissão (P1) e após o início da TN (P2). RESULTADOS: Foi observado um aumento significativo (36,3%) da hipofosfatemia entre P1 e P2 e, consequentemente, do risco de SR (25,6% vs 34,9%; p<0,001) com o início da TN. Após o início da TN, pacientes desnutridos apresentaram maior queda do fósforo sérico. Os pacientes com TN apresentaram aproximadamente 1,5 vez mais chance de desenvolver hipofosfatemia e risco de SR (OR=1,44 IC95% 1,10-1,89; p=0,01) quando comparado aos com dieta oral. Nutrição parenteral foi mais associada à hipofosfatemia versus nutrição enteral (p=0,001) e nutrição enteral suplementada com parenteral (p=0,002). CONCLUSÃO: A frequência de pacientes críticos com hipofosfatemia e em risco de SR é alta e esse risco aumenta após o início da TN, especialmente nos desnutridos e naqueles recebendo nutrição parenteral.

Coma irreversível em paciente portadora de esquizofrenia paranóide: encefalopatia de Wernicke após síndrome de realimentação: um relato de caso / Irreversible coma in a patient with paranoid schizophrenia: Wernicke encephalopathy after refeeding syndrome: a case report

Encefalopatia de Wernicke (EW) e síndrome de realimentação (SR) são duas condições frequentemente coexistentes, subdiagnosticadas e que podem implicar prognóstico reservado após sua instalação. Sua identificação precoce representa um desafio para os intensivistas, haja vista a falta de sensibilidade e especificidade das manifestações clínicas. Apresenta-se um relato de caso de uma paciente portadora de esquizofrenia paranoide, sem histórico de abuso de álcool, que desenvolveu quadro de coma irreversível após greve de fome, sendo feito diagnóstico tardio de EW associada a SR. Descreve-se a evolução clínica e neuropsiquiátrica com o intuito de enfatizar a necessidade crucial de alta suspeição diagnóstica, com reposição vitamínica imediata, vigilância de distúrbios eletrolíticos e progressão parcimoniosa do aporte nutricional. (AU)

Wernicke encephalopathy (WE) and refeeding syndrome (RFS) are two often coexisting, underdiagnosed conditions that may involve a poor prognosis after their onset. Early identification represents a challenge for intensivists, given the lack of sensitivity and specificity of clinical manifestations. We report a case of a patient with paranoid schizophrenia, without a history of alcohol abuse, who developed irreversible coma after a hunger strike, with a late diagnosis of WE associated with RFS. The clinical and neuropsychiatric outcomes are described herein in order to emphasize the crucial need for a high diagnostic suspicion, with immediate vitamin replacement, monitoring of electrolyte disorders, and gradual progression of nutritional support. (AU)

Risk of refeeding syndrome. case report

ABSTRACT Introduction: Refeeding syndrome (RS) is an acute metabolic disorder that occurs during nutritional repletion. Although it has been known for years, the early detection of risk factors for its onset and the implementation of measures to prevent it are not common in nutritional care. Case presentation: 48-year-old male patient, in critical care for 6 days, with suspected Wernicke-Korsakoff encephalopathy and high risk of refeeding syndrome according to criteria of the United Kingdom National Institute of Health and Clinical Excellence. The subject received enteral nutrition with 14 kcal/kg for the first 3 days, with subsequent increases aiming to achieve a nutritional goal of 25 kcal/kg on day 5. He also received daily supplementation of thiamine 600mg, folic acid 5mg and pyridoxine 50mg. Blood phosphorus decreased from 3 mg/dL to 2 mg/dL the day after initiating the nutritional plan and normalized by day 3. Discussion: The patient did not present severe hypophosphatemia or clinical manifestations of refeeding syndrome. Hypophosphatemia was resolved by maintaining a stable caloric restriction during the first days. Some professionals consider this restriction as very conservative, and others think that it may lead to achieve significant improvements in mortality reduction. Conclusions: The strategy for assessing the risk of refeeding syndrome, nutritional management and implemented follow-up were successful in preventing the patient from developing a refeeding syndrome.

RESUMEN Introducción. El síndrome de realimentación (SR) es un trastorno metabólico agudo que ocurre durante la repleción nutricional. Aunque ha sido conocido por años, la detección precoz de factores de riesgo para su desarrollo y la instauración de medidas para prevenirlo no son una práctica habitual en la atención nutricional. Presentación del caso. Paciente masculino de 48 años en cuidado crítico por 6 días, con sospecha de encefalopatía de Wernicke-Korsakoff y riesgo alto de SR según criterios del Instituto Nacional de Salud y Excelencia Clínica del Reino Unido. El sujeto recibió nutrición enteral con 14 kcal/kg los 3 primeros días, con aumentos posteriores que pretendían una meta de 25 kcal/kg al día 5 y suplementación diaria de tiamina 600mg, ácido fólico 5mg y piridoxina 50mg. El fósforo en sangre disminuyó de 3 mg/dL a 2 mg/dL al día siguiente del inicio de la nutrición y se normalizó para el día 3. Discusión. El paciente no presentó manifestaciones clínicas de SR ni hipofosfatemia severa; esta última se resolvió manteniendo estable la restricción calórica los primeros días. Para algunos profesionales dicha restricción puede ser muy conservadora; sin embargo, para otros puede llevar a mejoras significativas en la reducción de la mortalidad. Conclusiones. La estrategia para valorar el riesgo de SR, el manejo nutricional y el seguimiento implementado fueron acertados para evitar que el paciente desarrollara el síndrome.

Eating Disorders in Adolescents - Physical and Psychiatric Perspectives

@#Eating disorder (ED) referrals of school age children and adolescents, by their parents and school teachers, have become more common. Also, they are now presenting at an earlier age to the primary health care and school systems, with physical, medical and psychological symptoms. Nevertheless, there is an average of six months to two years between the onset of symptoms to formal assessment and treatment by specialist team. There are also more cases presenting to ED specialist clinic services, especially pre-pubertal children, with early onset and presentation before 14 years old. Mid and late adolescent presentations (after 14 years old) continue to make up more than two third of the cases. More than 60 percent of cases seen in specialist clinics are of the restrictive type anorexia nervosa, and often associated with persistent and excessive exercise. Thirty percent of cases presented are Bulimia nervosa, which tend to be episodic. Majority of single episode bulimia cases do not present themselves early to medical services but take on open source self-directed management. For patients with bulimia who comply to treatment program and recover after 6-12 months of therapy, they can also experience high relapse rate as they often discontinue their follow up. Avoidant-restrictive food intake disorder is more closely related to pre-pubertal onset eating disorder with arrested sexual maturity and growth failure, if left untreated. Psychiatric co-morbidities arising from body image disturbance, overdrive high achievement needs, prior exposure to adverse childhood experiences (ACE), dysfunctional family or peer relationships, include anxiety, avoidance behavior, obsessive rumination, depression, suicidal ideation and attempt. Death can arise from acute presentation and chronic state of ED, when associated with medical complications from refeeding syndrome, severe malnourishment, accidents and suicide. Early identification and assessment by family physicians would significantly improve the prognosis and mitigate against long term chronicity when share care with ED specialist services.

Refeeding Syndrome as a Possible Cause of Very Early Mortality in Acute Pancreatitis

BACKGROUND/AIMS: Refeeding syndrome (RFS) is a fatal clinical complication that can occur as a result of fluid and electrolyte shifts during early nutritional rehabilitation for malnourished patients. This study was conducted to determine the clinical implications of RFS in patients with acute pancreatitis (AP). METHODS: Between 2006 and 2016, AP patients with very early mortality were retrospectively enrolled from three university hospitals. RESULTS: Among 3,206 patients with AP, 44 patients died within 3 days after diagnosis. The median age was 52.5 years (range, 27 to 92 years), male-to-female ratio was 3:1, and median duration from admission to death was 33 hours (range, 5 to 72 hours). The etiology of AP was alcohol abuse in 32 patients, gallstones in five patients, and hypertriglyceridemia in two patients. Ranson score, bedside index for severity of AP, and acute physiology and chronic health evaluation-II were valuable for predicting very early mortality (median, [range]; 5 [1 to 8], 3 [0 to 5], and 19 [4 to 45]). RFS was diagnosed in nine patients who died of septic shock (n=5), cardiogenic shock (n=2), or cardiac arrhythmia (n=2). In addition, patients with RFS had significant hypophosphatemia compared to non-RFS patients (2.6 mg/dL [1.3 to 5.1] vs 5.8 mg/dL [0.8 to 15.5]; p=0.001). The early AP-related mortality rate within 3 days was approximately 1.4%, and RFS occurred in 20.5% of these patients following sudden nutritional support. CONCLUSIONS: The findings of current study emphasize that clinicians should be aware of the possibility of RFS in malnourished AP patients with electrolyte imbalances.

Challenges in a refeeding programme: case report of an Orang Asli boy at household level

@#Introduction: The refeeding programme in government hospitals is aimed at improving the nutritional status of malnourished children with weight-for-height z-score (WHZ) below -2.0, using special therapeutic food. However, there is a lack of data on the nutritional status of indigenous (Orang Asli) children when they return to the community after hospital discharge. Case Presentation: A 3-year-old Temiar boy residing in a tribal village in Hulu Perak was visited to determine his nutritional status following discharge from a refeeding programme in a government hospital. He was admitted to the hospital with a weight of 10.0 kg, height of 85.5 cm and WHZ of -2.09. The boy was later discharged weighing 11.0 kg, and with height unchanged at 85.5 cm and WHZ of -0.87. During our visit to the child’s home three months after discharge, his weight was 9.5 kg, height 86.0 cm, and WHZ –2.91. Discussion: The management of the case in the hospital was based on the Malnourished Orang Asli Protocols of the hospital. Household food insecurity, feeding and care practices, unhealthy household environment and the lack of communication between hospital and community health services were all identified as risk factors for malnutrition. Conclusion: The recurrence of malnutrition in this child, after successful improvement during hospital stay, highlights the importance of identifying factors that may affect nutritional status after hospital discharge. This knowledge will be beneficial in planning specific interventions, especially for Orang Asli children, living in remote villages

Protein and lipid metabolism adjustments in silver catfish (Rhamdia quelen) during different periods of fasting and refeeding / Ajustes no metabolismo de proteínas e lipídios no jundiá (Rhamdia quelen) durante diferentes períodos de jejum e realimentação

Abstract The fish may experience periods of food deprivation or starvation which produce metabolic changes. In this study, adult Rhamdia quelen males were subjected to fasting periods of 1, 7, 14, and 21 days and of refeeding 2, 4, 6, and 12 days. The results demonstrated that liver protein was depleted after 1 day of fasting, but recovered after 6 days of refeeding. After 14 days of fasting, mobilization in the lipids of the muscular tissue took place, and these reserves began to re-establish themselves after 4 days of refeeding. Plasmatic triglycerides increased after 1 day of fasting, and decreased following 2 days of refeeding. The glycerol in the plasma oscillated constantly during the different periods of fasting and refeeding. Changes in the metabolism of both protein and lipids during these periods can be considered as survival strategies used by R. quelen. The difference in the metabolic profile of the tissues, the influence of the period of fasting, and the type of reserves mobilized were all in evidence.

Resumo Os peixes podem sofrer períodos de privação de alimentos ou de fome, que produzem mudanças metabólicas. Neste estudo, jundiás machos adultos foram submetidos a jejum períodos de 1, 7, 14 e 21 dias e realimentação 2, 4, 6, e 12 dias. Os resultados demonstraram que a proteína do fígado foi esgotada depois de um dia de jejum, mas restabeleceu após 6 dias de realimentação. Após 14 dias de jejum, ocorreu a mobilização dos lípidos no tecido muscular sendo que estas reservas começaram a re-estabelecer-se após 4 dias de realimentação. Os triglicérides plasmáticos aumentam após um dia de jejum, e diminuiram após 2 dias de realimentação. O glicerol no plasma oscilou constantemente durante os diferentes períodos de jejum e realimentação. As alterações no metabolismo de proteína e lipídios durante estes períodos podem ser consideradas uma estratégias de sobrevivência utilizada pelo Rhamdia quelen. Sendo que a diferença no perfil metabólico tecidual bem como a influência do período de jejum e o tipo de reserva a ser mobilizada foram observadas neste estudo.

Efecto de la restricción de alimento y posterior realimentación sobre algunas variables fisiológicas y metabólicas en yamú (Brycon amazonicus) / Effects of food restriction and refeeding on some physiological and metabolic variables of yamú (Brycon amazonicus)

RESUMEN Se evaluó el efecto de la restricción de alimento y posterior realimentación sobre algunas variables fisiológicas en yamú (Brycon amazonicus) utilizando 1115 juveniles (peso inicial 217,75 g ± 14,74 g) distribuidos en tres estanques y asignados a los siguientes tratamientos: 1) Control (C), alimentación todos los días; 2) Restricción moderada (RM), restricción por 2 días y realimentación por 3 y 3) Restricción severa (RS), restricción total durante 5 semanas y realimentación a partir de la semana 6 hasta la 12. Se realizaron colectas de sangre los días 1, 35, 42, 56, 70 y 84, de 7 animales por tratamiento para determinación del hematocrito, proteína, glucosa, lactato, triglicéridos, colesterol, cortisol, T3 e insulina. Adicionalmente, los animales se sacrificaron para retirar el hígado y determinar el glucógeno hepático. El modelo experimental fue mixto de efectos fijos, con 3 tratamientos y 6 muestreos, con anidamiento del muestreo en los tratamientos. Los datos se analizaron a través de análisis de varianza y en los casos en que hubo diferencias significativas se empleó la prueba de Tukey-Kramer. No hubo diferencias significativas (p > 0,05) para hematocrito, proteína, glucosa, cortisol y lactato entre los tratamientos en ninguna de las muestras tomadas. La insulina y T3 mostraron diferencias entre tratamientos en el día 35, pero no en el 84, igual a lo ocurrido con colesterol y glucógeno hepático. Los triglicéridos mostraron diferencias a lo largo del estudio, en el día 84 RS presentó menores niveles. Los resultados permiten concluir que pese a la restricción parcial de alimento, no se generaron efectos negativos sobre el metabolismo de Brycon amazonicus.

ABSTRACT The effect of food restriction and refeeding on some physiological variables in yamú (Brycon amazonicus) was evaluated using 1115 juveniles (initial weight 217.75 g ± 14.74 g), distributed in three ponds. The groups were randomly assigned one of the following treatments: 1) Control (C), fed every day; 2) Moderate restriction (MR), restriction during 2 days and refeeding during 3; and 3) Severe restriction (SR), total restriction during 5 weeks and refeeding from week 6 to 12. Blood samples from 7 animals from each treatment were taken on days 1, 35, 42, 56, 70, and 84 to determine hematocrit, proteins, glucose, lactate, triglycerides, cholesterol, cortisol, T3, and insulin. The animals were sacrificed and their livers removed to calculate the hepatic glycogen. The experimental design used was a fixed effects mixed model of 3 treatments and 6 samples, with sampling nesting in the treatments. A variance analysis was performed to analyze the data; the Tukey-Kramer test a variance analysis was used in the cases with significant differences. No significant differences (p> 0.05) were found for hematocrit, protein, glucose, cortisol, and lactate. The insulin and T3 showed differences among treatments on day 35, but not on day 84, the same as cholesterol and hepatic glycogen. Triglycerides showed differences throughout the study, SR showed the lowest levels on day 84. The results allow us to conclude that, despite the partial feed restriction, there were no adverse effects on the metabolism of Brycon amazonicus.

Desempeño productivo y fisiológico de juveniles de Piaractus brachypomus sometidos a restricción de alimento / Productive and Physiological Performance of Juveniles of Piaractus brachypomus Subjected to Food Restriction / Desempenho produtivo e fisiológico de juvenis de Piaractus brachypomus submetidos à restrição de alimento

Resumen Se utilizaron 177 juveniles de Piaractus brachypomus, mantenidos durante 84 días en dos estanques asignados a dos tratamientos de alimentación: T1: diaria y T2: un día sí y un día no. Se realizaron colectas de sangre los días 1, 28, 42, 56, 70 y 84 de 7 animales por tratamiento para determinación de hematocrito, hemoglobina, proteína, glucosa, lactato, triglicéridos, colesterol, cortisol e insulina. Los animales fueron pesados, medidos y sacrificados para cálculo de índices hepatosomático (IHS), viscerosomático (IVS) y grasa visceral (IGV); al final del ensayo a los animales muestreados se les realizó análisis proximal y de energía en filete. El hematocrito presentó diferencias significativas entre tratamientos los días 56 y 84, siendo superior en T1 el día 56 e inferior el día 84. Excepto los días 1 y 42, en los que la hemoglobina fue superior en T1, no hubo diferencias significativas entre tratamientos. Para glucosa, insulina y lactato hubo diferencias significativas el día 28: las dos primeras fueron superiores en T1, mientras que el lactato lo fue en T2. La proteína aumentó significativamente en T1 el día 42, nivel que se mantuvo el día 56, disminuyendo el día 70 y manteniéndose así hasta el día 84. Para triglicéridos, colesterol y cortisol no hubo diferencias significativas entre tratamientos en ninguna de las colectas. Además, se presentaron diferencias significativas en peso los días 42 y 70, y en longitud el día 42, no existiendo diferencias entre tratamientos al final del ensayo. Para IHS e IVS hubo diferencias significativas el día 84, siendo superiores en T1, sin diferencias para IGV. La sobrevivencia fue 100% en ambos tratamientos. El análisis proximal y la energía del filete no presentaron diferencias entre tratamientos. Se concluye que la restricción alimenticia del 50% en el esquema alternado utilizado, no afectó la condición fisiológica de los animales, pues no se evidenció ningún daño metabólico importante, ni cambios en la composición del producto final.

Abstract 177 juveniles of Piaractus brachypomus were kept during 84 days in two ponds. Each group was assigned one of the following treatments: T1: fed every day, and T2: fed every other day. Blood samples from 7 animals of each treatment were taken on days 1, 28, 42, 56, 70, and 84 to determine hematocrit, hemoglobin, glucose, lactate, protein, triglycerides, cholesterol, cortisol, and insulin. Fish were weighted, measured, and sacrificed to remove the liver, viscera, and visceral fat to calculate the hepatosomatic index (HSI), viscerosomatic index (VSI), and visceral fat index (VFI). At the end of the trial, the group of sampled animals were filleted to do the energy and proximal analysis. There were significant differences in hematocrit between treatments, on days 56 and 84, they were higher in T1 on day 56, and lower in T1 on day 84. On days 1 and 42, hemoglobin was higher in T1, there were no significant differences among treatments. There were significant differences in glucose, insulin and lactate on day 28; the first two were higher in T1, while lactate was higher in T2. Protein significantly increased in T1 on day 42, and was the same on day 56, then decreased on day 70, and remained stable until day 84. There were no significant differences between treatments in triglycerides, cholesterol, and cortisol during any of the sample times. There were significant differences in the weight on days 42 and 70, and in length on day 42, but there were no significant differences between treatments at the end of the test. There were significant differences in IHS and IVS on day 84, they were higher in T1. There were no differences in IGV. Survival was 100% in both treatments. There were no differences in energy and proximal analysis of the fillets between the treatments. We can conclude that a 50% food restriction in the alternated scheme did not affect the physiological condition of the animals because there was not any significant metabolic damage or changes in the composition of the final product.

Resumo Juvenis de Piaractus brachypomus (177), foram mantidos por 84 dias em dois viveiros sendo alimentados assim: T1: alimentação todos os dias e T2: alimentação a cada dois dias. Realizaram-se coletas de sangue nos dias 1, 28, 42, 56, 70 e 84 de sete animais por tratamento para determinação do hematócrito, hemoglobina, glicose, lactato, proteína, triglicerídeos, colesterol, cortisol e insulina. Também foram pesados, medidos e sacrificados, para o cálculo dos índices hepatossomático (IHS), viscerossomático (IVS) e de gordura visceral (IGV). No hematócrito houve diferenças entre os tratamentos nos dias 56 e 84, sendo maior no T1 no dia 56 e menor no dia 84. Com exceção dos dias 1 e 42, em que a hemoglobina foi maior em T1, não houve diferenças entre os tratamentos. Para glicose, insulina e lactato, houve diferenças no dia 28. As duas primeiras foram maiores em T1, enquanto que o lactato foi maior em T2. A proteína aumentou em T1 no dia 42 y esteve alta até o dia 56. Porém, diminuiu no dia 70 e permaneceu baixa até o final. Para triglicerídeos, colesterol e cortisol não houve diferenças entre os tratamentos em nenhum dos tempos de coleta. Além disso, houve diferenças em peso nos dias 42 e 70 e em comprimento no dia 42. Porém, não houve diferenças no final do ensaio. Para IHS e IVS houve diferenças no dia 84, sendo maiores em T1. O IGV não apresentou diferenças no final do ensaio. A sobrevivência foi de 100% em ambos os tratamentos. As análises proximais e de energia não apresentaram diferenças entre os tratamentos. Pode-se concluir que a restrição alimentar de 50%, não afetou o estado fisiológico dos animais, devido a que nenhum dano metabólico importante foi evidente, nem alterações na composição do produto final.

Síndrome de realimentação em idosos: estudo de uma série de cinco casos / Refeeding syndrome in elderly individuals: evaluation of a series of five cases

Introdução: A subnutrição é um problema frequente em idosos e sua prevalência aumenta entre os mais frágeis, tornando prioritária uma adequada oferta nutricional diante de eventos agudos. Entretanto, tal oferta, em pacientes desnutridos ou com privação calórica subaguda, pode ocasionar alterações hidroeletrolíticas associadas a sintomas neurológicos, respiratórios e cardiológicos, incluindo falência cardíaca. Esses distúrbios ocorrem poucos dias após a introdução da dieta, o que caracteriza a síndrome de realimentação. Metodologia: Avaliou-se retrospectivamente cinco pacientes idosos internados por causa clínica e que desenvolveram síndrome de realimentação durante a internação hospitalar. Resultados: Todos os pacientes analisados eram desnutridos e frágeis, dos quais quatro eram do sexo feminino. A idade variou entre 82 e 85 anos e o tempo de privação alimentar entre 7 e 15 dias. Três pacientes eram portadores de demência grave e foram admitidos com delirium hipoativo. Hipofosfatemia ocorreu em 100% da amostra, seguida por hipocalemia (60%) e hipomagnesemia (40%). Quatro pacientes cursaram com edema periférico (80%), dois apresentaram íleo metabólico e três idosos (os que apresentaram menores níveis de fosfato) faleceram durante a internação. Conclusão: Todos os casos de síndrome de realimentação analisados cursaram com hipofosfatemia, com desfecho fatal naqueles com menores níveis deste íon. A associação com edema e íleo metabólico foi comum. Dada a escassez de dados disponíveis na literatura, novos estudos são de extrema importância. A avaliação eletrolítica antes e após o início de suporte nutricional é imprescindível em pacientes de risco, auxiliando no reconhecimento e no tratamento precoce dessa grave condição.

Introduction: Undernourishment is a common health problem among elderly individuals, and its prevalence grows among frail patients, which makes nutritional support a priority, especially in acute diseases. However, providing nutritional support to undernourished patients or to those under acute caloric deprivation may lead to electrolyte disturbances associated with neurological, respiratory, and cardiac symptoms, including cardiac arrest. These disturbances occur a few days after receiving nutritional support, and characterize the refeeding syndrome. Methodology: Five elderly patients hospitalized for clinical reasons and who developed refeeding syndrome during the duration of the stay, were retrospectively evaluated. Results: All patients analyzed were malnourished and frail, of whom four were women. The age group ranged between 82 and 85 years, and food deprivation time ranged between 7 to 15 days. Three patients had severe dementia and were admitted with hypoactive delirium. Hypophosphatemia occurred in 100% of the sample, followed by hypokalemia (60%) and hypomagnesemia (40%). Four patients developed peripheral edema, two developed metabolic ileus and three elderly persons (who had lower phosphorus values) died during the hospital stay. Conclusion: All refeeding syndrome patients developed hypophosphatemia, with fatal outcome among those whose phosphorus values were lower. The development of peripheral edema and metabolic ileus was frequent. Owing to the lack of data in literature, new researches on refeeding syndrome are extremely important. Electrolyte evaluation before and after nutritional support in patients at risk, is indispensable to facilitate recognition and treatment of this severe condition.

Falla multiorgánica asociada a síndrome de realimentación / Multiple organ failure refeeding syndrome associated / Falência de múltiplos órgãos associada à síndrome de realimentação

Resumen: El síndrome de realimentación es una entidad clínica subdiagnosticada, de no reconocerse puede causar desenlaces fatales. La literatura sobre la prevalencia de este trastorno es escasa. La presentación clínica es inespecífica y por tanto es de suma importancia la sospecha de esta entidad. Presentamos el caso de una paciente con múltiples factores de riesgo quien, posterior al inicio de nutrición parenteral hipercalórica, desarrolló disfunción orgánica múltiple manifestada con insuficiencia cardiaca aguda, edema agudo de pulmón, encefalopatía y oliguria. Mediante tratamiento de soporte hemodinámico, nutrición parenteral adecuada y corrección electrolítica se obtuvo un desenlace favorable.

Abstract: Refeeding syndrome is a commonly under diagnosed pathology, with potentially fatal outcomes when untreated. Nowadays few data exists about its prevalence. The clinical presentation is unspecific that is the reason why it is so important to recognize this disease. The case presented here is about a multiple risk factor patient who developed multiple organ failure with acute heart failure, acute lung edema, encephalopathy and diminishment of urine output after been treated with a hypercaloric parenteral nutrition. Treatment with hemodynamic support, an adequate parenteral nutrition and electrolyte correction, brought to a favorable clinical outcome.

Resumo: A síndrome de realimentação é uma entidade clínica subdiagnosticada, o seu não reconhecimento pode ser fatal. A literatura sobre a prevalência dessa difunção é escassa. A apresentação clínica é inespecífica e, portanto, é de suma importância suspeitar desta entidade. Relatamos o caso de uma paciente com múltiplos fatores de risco que, após o início da nutrição parenteral hipercalórica desenvolveu disfunção de múltiplos órgãos manifestado com insuficiência cardíaca aguda, edema agudo pulmonar, encefalopatia e oligúria. Obteve-se um resultado favorável no tratamento com o suporte hemodinâmico, nutrição parenteral adequada e correção electrolítica.

Protein and lipid metabolism adjustments in silver catfish (Rhamdia quelen) during different periods of fasting and refeeding

Abstract The fish may experience periods of food deprivation or starvation which produce metabolic changes. In this study, adult Rhamdia quelen males were subjected to fasting periods of 1, 7, 14, and 21 days and of refeeding 2, 4, 6, and 12 days. The results demonstrated that liver protein was depleted after 1 day of fasting, but recovered after 6 days of refeeding. After 14 days of fasting, mobilization in the lipids of the muscular tissue took place, and these reserves began to re-establish themselves after 4 days of refeeding. Plasmatic triglycerides increased after 1 day of fasting, and decreased following 2 days of refeeding. The glycerol in the plasma oscillated constantly during the different periods of fasting and refeeding. Changes in the metabolism of both protein and lipids during these periods can be considered as survival strategies used by R. quelen. The difference in the metabolic profile of the tissues, the influence of the period of fasting, and the type of reserves mobilized were all in evidence.

Resumo Os peixes podem sofrer períodos de privação de alimentos ou de fome, que produzem mudanças metabólicas. Neste estudo, jundiás machos adultos foram submetidos a jejum períodos de 1, 7, 14 e 21 dias e realimentação 2, 4, 6, e 12 dias. Os resultados demonstraram que a proteína do fígado foi esgotada depois de um dia de jejum, mas restabeleceu após 6 dias de realimentação. Após 14 dias de jejum, ocorreu a mobilização dos lípidos no tecido muscular sendo que estas reservas começaram a re-estabelecer-se após 4 dias de realimentação. Os triglicérides plasmáticos aumentam após um dia de jejum, e diminuiram após 2 dias de realimentação. O glicerol no plasma oscilou constantemente durante os diferentes períodos de jejum e realimentação. As alterações no metabolismo de proteína e lipídios durante estes períodos podem ser consideradas uma estratégias de sobrevivência utilizada pelo Rhamdia quelen. Sendo que a diferença no perfil metabólico tecidual bem como a influência do período de jejum e o tipo de reserva a ser mobilizada foram observadas neste estudo.

Rebound Feeding in the Wake of Short-Term Suspension of Food Intake Differs in the Presence of Estrous Cycle Peak versus Nadir Levels of Estradiol

BACKGROUND: Short-term interruption of feeding is ordinary in modern life but negatively impacts appetite control and body weight. Estradiol (E) imposes long-term inhibitory tonus on food consumption; however, E influence on energy repletion secondary to food deprivation (FD) is unclear. This study investigated the hypothesis that E signal strength regulates hyperphagic responses to FD of varying duration. METHODS: Ovariectomized female rats were implanted with E-containing silastic capsules (30 [E-30] or 300 µg [E-300]/mL) to replicate plasma concentrations at cycle nadir versus peak levels. RESULTS: Data show that food intake was increased equally in E-30 and E-300 rats after 12 hours of food deprivation (FD-12); yet, FD of 18 hours (FD-18) amplified refeeding by E-300 versus E-30. Caudal fourth ventricular administration of the 5′-monophosphate-activated protein kinase (AMPK) inhibitor compound C (Cc) did not modify FD-induced hyperphagia in E-30 (regardless of FD interval) or E-300 animals exposed to FD-12, but diminished refeeding after FD-18 in E-300 rats. Cc-reversible hyperglycemia occurred in refed FD-18 groups. Serum insulin was resistant to FD-12 plus refeeding, but was elevated by AMPK-dependent mechanisms in refed E-300 FD-18 rats; equivalent Cc-insensitive decrements in circulating leptin occurred in all FD groups. CONCLUSION: Current results show that estrous cycle peak, but not baseline, E levels engage hindbrain AMPK signaling to intensify hyperphagia in response to prolongation of FD. Observations of hindbrain AMPK-dependent hyperglycemia, alongside elevated insulin secretion, in refed rats exposed to FD-18 implicate this sensor in insulin resistance mechanisms of glucose partitioning in response to this metabolic imbalance.